Uterine Prolapse

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Chapter 122 Uterine Prolapse

INTRODUCTION

Description: Uterine prolapse is loss of the normal support mechanism resulting in descent of the uterus down the vaginal canal. In the extreme, this may result in the uterus descending beyond the vulva to a position outside the body (procidentia).

Prevalence: Some degree of uterine descent is common in parous women.

Predominant Age: Late reproductive and beyond; incidence increases with the loss of estrogen.

Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Loss of normal structural support as a result of trauma (childbirth), surgery, chronic intra-abdominal pressure elevation (such as obesity, chronic cough, or heavy lifting), or intrinsic weakness. Most common sites of injury are the cardinal and uterosacral ligaments and the levator ani muscles that form the pelvic floor, which may relax or rupture. Rarely, increased intra-abdominal pressure from a pelvic mass or ascites may weaken pelvic support and result in prolapse. Injury to or neuropathy of the S₁ to S₄ nerve roots may also result in decreased muscle tone and pelvic relaxation.

Risk Factors: Birth trauma, chronic intra-abdominal pressure elevation (such as obesity, chronic cough, or heavy lifting), intrinsic tissue weakness, or atrophic changes resulting from estrogen loss.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Pelvic pressure or heaviness (a sense of “falling out”)

• Mass or protrusion at or beyond the vaginal entrance

• New onset or paradoxical resolution of urinary incontinence

• Drying, thickening, chronic inflammation, and ulceration of the exposed tissues, which may result in bleeding, discharge, or odor

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Weight reduction, modification of activity (lifting), addressing factors such as chronic cough.

Specific Measures: Minimal prolapse does not require therapy. For those with more severe prolapse or symptoms, pessary therapy (Smith-Hodge, doughnut, cube, or inflatable ball), surgical repair, or hysterectomy (with colporrhaphy) should be considered. Postmenopausal women should receive estrogen and progesterone replacement therapy for at least 30 days before pessary fitting or surgical repair.

Diet: No specific dietary changes indicated.

Activity: No restriction.

Patient Education: Reassurance: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP012 (Pelvic Support Problems), AP081 (Urinary Incontinence).

Drug(s) of Choice

Estrogen and progesterone therapy (for postmenopausal patients) improves tissue tone and healing and is often prescribed before surgical repair or as an adjunct to pessary therapy.

Contraindications: Estrogen therapy should not be used if undiagnosed vaginal bleeding is present.

FOLLOW-UP

Patient Monitoring: Normal health maintenance. If a pessary is used, frequent follow-up (both initially and long term) is required. (Most recommend monthly checks of the vaginal epithelium for lesions and to reassess pessary placement and fit.)

Prevention/Avoidance: Maintenance of normal weight, avoidance of known (modifiable) risk factors.

Possible Complications: Thickening or ulceration of the vaginal tissues and cervix, urinary incontinence, kinking of the ureters, obstipation.

Expected Outcome: Uterine descent tends to worsen with time. If uncorrected, complete prolapse is associated with vaginal and cervical skin changes, ulceration, and bleeding.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy, though these conditions rarely coexist.

ICD-9-CM Codes: 618.1 (codes 618.2 to 618.4 are used when cystocele, urethrocele, or rectocele is present).

Cundiff GW, Amundsen CL, Bent AE, et al. The PESSRI study: Symptom relief outcomes of a randomized crossover trial of the ring and Gellhorn pessaries. Am J Obstet Gynecol. 2007;196:405.e1.

Swift S, Woodman P, O’Boyle A, et al. Pelvic Organ Support Study (POSST): The distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol. 2005;192:795.

Thomas AG, Brodman ML, Dottino PR, et al. Manchester procedure vs vaginal hysterectomy for uterine prolapse: a comparison. J Reprod Med. 1995;40:299.

Altman D, Falconer C. Perioperative morbidity using transvaginal mesh in pelvic organ prolapse repair. Obstet Gynecol. 2007;109:303.

American College of Obstetricians and Gynecologists. Urinary incontinence in women. ACOG Practice Bulletin 63. Obstet Gynecol. 2005;105:1533.

American College of Obstetricians and Gynecologists. Pelvic organ prolapse. ACOG Practice Bulletin 79. Obstet Gynecol. 2007;109:461.

Beecham CT. Classification of vaginal relaxation. Am J Obstet Gynecol. 1980;136:957.

Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:10.

DeLancey JO. The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment. Am J Obstet Gynecol. 2005;192:1488.

Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet. 2007;369:1027.

Lentz GM. Anatomic defects of the abdominal wall and pelvic floor. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:513.

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