Prolapsed Uterus

Picture of a doctor holding a model of the female reproductive system.

The uterus (the womb, in which a fetus develops) is normally held in place inside the pelvis with various muscles and ligaments. Sometimes, because of childbirth or difficult labor and vaginal delivery, these tissues are weakened. As a woman ages and with age-related decrease in the concentration of the hormone estrogen, her uterus can move downward into the vaginal canal, causing the condition known as a prolapsed uterus.

Muscle weakness or relaxation may allow the uterus to sag or come completely out of the body. Prolapsed uterus can be described in the following stages:

• First degree: The cervix descends downward into the vagina.
• Second degree: The cervix comes down to the opening of the vagina.
• Third degree: The cervix is outside the vagina.
• Fourth degree: The entire uterus is outside the vagina. This condition is also called procidentia. This is caused by weakness in all of the supporting ligaments.

Other conditions are usually associated with prolapsed uterus. They weaken the muscles and ligaments that hold the uterus in place:

• Cystocele: A herniation (or bulging) of the upper front vaginal wall where a part of bladder bulges into the vagina, which may lead to urinary frequency, urgency, retention, and retention.
• Enterocele: The herniation of the upper vagina along with a segment of small intestine into the vagina. Standing leads to a pulling sensation and backache and is relieved when lying down.
• Rectocele: The protrusion forward of the back wall for the bagina, along with concomitant bulging forward of the rectum into the vagina. This may make bowel movements difficult to the point where the woman may need to push on the inside of the vagina to empty the rectum.

• A feeling of fullness or pressure in the pelvis (it may be described as a feeling of sitting on a small ball)
• Low back pain
• Feeling that something is coming out of the vagina
• Painful sexual intercourse
• Difficulty with urination or moving the bowels
• Difficulty walking

The following conditions can cause a prolapsed uterus:

• Childbirth injury to the ligaments and muscles that support the walls of the bagina.
• Weakening and loss of tissue tone after menopause with loss of natural estrogen production by the ovaries/
• Conditions leading to increased pressure in the abdomen such as chronic cough (with bronchitis and asthma), straining (with constipation), pelvic tumors (rare), or an accumulation of fluid in the abdomen
• Being overweight or obese resulting in additional strain on pelvic muscles
• Radical surgery in the pelvic area leading to loss of external support

Other risk factors

• Heavy weight lifting resulting in increased intra-abdominal pressure due to straining.
• Racial factors (Caucasian and Asians are more commonly affected than African American people).

A prolapsed uterus is divided into four catagories or stages that indicate how far the uterus has dropped.

• Stage I: The cervix drops into the vagina and the uterus drops near the vaginal opeing.
• Stage II: The uterus drops to the vaginal opening.
• Stage III: The uterus comes out of the vagina.
• Stage IV: The entire uterus is out of the vagina, which is called procidentia.

A health care professional should be notified if you experience any of the following symptoms:

• The cervix can be felt near the opening of the vagina.
• Persistent urinary dribbling
• Persistent feeling of rectal fullness
• Pressure in your vaginal canal or the protrusion from the vaginal opening
• Continuous low back pain with difficulty while walking, difficulty with urination, and/or while attempting a bowel movement.

Seek medical care immediately if you experience the following:

• Obstruction or difficulty in urination and/or defecation
• Complete uterine prolapse (your uterus comes out of your vagina)

The health care professional can diagnose uterine prolapse with a medical history and physical examination of the pelvis.

• The doctor may need to examine the patient in both standing and recumbent positions.
• She may be asked to cough or strain down to increase the intra-abdominal pressure.
• Specific conditions, such as urethral obstruction due to complete uterine prolapse, may need to be confirmed with an intravenous pyelogram (IVP) or a renal ultrasound. In an IVP, dye is injected into a vein. A series of X-rays is then taken to follow the dye through the urinary tract.
• Ultrasound may also be needed to rule out other pelvic problems. In this test, a probe is passed over the abdomen or inserted into the vagina to create images using sound waves.
• Sometimes, other imaging tests such as MRI (magnetic resonance imaging) may be used to accurately image the pelvis. This test is usually only necessary in special circumstances.

The pelvic muscles can be strengthened by performing exercise. However, most of the support defects that are evident when uterine prolapse occurs are not dependent on the strength of the pelvic musculature. Repetitive childbirth injury, as well as other factors previously listed, tears the supporting ligaments surrounding the vagina. More importantly, a strong tissue layer called endopelvic fascia is torn as the vagina is stretched by the passage of delivering babies through the vaginal canal.

While contraction of the pelvic muscles may alleviate mild urinary leakage which occurs with increased intra-abdominal pressure (e.g. coughing, sneezing), such exercises will not correct any of the more profound defects associated with uterine prolapse.

Treatment depends on how weak the supporting structures around the uterus have become.

Estrogen replacement therapy may be used to help the body strengthen the muscles in and around the vagina. Estrogen cream or suppositories inserted into the vagina help in restoring the strength and vitality of tissues in the vagina but only in selected postmenopausal women. Estrogen therapy may be contraindicated (such as in a people with certain types of cancer) and has been associated with certain health risks including increased risk of blood clots and stroke, particularly in older postmenopausal women. Estrogen therapy will not heal damaged tissues responsible for uterine prolapse.

The choice of surgery for uterine prolapse depends upon many factors, including the patient's age, overall state of health, and desire for future childbearing. When indicated, and in severe cases of prolapse, the uterus can be removed (hysterectomy). During the procedure, the surgeon can also correct the sagging of the vaginal walls, urethra, bladder, or rectum. The surgery may be performed abdominally (through an incision on the abdomen), vaginally (through incisions made in the vaginal walls), or laparoscopically (using special instruments to perform the surgery through small tiny incisions.

If a woman does not want surgery or is a poor candidate for surgery, she may decide to wear a supportive device (pessary) in the vaginal canal to support the falling uterus. A pessary can be used on a temporary basis in preparation for surgery, or on a permanent basis in patients who cannot or will not undergo surgical correction. They come in many different shapes and sizes, and they must be fitted to each woman. If the prolapse is severe, a pessary may not be retained by the vagina (i.e. it will not stay inside the vagina). Pessaries may cause odor and vaginal discharge. They may also initiate vaginal erosions, leading to vaginal bleeding. Pessaries much be removed, cleaned, and reinserted at periodic intervals.

Follow-up for uterine prolapse is determined by how the condition was initially treated.

• If the woman had surgery, she needs to follow-up according to her surgeon's advice.
• If the woman has a pessary inserted in the vagina, it needs to be cleaned and checked by a health care professional for the correct position and fitting at regular intervals unless she is instructed on how to remove it and clean it herself at home. Many patients are unable to remove or reinsert a pessary. The individuals must return to their doctor for regular pessary care.

Pessaries can be effective temporarily or permanently if they are checked and cleaned on a regular basis. Surgical procedures may be used to correct existing pelvic support defect with or without concomitant hysterectomy.

• Reduce weight
• Avoid constipation by eating a high-fiber diet
• Do Kegel exercises to strengthen the pelvic muscles (may provide minimal protection against urinary leakage).
• Avoid heavy lifting or straining