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Uterine Prolapse

Uterus Prolapse


Presentation

A female with uterine prolapse will present with the following symptoms:

Performing any strenuous activity such as straining, squatting, exercising, lifting heavy weights, sitting for a long time or long-term constipation may worsen the symptoms.

Anorexia
  • Abstract A 74-year-old woman was admitted to our emergency room complaining of general weakness and anorexia that started 20 days earlier. She denied other underlying diseases that might have provoked chronic renal disease.[ncbi.nlm.nih.gov]
Rales
  • Her physical examination revealed a blood pressure of 140/90 mmHg, pulse rate of 80 beats/min, body temperature of 37.8  C, as well as uterine prolapse with infection and erosion on the surface of the uterus, crepitating rales in the basal segments of[ncbi.nlm.nih.gov]
Constipation
  • Stool softeners may be used for constipation, if present. A uterine prolapse is descent or dropping of the uterus through the cervix into the vagina.[symptoma.com]
  • Specialty Gynecology Symptoms Vaginal fullness, pain with sex, trouble urinating, urinary incontinence, constipation [1] Usual onset Gradual [2] Types 1st to 4th degree [1] Risk factors Pregnancy, childbirth, obesity, constipation, chronic cough [3] Diagnostic[en.wikipedia.org]
  • CASE: A 40-year-old woman, gravida 4, para 2, with an intrauterine gestation of 19 weeks presented to the emergency room complaining of inability to void for the previous 12 hours and difficulty voiding and constipation for the previous 6 weeks.[ncbi.nlm.nih.gov]
  • USH women weighed less, were younger, and more constipated with larger rectoceles. Levator parameters did not differ Romanzi et al. (Neurourol Urodyn 18(6):603-612, 1999).[ncbi.nlm.nih.gov]
  • Other factors that can increase your risk for the condition include: obesity chronic cough chronic constipation Your doctor can diagnose uterine prolapse by evaluating your symptoms and performing a pelvic exam .[healthline.com]
Localized Scleroderma
  • Localized scleroderma was noticed on her thigh and lower back. We discuss the possible role of scleroderma and ovarian failure on the occurrence of uterine prolapse in light of the literature.[ncbi.nlm.nih.gov]
Low Back Pain
  • Symptoms can include: Sensation of heaviness or pulling in your pelvis A bulge protruding from your vagina Pain with sexual activity Difficulty inserting tampons Low back pain The three main factors that contribute to the development of Uterine Prolapse[austinurogynecology.com]
  • According to Mayo Clinic , symptoms include: Sensation of heaviness or pulling in your pelvis Tissue protruding from your vagina Urinary problems, such as urine leakage or urine retention Trouble having a bowel movement Low back pain Feeling as if you[monthlygift.com]
  • You have continuing low back pain with difficulty in walking, urinating, and moving your bowels.[webmd.com]
Urinary Incontinence
  • Among them, 18 had urodynamic stress incontinence, 30 had occult stress urinary incontinence, and six had mixed urinary incontinence.[ncbi.nlm.nih.gov]
  • A questionnaire survey on pelvic floor distress inventory and pelvic organ prolapse/urinary incontinence and sexual function was implemented.[ncbi.nlm.nih.gov]
  • We will work with NHS England to produce a shared decision making tool, to be available when our guideline on urinary incontinence and pelvic organ prolapse publishes early next year.[nice.org.uk]
  • Urinary incontinence is common. The descending pelvic organs may intermittently obstruct urine flow, causing urinary retention and overflow incontinence and masking stress incontinence.[merckmanuals.com]
Pelvic Pain
  • Vaginal bleeding, abnormal discharge, dyspareunia, urinary retention, and pelvic pain are possible complications of therapy. Uterine prolapse is the loss of anatomical support for the uterus, typically surrounding the apex of the vagina.[bestpractice.bmj.com]
  • Find your relief Interstitial Cystitis Up to 12 million Americans suffer from interstitial cystitis (IC), often called painful bladder syndrome and generally considered a source of pelvic pain.[hackensackumc.org]
  • pain abdominal or lower back pain dyspareunia recurrent UTIs urinary incontinence symptoms worsened by prolonged standing or walking added pressure on muscles by gravity Physical exam inspection protrusion of tissue at opening of vagina (complete prolapse[step2.medbullets.com]
  • When to Call a Doctor Call a doctor if you develop pelvic pain or discomfort or unusual pelvic protrusion.[healthcommunities.com]
  • SYMPTOMS: • feeling of something coming down per vag • Backache or pelvic pain • Menstrual irregularities • Dyspareunia • Difficulty in urination, incomplete evacuation, urgency, frequency, dysuria. • Bowel symptoms: difficulty in defeacation, 11.[slideshare.net]
Dyspareunia
  • Symptoms include sensation of vaginal bulging, pelvic pressure, urinary frequency or incontinence, incomplete bladder emptying, defecatory dysfunction, and dyspareunia. Diagnosis is made by vaginal examination during resting and straining.[bestpractice.bmj.com]
  • Secondary outcomes were: operative time, blood loss, visceral injury, voiding dysfunction, duration of catheterization, length of hospital stay, mesh exposure, dyspareunia, malignant neoplasia and quality of life.[ncbi.nlm.nih.gov]
  • In 2nd- or 3rd-degree uterine prolapse, fullness, pressure, dyspareunia, and a sensation of organs falling out are common. Lower back pain may develop. Incomplete emptying of the bladder and constipation are possible.[merckmanuals.com]
  • […] occurrence not reported). 2.4.4 The Specialist Advisers considered theoretical adverse events to include osteomyelitis, bleeding from local major vessels, bladder or bowel perforation, urinary incontinence, bowel obstruction, mesh infection or rejection, and dyspareunia[web.archive.org]
  • Mechanism incomplete prolapse uterus drops part way down into the vagina creates a bulge complete prolapse uterus slips down and protrudes out of the vagina Presentation Symptoms heaviness or pressure in pelvis pelvic pain abdominal or lower back pain dyspareunia[step2.medbullets.com]
Urinary Stress Incontinence
  • For more serious cases, common symptoms include: tissue protruding from your vaginal opening pressure, heaviness or a pulling sensation in the pelvis or vagina urinary leakage or urinary stress incontinence problems with sexual intercourse, such as sensing[beaumont.org]
  • Urinary Problems Urinary stress incontinence is a common problem with relaxation of pelvic supports and uterine prolapse. When the bladder descends, the urethra and its sphincter sags into the vagina.[pregnancy.lovetoknow.com]
  • Also, there is a 25% incidence of postoperative urinary stress incontinence caused by induced fusion of the anterior and posterior vaginal walls and flattening of the posterior urethrovesical angle.[emedicine.medscape.com]
  • Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med . 2006;354(15):1557-156616611949 PubMed Google Scholar Crossref 11. Brubaker L, Nygaard I, Richter HE, et al; Pelvic Floor Disorders Network.[doi.org]
Dysuria
  • SYMPTOMS: • feeling of something coming down per vag • Backache or pelvic pain • Menstrual irregularities • Dyspareunia • Difficulty in urination, incomplete evacuation, urgency, frequency, dysuria. • Bowel symptoms: difficulty in defeacation, 11.[slideshare.net]
  • Figures and Tables - Analysis 1.17 Comparison 1 PFMT versus no treatment, Outcome 17 number with dysuria. Figures and Tables - Analysis 1.18 Comparison 1 PFMT versus no treatment, Outcome 18 number with stress incontinence.[doi.org]

Workup

Workup consists of a detailed history and physical examination. The physical examination should be thorough and should help in staging the condition.

Laboratory tests

In uncomplicated cases, laboratory tests are generally not required. In complicated cases, such as cases of uterine prolapse along with infection or ulceration, the following tests may be conducted:

  • Complete blood count
  • Cervical swab and culture
  • Urinalysis
  • Pregnancy testing
  • Pap smear
  • Biopsy

Imaging 

  • Pelvic Ultrasound: It is the imaging study of choice.
  • MRI: It may be conducted to stage the prolapse.

Test results

A physical examination and history are sufficient to form a diagnosis. In complicated cases, the results of laboratory tests and imaging studies may provide further insight in making a definitive diagnosis.

Pyuria
  • Case 1, she was admitted due to fever with pyuria. Uterine prolapse was noted by incidental finding. Urine culture showed Escherichia coli. She received total vaginal hysterectomy, which corrected the obstruction and bladder dysfunction.[ncbi.nlm.nih.gov]

Treatment

Vaginal hysterectomy

Often, a vaginal hysterectomy is used to correct uterine prolapse [7]. The procedure can be accompanied by a sacrocolpopexy, in which the apex of the vagina is attached to the sacrum [8].

Pessary insertion

A 2013 Cochrane review found some evidence that pessaries are effective in around 60% of women [9].

Post-surgery care

Generally, women should avoid heavy lifting after surgery and avoid sexual intercourse for 6-8 weeks [10]. If the prolapse remains corrected and the patient conceives, an elective cesarean section may be advisable [10]. 

Prognosis

It has been traditionally assumed that if left untreated, uterine prolapse will gradually worsen. There is some evidence, however, that this may not be the case, and that spontaneous remission may happen [6].

With treatment, prognosis is good, but since the defect is primarily due to physiological weakening of muscles and ligaments, relapse may occur. However, it is possible to preserve fertility in younger patients with adequate treatment.

Complications

Complications of uterine prolapse may include exposure or friction of the vaginal epithelial lining leading to vaginal sores and ulceration. Uterine prolapse and its accompanying symptoms such as urinary incontinence may lead to recurrent lower urinary tract infections. Hemorrhage may also occur in some cases. A uterine prolapse due to weakened muscles may become complicated by accompanying prolapse of other pelvic organs, such as the urinary bladder, resulting in a cystocele, or the rectum, resulting in a rectocele.

Etiology

The primary cause of uterine prolapse is pregnancy. Multiple factors associated with pregnancy such as trauma or complications during labor, malnutrition of the mother or weight of the fetus may result in undue stress on and damage of the muscles and ligaments supporting the uterus. Some of the damaged muscles and ligaments will never fully regain their strength and elasticity [4].

Other causes [5] that may lead to a uterine prolapse include:
lack of estrogen after menopause, old age, conditions that put a strain on the pelvic muscles such as chronic cough and obesity, pelvic tumor and long term constipation.

Epidemiology

Incidence

Pelvic organ prolapse affects millions of women; approximately 200,000 inpatient surgical procedures for prolapse are performed annually in the United States [1]. Approximately half of all women olde than 50 years complain of symptomatic prolapse [2].

Age

Chances of developing uterine prolapse is in direct proportion to increase in age. 11% to 19% of women will undergo surgery for pelvic organ prolapse (POP) or incontinence by age 80 to 85 years, and 30% of these women will require an additional pelvic organ prolapse or in continence surgery [3].

Race

Studies reveal that uterine prolapse is much more common in white and Hispanic women. 

Sex distribution
Age distribution

Pathophysiology

Uterine prolapse is due to weakening of uterosacral and other supporting ligaments of the uterus and pelvic floor muscles. The condition can be staged according to severity of the symptoms.

Staging

According to the Pelvic Organ Prolapse Quantification, uterine prolapse can be staged as per the following criteria:

  • Stage 0: No prolapse
  • Stage 1: Most distal portion of the prolapsed organ is >1 cm above the plane of the hymen
  • Stage 2: Most distal portion of the prolapsed organ is less than or equal to 1 cm above or below the plane of the hymen.
  • Stage 3: Most distal portion of the prolapsed organ is >1 cm below the plane of the hymen.
  • Stage 4: Total eversion of the prolapsed organ. 

Prevention

Uterine prolapse, or prolapse of any other pelvic organ for that matter, may be prevented by performing regular Kegel exercises and maintaining a healthy life style. Hormone replacement therapy for post-menopausal women may be helpful. Weight should be controlled and a high fibre diet should be implemented. Stool softeners may be used for constipation, if present.

Summary

A uterine prolapse is descent or dropping of the uterus through the cervix into the vagina. It is due to weakening of the various muscles and ligaments supporting the uterus, most important of which are the uterosacral ligaments. Others include the round ligament, broad ligament and ovarian ligaments.

Patient Information

Definition

Uterine prolapse is descent of the uterus (womb) into the vagina.

Cause

It is primarily due to weakening of the supporting muscles of the uterus during pregnancy. It may also occur due to normal aging, long term constipation, occupational hazards particularly in old age like sitting or standing for a long time, etc.

Symptoms

Symptoms include backache accompanied with a feeling of pressure in the lower pelvis or vagina. There may be increased vaginal discharge or bleeding. Urinary tract infections may occur and there may be urinary leakage and a constant feeling of a full-bladder.

Treatment

Treatment can be conservative in terms of exercise and lifestyle modifications, or it can be surgical. Treatment is optional and spends upon the severity of the symptoms. Mild cases may not require treatment at all.

Prevention

By performing regular Kegel exercises and taking a high-fibre diet, a uterine prolapse may be prevented. Hormone replacement therapy (HRT) may help. Obese women should reduce weight and maintain a healthy life style. 

References

Article

  1. Jones KA, Shepherd JP, Oliphant SS, et al. Trends in inpatient prolapse procedures in the United States, 1979-2006. Am J Obstet Gynecol 2010;202:501.e1.
  2.  Swift SE. The distribution of pelvic organ support in a population of subjects seen for routine gynecologic health care. Am J Obstet Gynecol. Aug 2000;183(2):277-85.
  3. Olsen AL, Smith VJ, Bergstrom JO, et el. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501.
  4. Tsikouras P, Dafopoulos A, Vrachnis N, Iliodromiti Z, Bouchlariotou S, Pinidis P, et al. Uterine prolapse in pregnancy: risk factors, complications and management. J Matern Fetal Neonatal Med. July 9 2013
  5. Lentz GM. Anatomic defects of the abdominal wall and pelvic floor: abdominal and Inguinal hernias, cystocele, urethrocele, enterocele, rectocele, uterine and vaginal prolapse, and rectal incontinence: diagnosis and management. In: Lentz GM, Lobo RA, Gershenson DM, Katz VL, eds. Comprehensive Gynecology. 6th ed. Philadelphia, Pa: Moseby Elsevier, 2012:chap 20.
  6. Handa VL, Garrett E, Hendrix S, et al. Progression and remission of pelvic organ prolapse: a longitudinal study of menopausal women. Am J Obstet Gynecol. 2004 Jan;190(1):27-32.
  7. Winters JC, Togamai JM, Chermansky CJ. Vaginal and Abdominal Reconstructive Surgery for Pelvic Organ Prolapse. In: Wein AJ, ed. Campbell-Walsh Urology. 10th ed. Philadelphia, Pa: Saunders Elsevier, 2011:chap 72.
  8. NICE Interventional Procedure Guidance IPG284: Sacrocolpopexy with hysterectomy using mesh for uterine prolapse repair by the National Institute for Health and Care Excellence. Issued: Jan 2009.
  9. Bugge C, Adams EJ, Gopinath D, et al. Pessaries (mechanical devices) for pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013 Feb 28;2:CD004010. doi 10.1002/14651858. CD004010.pub3.
  10. Thakar R, Santon S. Management of genital prolapse. BMJ. 2002 May 24;324(7348):1258-62. 

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Last updated: 2018-06-22 07:42