Prolapse refers to a collapse, descent, or other change in the position of the uterus in relation to surrounding structures in the pelvis.
The pelvis contains many soft tissue structures vital to normal body functions, supported primarily by the diaphragms, layers of muscles, fibrous coverings called fasciae, and various ligaments and tendons. These soft tissues of the pelvis derive their ultimate support from the bony pelvis. Prolapse of the uterus may be one of three types, depending on severity:
- First-degree prolapse occurs when the uterus sags downward into the upper vagina.
- Second-degree prolapse occurs when the cervix is at or near the outside of the vagina.
- Third-degree prolapse (sometimes referred to as total prolapse) occurs when the entire uterus is outside the vagina.
Prolapse may occur when the pelvic support system, the muscles and ligaments that normally hold the uterus in place, become stretched or slack, most often due to a long or difficult childbirth or multiple childbirths. During pregnancy there is a natural softening of pelvic tissues, and a laxity develops within the pelvic support system. The increasing weight of the uterus continuously bears down upon the pelvic diaphragm and may predispose the patient to subsequent pelvic relaxation. Chronic increases in intra-abdominal pressure, such as may be associated with obesity, abdominal or pelvic tumors, ascites, or repetitive downward thrusts of intra-abdominal pressure that may be due to coughing, constipation, or occupational stresses, can cause funneling of a weakened pelvic diaphragm and pelvic organ prolapse. Pelvic relaxation is rarely a problem in young women. It is much more likely to become symptomatic and to progress during the post-reproductive years. This can be due to estrogen deprivation and to atrophy of the pelvic diaphragm and the pelvic support system. Hormone replacement therapy sometimes improves the integrity of the pelvic tissue and may slow the progression of pelvic organ prolapse.
The major symptoms may be a feeling of heaviness, fullness or "falling out" in the vaginal area. The patient may also complain of backache or inability to control urination. In some cases where the cervix and uterus are low in the vaginal canal, the cervix may be seen protruding, giving the patient the impression that a tumor is bulging out of her vagina. It is not uncommon for the cervix or vaginal epithelium to become damaged or ulcerated, in which case the patient may report pain or vaginal bleeding. There is often discharge from the cervix and vagina when secondary infection occurs. Patients may also complain of difficulty walking comfortably.
The diagnosis of pelvic organ prolapse may be suggested by the patient's history, but must be documented by the physical examination. A pelvic examination is performed to determine which organs are involved, the extent to which each descends, and the location of any pelvic support defects. This is usually done with and then without a full bladder. In order to determine the true involvement of the pelvic organ prolapse, the examination may have to be performed several times and sometimes in different positions. Protrusions involving the front part of the vaginal wall affect the bladder and the bladder's continence mechanism. Those involving the back part of the vaginal wall affect the rectum and may cause problems with bowel movements. If the prolapse is due to disease or swelling, the underlying cause or disorder must first be controlled or eliminated before the uterus can be returned to its original position and secured there.
Non-Surgical Treatment In mild cases, exercises to strengthen the muscles of the pelvic floor may be helpful. An obese patient may be encouraged to lose weight in order to reduce pressure on the pelvic organs. Patients should be encouraged not to wear constricting clothing (such as girdles), and they should avoid lifting heavy objects. A pessary (a plastic ring) may be placed within the vagina to support the pelvic organs for patients who may not be suitable for or do not desire surgery. There are many different types and sizes of supportive pessaries available. Before these devices can be inserted, they require that the uterus and cervix be positioned in their usual position in the pelvis. Acute pelvic infections and fixed uterine retroversion are contraindications to the use of a vaginal pessary. All pessaries should be removed, cleaned, and reinserted at regular intervals. Unfortunately, they sometimes cause pelvic discomfort, vaginal discharge, vaginal ulceration, and bleeding. Such complications may require at least temporary discontinuance of use, as recommended by your physician. Surgical Treatment There are several different methods of surgical repair depending on the degree of prolapse, the condition of the pelvic support system, and which other structures are involved. In a post-menopausal woman, estrogen replacement for at least 30 days in the form of systemic estrogen or vaginal estrogen cream may help improve the vitality of the vaginal epithelium, the cervix, and the vasculature (blood supply) of these organs, making the operative procedure and the healing process more efficient. Ulcers should also be healed to avoid risk of infection and breakdown of the surgical repair. There are many options for surgical repair, including those that use the abdominal route, the vaginal route, or a combination of both.