Uterine Prolapse

Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken, providing inadequate support for the uterus. The uterus then descends into the vaginal canal.

Uterine prolapse often affects postmenopausal women who’ve had one or more vaginal deliveries. Damage to supportive tissues during pregnancy and childbirth, effects of gravity, loss of oestrogen, and repeated straining over the years all can weaken your pelvic floor and lead to uterine prolapse.

If you have mild uterine prolapse, treatment usually isn’t needed. But if uterine prolapse makes you uncomfortable or disrupts your normal life, you might benefit from treatment. Options include using a supportive device (pessary) inserted into your vagina or having surgery to repair the prolapse.

Symptoms

Uterine prolapse varies in severity. You may have mild uterine prolapse and experience no signs or symptoms. Or you could have moderate to severe uterine prolapse. If that’s the case, you may experience the following:

• Sensation of heaviness or pulling in your pelvis
• Tissue protruding from your vagina
• Urinary difficulties, such as urine leakage or urine retention
• Trouble having a bowel movement
• Low back pain
• Feeling as if you’re sitting on a small ball or as if something is falling out of your vagina
• Sexual concerns, such as sensing looseness in the tone of your vaginal tissue
• Symptoms that are less bothersome in the morning and worsen as the day goes on

Causes

Pregnancy and trauma incurred during childbirth, particularly with large babies or after a difficult labour and delivery, are the main causes of muscle weakness and stretching of supporting tissues leading to uterine prolapse. Loss of muscle tone associated with aging and reduced amounts of circulating oestrogen after menopause also may contribute to uterine prolapse. In rare circumstances, uterine prolapse may be caused by a tumour in the pelvic cavity.

Genetics also may play a role in strength of supporting tissues. Women of Northern European descent have a higher incidence of uterine prolapse than do women of Asian and African descent.

Complications

Possible complications of uterine prolapse include:

• Ulcers. In severe cases of uterine prolapse, part of the vaginal lining may be displaced by the fallen uterus and protrude outside your body, rubbing on underwear. The friction may lead to vaginal sores (ulcers). In rare cases, the sores could become infected.
• Prolapse of other pelvic organs. If you experience uterine prolapse, you might also have prolapse of other pelvic organs, including your bladder and rectum. A prolapsed bladder (cystocele) bulges into the front part of your vagina, which can lead to difficulty in urinating and increased risk of urinary tract infections. Weakness of connective tissue overlying the rectum may result in a prolapsed rectum (rectocele), which may lead to difficulty having bowel movements.

Diagnosis

• Pelvic exam. Your doctor will perform a complete pelvic exam to check for signs of uterine prolapse. You may be examined while lying down and while standing up. Your doctor may ask you to bear down as if having a bowel movement to see how much that affects the degree of prolapse. To check the strength of your pelvic muscles, you may also be instructed to contract them, as if you are stopping the stream of urine.
• Imaging tests. Your doctor may recommend an ultrasound or magnetic resonance imaging (MRI) to further evaluate your condition.

Treatments

Lifestyle changes

Lifestyle changes may be the first step to ease symptoms of uterine prolapse:

• Achieve and maintain a healthy weight, to minimize the effects of being overweight on supportive pelvic structures.
• Perform Kegel exercises, to strengthen pelvic floor muscles.
• Avoid heavy lifting and straining, to reduce abdominal pressure on supportive pelvic structures.

Vaginal pessary

A vaginal pessary fits inside the vagina and is designed to hold the uterus in place. The pessary can be a temporary or permanent form of treatment. Vaginal pessaries come in many shapes and sizes, so your doctor will measure and fit you for a device. Once the pessary is in place, you may have you walk, sit, squat and bear down to make sure that the pessary fits you correctly, doesn’t become dislodged and feels reasonably comfortable.

You may be asked to return a few days after insertion of the pessary to check that it’s still in the correct position.

Drawbacks to these devices:   

• A vaginal pessary may be of little use for a woman with severe uterine prolapse.                                     
• Vaginal pessary can irritate vaginal tissues, possibly to the point of causing sores or ulcerations.
• Women with vaginal Pessaries that aren’t removed frequently for cleaning may report a foul-smelling discharge.                                                                                                                                               
• Pessaries may interfere with sexual intercourse.

Surgery to repair uterine prolapse

If lifestyle changes fail to provide relief from symptoms of uterine prolapse, or if you’d prefer not to use a pessary, surgical repair is an option.     

Surgical repair of uterine prolapse usually requires vaginal hysterectomy, repair of any associated bladder or rectal prolapse and removal of excess vaginal tissue. In some cases, surgical repair may be possible through some synthetic material onto weakened pelvic floor structures to support your pelvic organs (Mesh repair).

Dr Metawa, generally prefer to perform uterine prolapse repair vaginally because vaginal procedures are associated with less pain after surgery, faster healing and a better cosmetic result.

You might not be a good candidate for surgery to repair uterine prolapse if you plan to have more children. Pregnancy and delivery of a baby put strain on the supportive tissues of the uterus and can undo the benefits of surgical repair. Also, for women with major medical problems, anaesthesia for surgery might pose too great a risk. Pessary use may be your best treatment choice for bothersome symptoms in these instances.