Continuing Education Activity

Uterine prolapse is the herniation of the uterus into the vaginal canal due to the weakening of its support structures. This is a common condition that is not life-threatening; however, it causes significant morbidity among women. This activity describes the etiology, evaluation, and treatment of uterine prolapse and explains the role of the interprofessional team in evaluating and treating patients with this condition.

Objectives:

• Describe the etiology of uterine prolapse.
• Identify the presentation of uterine prolapse.
• Review the management considerations for patients with uterine prolapse.

Introduction

Uterine prolapse is the herniation of the uterus from its natural anatomical location into the vaginal canal, through the hymen, or through the introitus of the vagina. This is due to the weakening of its surrounding support structures. Uterine prolapse is one of the multiple conditions that are classified under the broader term of pelvic organ prolapse. This activity describes the etiology, evaluation, and treatment of uterine prolapse and explains the role of healthcare providers in evaluating and treating patients with this condition. 

In its usual state, the uterus rests in the apical compartment of pelvic organs. The uterus and vagina are suspended from the sacrum and lateral pelvic sidewall via the uterosacral and cardinal ligament complexes. The weakening of these ligaments allows for the prolapse of the uterus into the vaginal vault. 

Although uterine prolapse is not inherently life-threatening, it can lead to sexual dysfunction, poor body image, and lower quality of life due to associated bowel or bladder incontinence.

Etiology

The risk factors for uterine prolapse are the same as for other pelvic organ prolapses. The Oxford Family Planning Association study found that pelvic organ prolapse became more likely with successive births.[1] Women with BMI >25 were more likely to experience uterine prolapse than women with BMI in the normal range.[2] Advancing age has been shown to correlate markedly with rates of prolapse.[3] Additional risk factors include connective tissue disorders such as Marfan syndrome and Ehler’s Danlos syndrome.[4]

Epidemiology

It is difficult to distinguish rates of uterine prolapse from pelvic organ prolapse as most studies cohort them together. In a cross-sectional study of 1961 women, pelvic organ prolapse affected 9.7% of women between ages 20-39 and 49.7% of women >80 years old.[5] Therefore, approximately 50% of women in the US can be expected to have some degree of pelvic organ prolapse in advanced age. In less developed countries such as Nepal, greater than 1 million women out of approximately 15 million women have been found to have uterine prolapse, equating to approximately 7% of the Nepalese female population.[6]

History and Physical

The most common complaint of female patients with uterine prolapse is the visualization or sensation of a bulge in the vaginal area, associated with vaginal pressure. Other symptoms include increased urinary urgency or frequency, the sensation of incomplete bladder emptying, and dyspareunia. The symptoms will come on gradually and may worsen over time as the prolapse progresses. The number and degree of symptoms have been shown to increase with worsening severity of prolapse. However, specific symptoms that patients experience do not correlate well with the stage of prolapse, and many patients are completely asymptomatic in the early stages of uterine prolapse.[7]

In addition to symptoms reported by patients, the pelvic exam is crucial to the diagnosis of uterine prolapse due to direct visualization of the prolapsed segment. A pelvic exam should be performed while the patient is at rest and during the Valsalva maneuver. Visualization of the prolapsed segment with respect to the hymen or introitus is used for staging purposes (see below for the POP-Q method of staging).

Evaluation

There are no laboratory studies that have been shown to aid in the diagnosis of uterine prolapse. The major modality for diagnosis of this condition is history given by the patient in combination with pelvic exam findings, as mentioned above. However, prolapsed segments can be seen on multiple imaging modalities such as ultrasound, CT, and MRI and may serve to confirm the diagnosis.[8]

Treatment / Management

Treatment of uterine prolapse is largely dependent on the extent to which a patient is experiencing symptoms. Conservative treatments include pelvic floor muscle training and vaginal pessaries. There are many surgical options for treatment, as well. 

Proper diagnosis and management of uterine prolapse can majorly impact a patient’s quality of life and can have long-term physical and mental health effects. Healthcare practitioners should thoroughly counsel patients with uterine prolapse so they can make informed decisions and choose the treatment that is right for them.

Pelvic floor muscle training is typically taught to patients in association with a physiotherapist. They have been shown to result in subjective improvement in symptoms by patients as well as objective improvement in the POP-Q score by examiners.[9]

Vaginal pessaries are objects often made of silicone that are inserted into the vagina to provide support for the prolapsed pelvic organs. It has been found that vaginal pessary has been a successful solution in 84% of cases of advanced pelvic organ prolapse with mild adverse events in 31% of cases.[10] While pessaries do not reverse the herniation of pelvic organs, they can decrease symptoms and prevent the progression of prolapse. Patients must be fitted for a pessary and commonly try several pessaries before finding the appropriate one. Patients should have empty bowels and bladder when being fitted for a pessary. The examiner should be able to sweep a single finger between the pessary and vaginal walls. The patient should be able to walk, bend, and urinate comfortably without shifting the pessary. Complications of pessary placement include vaginal irritation/ulceration, discharge, pain, bleeding, and odor.[11] 

Regular reassessments of pessary fit should be performed to ensure that the pessary is not rubbing against the walls of the vagina, as this can lead to irritation of the vaginal mucosa and predispose patients to infection. Rare complications include movement of the pessary into the bladder or rectum, causing fistula, fecal impaction, and urosepsis [3]. Patients with dementia or poor follow up are not good candidates for pessary placement as they require frequent cleaning and regular reassessment of position to prevent complications. 

The decision for surgical management should be made after a detailed discussion with the patient regarding the desire for future vaginal intercourse, effects on body image, cultural views, alternative treatments, and potential complications. In-depth descriptions of surgical techniques are beyond the scope of this article. 

Hysterectomy can be performed via a vaginal or transabdominal approach as a treatment for uterine prolapse. It has been found that vaginal approaches are less invasive and offer the opportunity to repair pelvic floor defects. Additional procedures can be performed concomitantly to reduce the risk of prolapse of other pelvic organs. 

Uterine preservation strategies have also been developed to suit those patients that wish to maintain future fertility or desire to retain their uterus. Another patient-centered lifestyle advantage includes a natural transition to menopause. Patients who undergo uterine-sparing treatments require continued follow-up for surveillance of gynecological cancers; therefore uterine preservation is contraindicated in patients that have a history of uterine or cervical pathology. Hysteropexy allows for decreased intraoperative blood loss, shorter operative time, and faster recovery compared to hysterectomy with prolapse repair.[12]

Colpoclesis is an obliterative, noninvasive surgical option that involves suturing the walls of the vagina together to completely occlude the vaginal canal and provide muscular support for the remainder of the pelvic organs. This procedure is ideal for those post-hysterectomy patients that do not desire to have future vaginal intercourse.

Differential Diagnosis

Uterine prolapse is most frequently diagnosed during the physical exam after a discussion with a patient regarding the history of illness. Other possible diagnoses may include urethral prolapse, cystocele, enterocele, rectocele, abscess, and mass of gynecologic origin.

Staging

There are many staging systems that have been used for the classification of pelvic organ prolapse. However, many systems rely on interobserver reliability, require multiple measurements, and make the agreement in stage among different examiners difficult. 

The Pelvic Organ Prolapse Quantification (POP-Q) system was created in 2002.[13] It only takes into account the location of the most distal portion of the prolapsed segment in relation to the hymen, with measurements proximal to hymen denoted by negative numbers and measurements distal to hymen as positive numbers with the hymen being used as a reference point of “0”. Measurements are taken while the patient is performing the Valsalva maneuver. 

• Stage 0: no demonstrable prolapse
• Stage 1: the most distal portion of the prolapsed segment is >1 cm above the level of the hymen
• Stage 2: the most distal portion of the prolapsed segment is >1 cm or less proximal or distal to the hymen
• Stage 3: the most distal portion of the prolapsed segment protrudes >1 cm below the hymen but 2 cm less than the total length of the vagina
• Stage 4: complete eversion of the vagina

Prognosis

Uterine prolapse is not in itself life-threatening. It can cause poor body image, low self-esteem, anxiety, depression, physical discomfort, bowel and bladder incontinence, and sexual limitations.

Complications

The weakness of pelvic floor attachments allowing for prolapse of the apical compartment can additionally allow for prolapse of the anterior and posterior compartments resulting in a compounded cystocele, rectocele, and/or enterocele. These often concomitant conditions can result in urinary incontinence, fecal incontinence, and long term morbidity.

Deterrence and Patient Education

Upon diagnosis, patients should be reassured by their physician that uterine prolapse is a common and well-known condition. Additionally, educating patients regarding potential sequelae and available treatments will allow them to know what to expect and make them active participants in their own care. Patients may feel negative about their condition because they believe it is not "normal", but reassurance in this fashion can help them to see that their problem is not strange or unheard of and can lead to the destigmatization of uterine prolapse.

Enhancing Healthcare Team Outcomes

Patients with uterine prolapse may undergo initial evaluation for their condition in a variety of clinical settings. It is common for patients to not only present to their gynecologist for complaints of vaginal discomfort, but also the emergency department, urgent care centers, or their primary care physician’s office. Once diagnosed, it is imperative to provide the patient with proper follow up for uterine prolapse as progression can lead to long term morbidity. Therefore a patient that is diagnosed with uterine prolapse should be referred to a physician with experience in treating uterine prolapses, such as gynecologists or family practice physicians.

If there is significant morbidity, and the patient is amenable to surgery, they should be referred to a surgeon. In addition to physical discomfort, it is common for patients to experience anxiety, depression, and poor self-esteem as a result of their condition thus, referral for psychotherapy should be offered. Healthcare providers must work together to provide patients with holistic care to minimize the physical and mental morbidity that is typically associated with uterine prolapse.