Uterine or Pelvic Organ Prolapse
The gradual increase in life expectancy in developed countries over the past century has produced an increase in demand in the health care system for professionals with knowledge of the disorders of the elderly population.
Pelvic organ prolapse (POP) and urinary incontinence (UI) are common conditions that affect many adult women today. POP is the descent or abnormal herniation of the pelvic organs from their normal sites of union or their normal position in the pelvis.
The uterus is a formation of muscles that must be held in place by the muscles and pelvic organs. In case these muscles weaken, they are not able to support the weight of the uterus, causing a prolapse.
Uterine prolapse occurs in the event that the uterus slips from its position into the vagina or birth canal. It has two variants, incomplete or complete.
An incomplete prolapse occurs in case the uterus only partially sinks in the vagina. A complete prolapse describes a situation in which the uterus falls so far that some tissues rest outside the vagina.
History of the procedure
The uterine prolapse was described for the first time in the papyri of Kahun in approximately 2000 BC Hippocrates described numerous non-surgical treatments for this condition.
In 98 AD, Sorano of Rome described for the first time the elimination of the prolapsed uterus when it became septic.
The first successful vaginal hysterectomy for the cure of uterine prolapse was self-performed by a peasant woman named Faith Raworth, as described by Willouby in 1670.
She was so weakened by the prolapse that she pulled out her cervix and cut the prolapse with a strong knife. She survived the hemorrhage and continued to live the rest of her life weakened by urinary incontinence.
From the beginning of the 19th century until the end of the century, other successful surgical approaches were used to treat this condition.
What are the symptoms of uterine prolapse?
Women who have a minor uterine prolapse may not have any symptoms. Moderate to severe prolapse can cause symptoms, such as:
- Feel as if you were sitting on a ball.
- Vaginal bleeding
- Increased menstrual bleeding
- Problems during sexual intercourse
- See how the uterus or cervix leaves the vagina.
- A feeling of tugging or heaviness in the pelvis.
- Recurrent bladder infections.
If you develop these symptoms, it is important to consult your doctor and receive treatment immediately. Without proper care, the condition can affect the bowel, bladder, and sexual function.
The uterine prolapse is a defect of the apical segment of the vagina and is characterized by the eversion of the vagina with the associated descent of the uterus.
Because the vagina is typically involved, many terms define the condition of “uterovaginal prolapse”. Patients can present with different degrees of descent.
In the most severe cases, the uterus protrudes through the genital hiatus.
It is the most disturbing type of pelvic relaxation, as it is often associated with concomitant vagina defects in the anterior, posterior, and lateral compartments.
Risk factors for a Pelvic Organ Prolapse
The likelihood of a woman having a prolapsed uterus increases as the woman ages and her estrogen levels decrease. Estrogen helps keep the muscles of the pelvis strong.
Damage to the muscles and tissues of the pelvis during pregnancy and delivery also leads to prolapse. Ladies who have had vaginal deliveries and women with menopause are at greater risk.
Any activity that presses the pelvic muscles increases the risk of uterine prolapse. Other elements that can increase your danger for the condition include:
- Chronic cough.
- Chronic constipation
The exact prevalence of uterine prolapse is difficult to determine. However, it is estimated that the risk of 11% of patients puts their lives at risk to correct incontinence or prolapse during surgery.
It was found that more than 50% of the asymptomatic women who present for the annual gynecological examination have at least 2 stages prolapse on the exam.
Pelvic floor defects are created as a result of labor and are caused by the stretching and tearing of the endopelvic fascia and the levator muscles and the perineal body.
Partial paranasal and perineal neuropathies are also associated with delivery. The altered nervous transmission to the pelvic floor muscles may predispose them to a decrease in tone, leading to greater flaccidity and stretching.
Therefore, multiparous women are at particular risk of uterine prolapse. Genital atrophy and hypoestrogenism also play important contributory roles in the pathogenesis of prolapse.
However, the exact mechanisms are not fully understood. Prolapse can also result from pelvic tumors, sacral nerve disorders and diabetic neuropathy.
Other medical conditions that can result in prolapse are those associated with increases in intra-abdominal pressure (eg, obesity, chronic lung disease, smoking, constipation).
Certain rare abnormalities in the connective tissue (collagen), such as Marfan’s disease, have also been linked to genitourinary prolapse.
However, a thorough evaluation and definition of all support defects is critically important because most women with uterine prolapse have multiple defects.
Patients with mild uterine prolapse do not require therapy because they are usually asymptomatic. However, when symptoms occur, many patients initially opt for conservative treatment.
Patients who are surgical candidates or resist surgery may try pessaries for symptom relief. Topical estrogen is an important complement in the conservative treatment of patients with PU.
When surgical repair is chosen for prolapse of the uterus, a clear surgical plan must be formulated. The pelvic surgeon should consider surgical risks, coital activity, and normal vaginal anatomy. The correct functioning must adapt to each patient.
Other questions that must be answered include whether the operation is performed abdominally, vaginally or laparoscopically and whether a hysterectomy should be performed.
A hysterectomy is not necessarily a mandatory part of surgical repair because several types of uterine suspensions can be performed through the abdominal or vaginal route.
However, for practical reasons, the uterus is frequently removed to provide better access to the apical meeting points, particularly the uterosacral, cardinal, sacrospinous, and anterior sacral ligaments.
The primary management of severe uterine prolapse is surgical. For patients in whom conservative treatment has failed, a variety of surgical approaches to correct uterine prolapse are available.
When planning the appropriate approach, the surgeon should consider the operative risk, the coital activity and the anatomy of the vaginal canal. The following list illustrates the variables that should be considered.
Important considerations for non-surgical or surgical decision making
- Medical condition and age.
- Severity of symptoms.
- The patient’s choice (ie, surgery or no surgery).
- Patient’s fitness for surgery.
- Presence of other pelvic conditions that require simultaneous treatment, including urinary or fecal incontinence.
- Presence or absence of urethral hypermobility.
- Presence or absence of pelvic floor neuropathy.
- History of anterior pelvic surgery.
How is Uterine Prolapse diagnosed?
The doctor diagnoses uterine prolapse by evaluating his symptoms and performing a pelvic exam. During this test, you will then insert a device called a speculum that allows you to see inside the vagina and examine the vaginal canal and uterus.
You may be in bed, or your doctor may ask you to stop during this test. You can also ask him to hold on like he is having a bowel movement to determine the degree of prolapse.
Treatment is not always necessary for this condition. If the prolapse is severe, talk to your doctor about which treatment option is right for you.
Non-surgical treatments include:
- Losing weight to remove stress from pelvic structures.
- Avoiding heavy work.
- Do Kegel exercises, which are pelvic floor exercises that help strengthen the vaginal muscles.
- Take estrogen replacement therapy.
- Use a pessary, which is a device inserted into the vagina that fits under the cervix and helps push up and stabilize the uterus and cervix.
Surgical treatments include uterine suspension or hysterectomy:
During uterine suspension, the surgeon places the uterus back into its original position by coupling pelvic ligaments or using surgical materials. During a hysterectomy, the surgeon removes the uterus from the body through the abdomen or vagina.
Surgery is often effective, but it is not recommended for women who plan to have children in the future. Pregnancy and childbirth can put immense strain on the pelvic muscles, which can undo surgical repairs of the uterus.
How can you prevent?
Uterine prolapse may not be preventable in every situation. However, you can do things to reduce your risk, including:
- Do regular physical exercise.
- Keep a healthy weight.
- Practice Kegel exercises.
- Use of estrogen replacement therapy during menopause.
Contraindications for the surgical correction of uterine prolapse are based on the patient’s comorbidities and their ability to tolerate surgery. Patients with mild uterine prolapse (Stage I) do not require surgery because they are usually asymptomatic.
Patients who contemplate a future pregnancy may delay surgery, however, they may require surgery to correct the recurrent prolapse caused by pregnancy.
Therefore, for pre-menopausal women contemplating a future pregnancy, it is necessary to perform adequate preoperative counseling regarding the time of surgery to eliminate uterine prolapse, before or after completing labor.
Contraindications for uterine preservation surgery include any uterine abnormality, uterine fibroids, a history of current or recurrent cervical dysplasia.
But also, postmenopausal vaginal bleeding, abnormal menstrual bleeding, hereditary colonic cancer, familial cancer, current or past history of selective modulators of estrogen receptors.
Knowledge of the anatomy of the pelvis is essential to understanding prolapse. The teleological reasoning helps in the understanding of uterine prolapse.
The pelvic floor evolved into primates, particularly humans, who, as bipeds, spend most of their waking hours in the upright position.
As its name suggests, the pelvic floor is the lowest limit on which all pelvic and abdominal contents rest.
The pelvic floor is composed of a sling of various muscle groups (elevators) and ligaments (endopelvic fascia) connected at the perimeter to the 360 ° ovoid bone pelvis.
In addition, the knowledge of the biaxial orientation of the vagina and the uterus is fundamental to understand the anatomical and functional relationships and for the correct surgical restoration of the pelvic supports, as well as functionally recover all the reproductive organs.
Postoperatively, the patient is instructed to avoid any exercise or heavy lifting and to abstain from intercourse for 6 weeks after discharge from the hospital. After the 6-week follow-up visit, the patient is instructed to progressively return to their usual daily activities.
Emphasize the need to avoid the causes of increased intra-abdominal pressure, such as constipation, weightlifting and smoking, for at least 3 months. This facilitates proper healing and avoids surgical failures.
For postmenopausal patients with significant vaginal atrophy, the authors usually recommend a short-term treatment of vaginal estrogen therapy (unless contraindicated) in order to maintain the integrity of the pelvic tissues and maximize surgical success.
If conservative treatment is used, depending on the symptoms, patients should be instructed to remove and clean the pessary and / or shower weekly with a vinegar solution to reduce the chances of complications.