UTERINE PROLAPSE

UTERINE PROLAPSE - Eric L. Jenison, MD; Michael P. Hopkins, MD, MEd; Jennifer L. Savitski, MD
BASICS
DESCRIPTION
• Uterine prolapse occurs when the integrity of supporting structures is lost. This allows the uterus to descend into the vagina. In advanced cases, complete protrusion with inversion of the vagina occurs.
• Before menopause, the degree and severity of prolapse are usually related to the number of children and the difficulty of childbirth. After menopause, atrophy and loss of tissue integrity lead to further prolapse.
• System(s) Affected: Gastrointestinal; Renal/Urologic; Reproductive
• Synonym(s): Uterine prolapse; Genital prolapse; Genital relaxation; Uterine descensus; Total or partial procidentia; Dropped uterus
ALERT
Geriatric Considerations
This is largely a disease of aging, and incidence will be much higher as the median age of the population increases.
Pediatric Considerations
Prolapse in newborns has been reported, but it is rare and usually associated with congenital disorders and neuropathies.
GENERAL PREVENTION
• Kegel exercises will increase the strength of the pelvic diaphragm muscles and may provide some pelvic support.
• Weight loss and proper management of conditions that would increase abdominal pressure help to prevent prolapse.
EPIDEMIOLOGY
• Predominant age: Perimenopausal and postmenopausal women
• Predominant sex: Female only
Prevalence
~30-50% of women experience some degree of prolapse.
RISK FACTORS
• Childbirth, particularly multiple parity
• Advancing age
• White race
• Various connective tissue and neurogenic disorders
• Conditions resulting in increased intra-abdominal pressure (e.g., obesity, abdominal or pelvic tumors, pulmonary disease with chronic coughing, chronic constipation)
• Occupations requiring heavy lifting
Genetics
• Common among white people
• Less common among Asians and African Americans and particularly uncommon in South African Bantus and in West Africans
ETIOLOGY
• Advancing age and vaginal childbirth are the most important factors.
• Incidence of prolapse increases with frequency and difficulty of vaginal deliveries; 2% of prolapse occurs in nulliparous women.
• Although this disorder in large part results from the distention and distortion of supporting tissues with vaginal childbirth, pregnancy regardless of mode of delivery may contribute to prolapse.
• Other causes of prolapse include connective tissue disorders with lax tissue (e.g., Marfan syndrome), neurogenic disorders (e.g., multiple sclerosis), cloacal agenesis, chronic constipation, pelvic tumors or ascites, and chronic coughing resulting from chronic lung disease.
• Patients who have undergone radical vulvectomy with loss of the external supporting structures have a higher rate of prolapse.
ASSOCIATED CONDITIONS
Cystocele, rectocele, enterocele, and vaginal vault prolapse are often associated with uterine prolapse.


DIAGNOSIS
SIGNS AND SYMPTOMS
• Often asymptomatic
• Pelvic pressure and low back pain
• Bulging sensation in vagina or at introitus.
• Dyspareunia
• Difficulty with urination or defecation
History
• Number of pregnancies, mode of deliveries, episiotomies, extent and repair of vaginal/perineal lacerations.
• Previous pelvic surgery
• Congenital abnormalities
• Medical conditions that chronically increase intra-abdominal pressure (e.g., COPD)
Physical Exam
Diagnosis is confirmed by pelvic examination. With coughing and straining, the cervix will prolapse toward introitus or beyond. The patient may need to be examined standing as well as lying down to confirm diagnosis.
TESTS
Lab
• Evaluation of renal function to rule out ureteral obstruction
• Urinalysis to rule out urinary tract infection
Imaging
• Intravenous pyelogram to rule out ureteral obstruction in complete uterine prolapse (optional)
• Pelvic ultrasound or CT scan to rule out other pelvic pathology, if suspected (optional)
Diagnostic Procedures/Surgery
• If surgical correction is planned, urodynamic studies should be performed to evaluate for potential urinary incontinence masked by the prolapse. (1)[B]
• If ulceration or bleeding is present, Pap smears and appropriate cervical and endometrial biopsies should be done to rule out concomitant malignancies.
Pathological Findings
• Hyperkeratosis of the cervical and vaginal tissues occurs with prolapse beyond the introitus due to chronic irritation and drying. As the irritation becomes more pronounced, bleeding and ulceration occur.
• Degrees of prolapse
- 1st-degree prolapse: To the ischial spine
- 2nd-degree prolapse: To the introitus
- 3rd-degree prolapse: Just beyond the introitus
- 4th-degree prolapse: Complete uterine and vaginal inversion involving bladder and bowel
TREATMENT
STABILIZATION
• Outpatient
• Inpatient when surgery is necessary
GENERAL MEASURES
• Treatment depends on multiple variables including the severity of prolapse, age, sexual activity, associated pelvic pathology, and desire for future fertility.
• Treatment of 1st- and 2nd-degree prolapse is expectant unless patient is symptomatic.
• Conservative therapies include estrogen replacement (see below), pessary use, and physical therapy (see below).
• Pessaries are indicated for women who are unfit for or decline surgery. Proper fitting and maintenance are required. (2)[C]
• Pessaries may also be used in the preoperative evaluation of prolapse. (2)[C]
• Surgery is indicated for women who fail conservative therapies and/or desire definitive treatment. (1)[B]
Diet
Avoid constipation.
Activity
• Heavy lifting, sexual intercourse, and other activities that increase intra-abdominal pressure should be avoided for 6-12 weeks after surgical correction.
• Maintain ideal body weight.
SPECIAL THERAPY
Physical Therapy
Biofeedback and pelvic muscle training (Kegels) may be an option for women with mild prolapse and/or those wishing conservative therapy. (2)[C]
MEDICATION (DRUGS)
• Estrogen replacement therapy (oral or vaginal cream) can increase blood supply to vaginal tissues and supporting tissue strength. This is especially important in postmenopausal women using pessaries or undergoing reconstructive pelvic surgery. (1,3)[B]
• Contraindications: Those associated with the use of estrogen. Refer to the manufacturer's literature.
• Precautions: If estrogen therapy is used and the uterus is present, progesterone should be prescribed to offset the potential for endometrial carcinoma.
• Significant possible interactions: Refer to the manufacturer's literature.
SURGERY
• Surgically able patients without additional pelvic pathology: Vaginal hysterectomy with or without enterocele, cystocele, rectocele, paravaginal repair, culdoplasty, and vaginal vault suspension depending on coexisting pelvic organ prolapse. (1)[B]
• If vault suspension is necessary in conjunction with hysterectomy, abdominal approach has decreased risk of recurrent prolapse compared to vaginal approach. (4)[A]
• Uterine suspension is an option for patients who desire to maintain reproductive function. (1)[B]
• Older women who are not sexually active can be treated with a colpocleisis or vaginal obliteration procedure.
FOLLOW-UP
PROGNOSIS
• It is expected that the incidence and severity of prolapse will increase as patients age.
• Although surgical correction is usually successful initially, reoperation rate is ~29%. (1)
COMPLICATIONS
• Ureteral obstruction and renal failure
• Incarceration of bowel herniations
• Pessary use may not always be effective, and may cause discomfort, ulcers, and infection.
PATIENT MONITORING
• Expectant management is appropriate, with periodic follow-up examinations.
• If a pessary is placed, it should be removed, cleaned, and replaced every 3-6 months. (2)[C]
REFERENCES
1. Thakar R, Stanton S. Regular review: Management of genital prolapse. BMJ. 2002;324:1258-1262.
2. Trowbridge ER, Fenner DE. Conservative management of pelvic organ prolapse. Clin Obstet Gynecol. 2005;48(3):668-681.
3. Drutz HP, Alnaif B. Surgical management of pelvic organ prolapse and stress urinary incontinence. Clin Obstet Gynecol. 1998;41(3):786-793.
4. Maher C, et al. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2006;1.