Uterine prolapse occurs when the uterus descends into the vaginal canal. Learn about its causes, symptoms, and management at Meri Sehat.

Uterine Prolapse

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Ismail Munir

Overview

Uterine prolapse is defined as a herniation of the uterus into the vagina. 
&nbsp;

The uterus is held in place with the help of pelvic muscles and ligaments. Over time, these muscles or ligaments may weaken, causing the uterus to protrude out of the vagina.

The degree of uterine prolapse depends on how frail the uterus&#39; stabilizing muscles have become. The uterus may slip partially into the vagina in an incomplete prolapse. This results in a bump or bulge. Whereas, in a complete prolapse, the uterus shifts so much that it bulges out of the vagina. 
&nbsp;

Multiple vaginal deliveries and menopause are common risk factors for uterine prolapse. An estimated 50% of women aged 50 to 79 years experience some degree of uterine or other forms of pelvic organ prolapse<a href="#accordion">[4]</a>. Uterine prolapse affects 2-88 per 1000 women in the population, making it a common issue<a href="#accordion">[1]</a>. 
&nbsp;

Uterine prolapse is classified under pelvic organ prolapse. Depending on how far down the uterus slips, it can be divided into complete or incomplete prolapse.

<ul>
	<li>Incomplete Uterine Prolapse - The uterus only partially descends into the vaginal canal, but does not protrude. It can cause a slight bulge.</li>
	<li>Complete Uterine Prolapse - The uterus protrudes out of the vagina. 
	&nbsp;</li>
</ul>

Signs and Symptoms

Mild cases of uterine prolapse may not cause any symptoms. However, as the uterus descends further, it can put pressure on the bowel or bladder. Thus, resulting in the following symptoms: 
&nbsp;

<ul>
	<li>The sensation of sitting on a ball</li>
	<li>Pain in the pelvis, lower back, or abdomen.&nbsp;</li>
	<li>Uterine bleeding</li>
	<li>Pain during sexual intercourse</li>
	<li>Bulge within the vagina</li>
	<li>A tugging or heavy sensation in the pelvis region</li>
	<li>Constipation</li>
	<li>Recurring urinary infections</li>
	<li>Difficulty emptying the bladder</li>
	<li>Urinary incontinence</li>
	<li>Urinary frequency or urgency</li>
</ul>

If left untreated, uterine prolapse can lead to bowel, bladder, and sexual dysfunction. 
&nbsp;

Note: If you experience any of these symptoms, consult your doctor immediately and seek treatment. 
&nbsp;

Causes

The pelvic floor muscles, along with the ligaments and tissues, support the uterus, vagina, rectum, bladder, and bowel, keeping them in place. If these muscles weaken or get damaged, they may eventually lose the ability to support the pelvic organs. As a result, the uterus or other organs may slip into the vagina. 
&nbsp;

Following are some common causes of weakened pelvic muscles and tissues:

<ul>
	<li><a href="https://merisehat.pk/disease/menopause">Menopause </a>(low estrogen levels cause a loss of muscle tone)</li>
	<li>Pregnancy, especially multiple pregnancies</li>
	<li>Vaginal delivery, especially if the baby is large&nbsp;</li>
	<li><a href="https://merisehat.pk/disease/obesity">Obesity</a></li>
	<li><a href="https://merisehat.pk/disease/fibroids">Fibroids</a></li>
	<li>Chronic coughing or straining</li>
	<li>Chronic <a href="https://merisehat.pk/disease/constipation">constipation</a></li>
	<li>Repeated heavy lifting 
	&nbsp;</li>
</ul>

Depending on how weak the pelvic floor muscles are, uterine prolapse can be mild or severe. 
&nbsp;

There are no specific screening tests for uterine prolapse. A detailed history and physical examination typically point to the condition. 
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Diagnosis

To evaluate a person for uterine prolapse, the doctor will first take a detailed clinical history and perform a pelvic exam. Generally, the most common finding is a visible bulge in the vagina. Doctors typically perform the pelvic exam at rest and during the Valsalva maneuver. A speculum is inserted into the vagina, to allow visualization of the vaginal canal and uterus. Moreover, during the pelvic exam, the degree of prolapse can be assessed by instructing the patient to strain, cough, or act like they&rsquo;re holding in their urine. 
&nbsp;

Based on how far the uterus descends into the vagina, uterine prolapse is classified into 4 stages<a href="#accordion">[5]</a>. These include: 
&nbsp;

<ul>
	<li>Stage 0: No prolapse present</li>
	<li>Stage I:&nbsp; The uterus enters the upper half of the vagina (&gt;1cm above the hymen).</li>
	<li>Stage II: The uterus enters the lower part of the vaginal canal, near the opening.</li>
	<li>Stage III: The uterus protrudes out from the vagina.</li>
	<li>Stage IV: The entire uterus protrudes completely from the vagina. 
	&nbsp;</li>
</ul>

Although a combination of history and pelvic exam findings are enough to base a diagnosis, the doctor may conduct imaging scans to visualize the prolapsed segments and confirm the diagnosis. These include:

<ul>
	<li>Pelvic ultrasound</li>
	<li>Pelvic floor MRI</li>
	<li>Abdominal and pelvic CT scan 
	&nbsp;</li>
</ul>

Moreover, If the individual has urination problems, their bladder function may be tested. This is known as urodynamic testing.

<ul>
	<li>Uroflowmetry determines the quantity and strength of the urine stream.</li>
	<li>The cystometrogram determines how full the bladder must be before the individual needs to use the restroom. 
	&nbsp;</li>
</ul>

Treatment

Uterine prolapse can be treated surgically or non-surgically. The treatment plan will be determined by the severity of the prolapse, the individual&rsquo;s general health, and their age. Moreover, it depends upon whether or not the women want children in the future. Most people respond well to treatment.

Among the treatment options available are, 
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<h5>Nonsurgical Options</h5>

<ul>
	<li>Exercise</li>
</ul>

Kegel exercises are special exercises that can help strengthen the pelvic floor muscles. In minor cases of uterine prolapse, this may be the only treatment required. To perform Kegel exercises, one must tighten their pelvic muscles as if trying to keep urine from coming out. The muscles are held tight for a few seconds before releasing. This should be repeated up to 10 times. These exercises can be performed whenever and wherever, up to four times a day. 
&nbsp;

<ul>
	<li>Vaginal Pessary</li>
</ul>

This is a silicone doughnut-shaped device that can be inserted into the vagina. It helps to support and stabilize the uterus. A doctor will fit and insert the pessary, which must be cleaned on a regular basis and can be removed prior to sexual intercourse. 
&nbsp;

<ul>
	<li>Vaginal Estrogen</li>
</ul>

This can help improve vaginal tissue regeneration and strength. However, it alone is not sufficient and does not reverse a prolapse. 
&nbsp;

<ul>
	<li>Diet And Lifestyle</li>
</ul>

Changes in the diet and lifestyle may help relieve symptoms, such as constipation, and maintain a healthy weight. An increase in the consumption of fluids and fiber is recommended, along with regular exercise. 
&nbsp;

<h5>Surgical Options</h5>

As per the American Congress of Obstetrics and Gynecologists&#39; screening recommendations, a Pap smear should be conducted prior to surgery<a href="#accordion">[6]</a>. 
&nbsp;

<ul>
	<li>Hysterectomy</li>
</ul>

Uterine prolapse can be treated by surgical removal of the uterus, a procedure called hysterectomy. This can be accomplished via a vaginal (vaginal hysterectomy) or abdominal incision (abdominal hysterectomy). 
&nbsp;

<ul>
	<li>Prolapse Repair Without Hysterectomy</li>
</ul>

This procedure involves repositioning the uterus to its normal position. Uterine suspension can be achieved by reattaching the pelvic ligaments to the lower part of the uterus in order to keep it in place. Depending on the technique used by the doctor, the surgery can be performed through the vagina or through the abdomen. This procedure is mostly reserved for women wishing to have children in the future.&nbsp; 
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Other pelvic organs may also protrude through the vagina with uterovaginal prolapse. These include: 
&nbsp;

<ul>
	<li>Anterior Prolapse - Anterior prolapse is caused by a weakening of connective tissue between the bladder and the vaginal roof. It has the potential to cause the bladder to bulge into the vagina. This is known as a cystocele or a prolapsed bladder 
	.</li>
	<li>Posterior Vaginal Prolapse - It is also called a rectocele. When the connective tissue between the rectum and the vaginal floor is weak, the rectum can bulge into the vagina. This may cause bowel problems. 
	&nbsp;</li>
</ul>

The following factors can increase the risk of uterine prolapse:

<ul>
	<li>Women with BMI&gt;25</li>
	<li>Advancing age</li>
	<li>Having one or more vaginal births</li>
	<li>Being older when having your first child</li>
	<li>Delivering a large baby</li>
	<li>History of pelvic surgery</li>
	<li>Chronic constipation</li>
	<li>Family history of connective tissue disorders</li>
	<li>Family history of uterine prolapse</li>
	<li>Being white or Hispanic</li>
	<li>Smoking</li>
	<li>Connective tissue disorders, such as Marfan syndrome and Ehler&rsquo;s Danlos syndrome 
	&nbsp;</li>
</ul>

The following factors can lower the risk of uterine prolapse: 
&nbsp;

<ul>
	<li>Avoid constipation - It is advised to consume plenty of fluids and fiber-rich foods like fruits, vegetables, beans, and whole grains.</li>
	<li>Heavy lifting should be avoided - Lifting something heavy should be done correctly. This involves using the legs rather than the waist or back.</li>
	<li>Coughing must be controlled - Treatment should be sought for a persistent cough or bronchitis.</li>
	<li>Quit smoking</li>
	<li>Avoid gaining weight - A doctor should be consulted for losing weight and maintaining a healthy weight. 
	&nbsp;</li>
</ul>

Key Points

<ul>
	<li>The uterus is held in place with the help of pelvic muscles and ligaments. Over time, these muscles or ligaments may weaken, causing the uterus to protrude out of the vagina.</li>
	<li>Menopause, aging, multiple vaginal deliveries, chronic constipation, and repeated weight lifting can weaken pelvic floor muscles, causing uterine prolapse.</li>
	<li>Urine leakage, pelvic fullness, vaginal bulging, lower-back pain, and constipation are all common symptoms.</li>
	<li>Uterine prolapse can be treated with lifestyle adjustments, a vaginal suppository, or a hysterectomy.</li>
	<li>Weight loss, a high-fiber diet, quitting smoking, and doing Kegel exercises may help prevent uterine prolapse.</li>
</ul>

[1] Vierhout ME. Diagnosis of uterovaginal prolapse. Ned Tijdschr Geneeskd. 2004;148(49):2432–6.

[2] Korbly NB, Kassis NC, Good MM, Richardson ML, Book NM, Yip S, et al. Patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse. Am J Obstet Gynecol. 2013;209(5):470--e1.

[3] Rogers RG, Meyer I, Smith AL, Ackenbom M, Barden L, Korbly N, et al. Improved body image after uterovaginal prolapse surgery with or without hysterectomy. Int Urogynecol J. 2022;33(1):115–22.