Uterine Prolapse

Symptoms

• Pelvic pressure or heaviness, a sensation of fullness in the pelvis or vagina.
• Feeling or seeing a bulge or lump protruding from the vagina.
• Low back pain, often described as a dragging sensation.
• Symptoms typically worsen at the end of the day, after prolonged standing, or with physical exertion.
• Urinary symptoms such as stress urinary incontinence (urine leakage with cough or sneeze), urinary frequency or urgency, difficulty starting or completing urination, or needing to change position to urinate.
• Bowel symptoms including constipation, a feeling of incomplete bowel emptying, or needing to press on the vagina or perineum to have a bowel movement.
• Sexual dysfunction, which may include painful intercourse (dyspareunia), decreased sensation, or avoidance of intercourse.
• Recurrent urinary tract infections (UTIs) due to incomplete bladder emptying.
• Vaginal discharge or bleeding from ulceration of exposed tissue.
• Acute urinary retention (inability to pass urine), which is an emergency symptom.
• Severe pain, which is not typical and warrants investigation.
• Significant bleeding from ulcerated tissue, which is an emergency symptom.
• Evidence of renal compromise (kidney problems) in rare, severe cases.

Causes & Risk Factors

• Damage to and weakening of the pelvic floor muscles (levator ani complex) and connective tissues (endopelvic fascia) that support the uterus and other pelvic organs.
• Childbirth-related trauma, including direct muscle injury, nerve damage (pudendal nerve), and fascial tears during vaginal delivery.
• Hormonal changes, particularly postmenopausal estrogen loss, which leads to atrophy and weakening of pelvic tissues.
• Chronic increased intra-abdominal pressure from conditions like obesity, chronic cough, or straining due to constipation, which can overcome pelvic floor support over time.
• Parity and childbirth: The risk increases with each vaginal delivery, especially with prolonged second stage of labor, instrumental delivery (forceps > vacuum), and birth weight of infant >4000g.
• Advancing age: Prevalence increases with age due to weakening connective tissues.
• Menopause: Estrogen deficiency leads to atrophy and weakening of pelvic support structures.
• Obesity/Increased Body Mass Index (BMI): Elevated intra-abdominal pressure strains the pelvic floor. A 5-unit increase in BMI is associated with a 40-75% increased risk.
• Prior pelvic surgery: Hysterectomy is a significant risk factor for subsequent vaginal vault prolapse.
• Genetics/Family History: A positive family history increases risk. Certain collagen-related genetic disorders (e.g., Ehlers-Danlos syndrome) are associated with POP.
• Race/Ethnicity: Higher prevalence in Caucasian and Hispanic women compared to African American women.
• Chronic constipation and straining: Increases intra-abdominal pressure.
• Chronic respiratory conditions: Conditions involving chronic coughing (e.g., COPD, asthma) increase intra-abdominal pressure.
• Heavy lifting/Occupational factors: Repetitive heavy lifting may contribute.
• Cesarean Delivery: Associated with a lower risk of POP compared to vaginal delivery, though not recommended solely for prevention due to other risks.

Diagnosis

• Detailed obstetric history (number of births, mode of delivery, birth weights).
• Surgical history, especially any prior hysterectomy.
• Assessment of symptoms, including specific questions about bulge, urinary, bowel, and sexual symptoms, sometimes using validated questionnaires.
• Review of contributing factors such as constipation, chronic cough, or heavy lifting.
• Standard pelvic examination performed in both lithotomy (lying down) and standing positions, with and without straining (Valsalva maneuver), to assess the maximum extent of prolapse.
• Pelvic Organ Prolapse Quantification (POP-Q) System: An objective, site-specific system used to describe and stage prolapse based on measurements relative to the hymen (Staging 0-IV).
• Assessment of pelvic floor muscle strength using scales like the Modified Oxford Scale.
• Urinalysis to rule out urinary tract infection.
• Renal function tests (creatinine) if there is suspicion of urinary obstruction (e.g., severe prolapse, hydronephrosis on imaging).
• Renal Ultrasound to assess for hydronephrosis in women with severe (Stage III/IV) prolapse or symptoms of urinary retention.
• Dynamic Pelvic MRI or Ultrasound may be used in complex cases or for surgical planning, but is not routinely recommended for initial diagnosis.

Treatment Options

• Watchful waiting (expectant management) for asymptomatic or minimally symptomatic women with mild prolapse (Stage I/II), including education and reassurance.
• Pelvic Floor Muscle Training (PFMT), often supervised, as a first-line treatment for mild to moderate prolapse to improve muscle strength and coordination.
• Weight management for overweight or obese women to reduce intra-abdominal pressure.
• Dietary and fluid management to manage constipation and avoid straining.
• Vaginal Pessaries: Removable devices inserted into the vagina to support the uterus, a first-line treatment for symptomatic prolapse of all stages. Requires regular cleaning and replacement.
• Topical Estrogen: Used in postmenopausal women to improve vaginal tissue health, which can aid pessary tolerance and optimize tissue quality before surgery.
• Surgical intervention for symptomatic women who have failed or declined conservative management.
• Reconstructive procedures (uterine-preserving) such as Sacrohysteropexy (suspension of the uterus to the sacrum using mesh) or Uterosacral/Sacrospinous Hysteropexy (suspension to native ligaments via a vaginal approach).
• Extirpative/Obliterative procedures such as Hysterectomy with Apical Suspension (removal of the uterus combined with suspension of the vaginal vault) or Colpocleisis (surgical closure of the vaginal canal for medically frail, non-sexually active women).
• Referral to a specialist for failure of conservative management, desire for surgery, diagnostic uncertainty, complications like ulceration or urinary retention, or presence of hydronephrosis.

Frequently Asked Questions