Uterine Prolapse – Causes, Symptoms, Treatment

Uterine prolapse is when the uterus descends toward or into the vagina. It happens when the pelvic floor muscles and ligaments become weak and are no longer able to support the uterus.

The uterus is a muscular ‘sac’ that stretches and bends with the demands of pregnancy and childbirth. It sits inside the pelvic cavity and is held in place by a combination of the other organs in the pelvis and the pelvic floor muscles and ligaments. When the pelvic floor muscles are weak they loosen and stretch out of place, no longer acting as support for the pelvic organs. In the case of uterine prolapse, this can allow the uterus to droop and bulge into the vaginal space as an incomplete uterine prolapse. If untreated, the uterus can drop so low that it uncomfortably, and often painfully, protrudes outside the vagina as a complete uterine prolapse, also known as procidentia.

As with most medical problems, it’s important not to put off treatment. Allowing your prolapse to go untreated for a long period of time leads to weakened pelvic muscles and damage to associated nerves – increasing the risk of the prolapse reoccurring. So avoid unnecessary delays and speak to your doctor if you have any concerns.

Stage Uterine Prolapse

Uterine prolapse can be incomplete or complete, depending on how far it has fallen into the vagina, away from its natural position:

• Incomplete uterine prolapse – The uterus has partially dropped into the vagina and the tissue isn’t visible from the outside.
• Complete uterine prolapse – When the uterus drops down into the vagina sufficiently that some tissue of the uterus is visible on the outside of the vagina. This is also known as procidentia.

Uterine prolapse can cause other organs within the pelvic cavity to prolapse, as it adds weight to the already weakened pelvic floor muscles:

• An anterior vaginal prolapse or cystocele – This is a type of bladder prolapse when the bladder bulges into the vagina from the front (anterior) vaginal wall. This generally happens when tissues between the vagina and the bladder are weak.
• Posterior vaginal prolapse or rectocele – A rectocele prolapse occurs when the tissues at the back (posterior) of the vagina, between the vagina and the rectum, weaken. The rectum is forced downwards and bulges into the vagina.

Both of these secondary prolapses can be of varying degrees of severity, remaining within the vagina, or protruding from it on the outside.

A very severe uterine prolapse can also cause part of the vaginal wall to collapse on itself, and end up protruding from the vagina. It isn’t often that a uterine prolapse occurs on its own, it’s usually as part of another organ prolapsing into it and taking the vaginal walls with it.

Causes of Uterine Prolapse

Here is a list of the possible causes of a prolapsed uterus. Having these does not mean you will definitely go on to develop a prolapsed uterus, they are just risk factors:

• Pregnancy – During pregnancy the body changes in many ways. The uterus can stretch well beyond its rebound ability, leaving it loose. And the extra weight of the baby on the pelvic floor can weaken the muscles.
• Childbirth – Again, around 50% of women who give birth vaginally will experience some level of prolapse. A large baby or a difficult birth where you’ve had to push a lot or forceps were used may increase your risk. More than one birth also increases your risk of experiencing a vaginal prolapse. Mothers of four babies, all delivered vaginally, are at 12 times greater risk than women who have not given birth vaginally.
• Menopause – The change in hormones you experience during this time of your life, particularly the drop in estrogen, can cause your pelvic floor muscles to weaken. Effects can be worsened by the general loss of muscle tone associated with aging.
• Persistent coughing – Constant heavy coughing can add pressure to the pelvic floor. If you smoke and have a persistent smoker’s cough or if you have a lung condition that results in a cough, such as asthma or bronchitis, then you could be at a higher risk.
• Constipation – Continued straining to pass a stool will put extra pressure on the pelvic floor and could cause it to weaken.
• Bodyweight – Being overweight or obese can increase your chances of suffering a prolapse due to the weight on your pelvic area.
• Heavy lifting – Repeated and incorrect heavy lifting puts extra pressure on your pelvic floor.
• Strenuous activity – Heavy, high impact exercises such as running or plyometric training (jump training) can cause the pelvic floor muscles to weaken.
• Previous pelvic surgeries – A hysterectomy or previous vaginal prolapse surgery can weaken the pelvic floor muscles, and is likely to be part of the cause of any future pelvic organ prolapses.
• Genetics – A family history of prolapse can suggest you are at a higher risk.

Symptoms of Uterine Prolapse

If you’re developing a uterine prolapse, then you may notice an odd feeling inside your vagina, like there’s something inside that is falling out. At that stage, it likely that you also experience a number of the other symptoms listed below, and as a prolapse advances, you will likely experience even more of the following complaints:

• a feeling of pressure inside the pelvic area, especially when sitting down
• a dragging feeling inside the pelvic area, and/or feeling that something is going to fall out
• feeling like you are sitting on a small ball
• vaginal bleeding, outside of your menstruation
• noticeable tissue protruding from the vagina, that may also be painful and bleed
• discomfort or pain during sex
• loss of feeling or tightness when having sex
• pelvic or lower back pain
• persistent or frequent urinary tract and bladder infections (cystitis)
• urinary stress incontinence – the inability to hold in urine when you cough, sneeze, laugh, exercise or lift heavy objects
• difficulty or pain passing urine
• difficulty or pain having a bowel movement – constipation and a feeling of not having fully emptied your bowel
• pain or difficulty walking normally
• symptoms that get progressively worse as the day goes on

With the number of different prolapse conditions and their close proximity to each other in the body, it can be difficult to know which symptoms point to which condition. Visiting your doctor to get a diagnosis is important and can help you decide which course of treatment is best for you.

Diagnosis of Uterine Prolapse

• Plain Films – Plain films are usually not appropriate for the evaluation of pelvic prolapse.[rx] Barium defecography is in use at some places as a part of the assessment of pelvic floor dysfunctions, however, with the advent of newer and non-ionizing radiation imaging techniques like MR defecography, barium defecography has become largely obsolete.
• Computed Tomography – Due to concern for radiation exposure and availability of MRI, which provides a better soft-tissue resolution, computed tomography (CT) is usually not appropriate for the evaluation of pelvic prolapse; however, one should look on the sagittal abdomen and pelvis images for a hint of pelvic floor prolapse by drawing a pubococcygeal line and see for overt prolapse and then recommend a dynamic MRI pelvis (MR Defecogram) for further evaluation.[rx]
• Magnetic Resonance – Dynamic magnetic resonance imaging (MRI) provides an accurate assessment of pelvic prolapse. MRI provides a better anatomic detail compared to the transtibial ultrasound and is also useful as a preoperative tool. Furthermore, the MRI examination does not require bowel preparation and does not involve sensitive pelvic exposure. Despite its benefits, the MRI is not widely available, expensive, and contraindicated in patients with MRI incompatible devices or hardware.
• Ultrasonography – Translabial ultrasound is a relatively inexpensive way of evaluating pelvic prolapse and is widely available. Besides, the ultrasound does not produce ionizing radiation and allows dynamic evaluation of the pelvic floor. However, the diagnostic quality of the ultrasound exam depends on the sonographer’s skill level and the interpreting radiologist’s familiarity with the examination.
• Nuclear Medicine – Nuclear medicine studies are usually not appropriate for the evaluation of pelvic prolapse.[rx]
• Angiography – Angiography is usually not appropriate for the evaluation of pelvic prolapse.[rx]

Treatment of  Uterine Prolapse

Non-Pharmacological

• Kegel exercises – These are also known as pelvic floor exercises. You can do them quickly and easily, at any time of day as no one will know you’re doing them. They help to strengthen the pelvic floor muscles. You can make them even more effective by using an electronic pelvic toner.
• Maintain your weight – Making sure you stick to a healthy weight will put less pressure on your pelvic floor muscles, giving you more chance of keeping them strong. The National Institute for Heath and Care Excellence (NICE) recommends keeping your BMI under 30.
• Avoiding constipation – Eating a high fiber diet of fruits, vegetables, and wholegrain cereals will help your bowels stay regular, as will drinking plenty of water.
• Avoid straining on the toilet – Straining on the toilet puts unnecessary pressure on the pelvic floor muscles. Using a toilet stool when you pass a bowel movement will help avoid straining as it puts your body in the optimum position for fully emptying your bowels.
• Lift heavyweights (and children) safely – Lifting correctly will make all the difference to not only your back but your pelvic area too. The National Health Service (NHS) suggest holding the load close to your waist and avoid bending your back.
• Avoid too much high impact exercise – High impact exercises are great for overall health. But if you’re worried about uterine prolapse, then gentler, lower impact exercise will be better for you.
• Treat that cough – Persistent heavy coughing can cause a weakening in the pelvic floor muscles that may not become apparent straight away. Get medical help for a cough that lasts longer than a week.

If you have the beginnings of uterine prolapse, then adopting the preventative steps listed above may be all you need to treat it, or at least stop it from getting worse. Targeted pelvic floor muscle exercises are a popular choice for seeing a quick and effective improvement in your prolapse.

Your doctor may also discuss the following treatments, depending on your personal circumstances:

• Hormone replacement therapy – If you’re menopausal, your doctor may suggest estrogen replacement therapy or creams to help top up your estrogen levels which in turn may help strengthen your pelvic floor. This can be in the form of cream you apply to your vagina or a tablet that you would insert. This treatment is often recommended for mild uterine prolapses.
• Uterine prolapse pessaries – A vaginal pessary will help to better support even severe uterine prolapses. It’s a small device, usually made from silicone, that is placed inside the vagina to help support the vaginal wall and prevent other pelvic organs from collapsing further into it. Different shapes and sizes of vaginal pessaries suit different shapes and sizes of women. Your doctor can help you find the right one and help you change the pessary every four to six months. This is commonly the favored treatment for those unable to undergo surgery due to other medical conditions or those wishing to have children in the future. They can also be used whilst you strengthen your pelvic floor.

Surgery

Surgery is considered as an option only when symptoms are severe and cannot be treated through other means, as there is a risk of further damage in the case of complications. Non-surgical treatments are also preferred when future children are desired, which can reduce the success of previous surgical procedures. If you are advised to have a surgical intervention for your uterine prolapse, there are several surgical procedures currently available and may be completed in conjunction to repair all prolapses you are experiencing:

• Uterine suspension surgery – Your surgeon will move your uterus back to where it should be, then use either your own pelvic ligaments or a biological or synthetic mesh lining for additional support. Using a mesh lining is currently only recommended within the context of research, as current evidence into the safety of the procedure is insufficient. This surgery is usually completed through the vagina but maybe through the abdomen to avoid damaging the vagina.
• Laparoscopic suture hysteropexy (ligament) surgery – Through a laparoscopy (keyhole surgery), the damaged pelvic (uterosacral) ligaments can be repaired by connecting the strong top and bottom of the ligaments, reducing the pressure on the weakened middle. This surgery preserves the uterus and allows the patient to become pregnant. This is a relatively new procedure, therefore there are not yet any long term studies into its success.
• Vaginal hysteropexy (ligament) surgery – As above, this surgery looks at connecting the strong sections of the ligaments. It is completed through the vagina and into the abdomen – therefore leaves no scarring. This method of accessing the abdomen is favoured where other prolapses are due to be repaired at the same time.
• Hysterectomy – This is the complete removal of the uterus and is often performed in a uterine prolapse emergency or when a uterine prolapse is severe. This can be performed through the vagina, or through the abdomen. The vaginal walls are then attached to healthy ligaments as support for the other organs. This surgery prevents any future pregnancies and is often followed by further pelvic organ prolapses as the uterus is no longer there to support the other pelvic organs, so it is important to consider other options before choosing a hysterectomy.

References

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