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Uterine Prolapse

Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken, providing inadequate support for the uterus. The uterus then descends into the vaginal canal.

The uterus, or womb, is said to be prolapsed when it has moved downward from its normal position. This can happen when the tissues that normally support the uterus - the pelvic floor muscles and ligaments - become stretched and weak. The uterus drops down the vagina closer to the vaginal opening, occasionally even protruding through it. The bladder and bowel can also drop down. This condition is very common, and while it may not necessarily cause symptoms, a prolapsed uterus (also called uterine prolapse) can affect a woman's physical and sexual activity as well as her quality of life.


Symptoms of Uterine Prolapse

  • A feeling as if sitting on a small ball

  • Difficult or painful sexual intercourse

  • Frequent urination or a sudden, urgent need to empty the bladder

  • Low backache

  • Pain during intercouse

  • Protruding of the uterus and cervix through the vaginal opening

  • Repeated bladder infections

  • Sensation of heaviness or pulling in the pelvis

  • Vaginal bleeding or increased vaginal discharge

Many of the symptoms are worse when standing or sitting for long periods of time.


Causes of Uterine Prolapse

The uterus is held in place within the pelvis by a group of muscles and ligaments. As these structures weaken, they become unable to hold the uterus in position, and it begins to sag. There are several factors that may contribute to the weakening of the pelvic muscles, including:

  • Loss of muscle tone as the result of aging

  • Injury during childbirth, especially if the woman has had many babies or large babies (more than 9 pounds)

  • Other factors (Obesity, chronic coughing or straining and chronic constipation all place added tension on the pelvic muscles, and may contribute to the development of uterine prolapse.)


Diagnosis and Tests

Tests or exams to diagnose uterine prolapse include:

  • Pelvic exam - Your doctor will perform a complete pelvic exam to check for signs of uterine prolapse. You may be examined while lying down and while standing up. Your doctor may ask you to bear down as if having a bowel movement to see how much that affects the degree of prolapse. To check the strength of your pelvic muscles, you may also be instructed to contract them, as if you are stopping the stream of urine.

  • Questionnaire - You may fill out a form that helps your doctor assess your degree of prolapse and how much it affects your quality of life. Information gathered also helps guide treatment decisions.

  • Imaging tests - Imaging tests aren't generally needed for uterine prolapse, but they're sometimes helpful in assessing the degree of prolapse. Your doctor may recommend an ultrasound or magnetic resonance imaging (MRI) to further evaluate your condition.


Risk factors

Certain factors may increase your risk of uterine prolapse:

  • One or more pregnancies and vaginal births

  • Giving birth to a large baby

  • Increasing age

  • Frequent heavy lifting

  • Chronic coughing

  • Frequent straining during bowel movements

  • Genetic predisposition to weakness in connective tissue

Some conditions, such as obesity, chronic constipation and chronic obstructive pulmonary disorder (COPD), can place a strain on the muscles and connective tissue in your pelvis and may play a role in the development of uterine prolapse.


Stages of Prolapse

Prolapse of the uterus can happen in stages.

  • In first-degree prolapse the uterus moves down into the vagina, but the lower section of the uterus (the cervix) still remains inside the vagina.

  • In second-degree prolapse the cervix now passes out of the opening of the vagina.

  • In third-degree prolapse the whole of the uterus is outside the vagina (called procidentia).


When to Seek Medical Care

Notify your health care provider if you experience any of the following symptoms:

  • You feel the cervix near the opening of the vaginal canal. Or you suffer persistent discomfort from urinary dribbling or the urge to have a bowel movement (rectal urgency).

  • You may not feel the cervix but just pressure in your vaginal canal and the feeling of something coming out of your vagina.

  • You have continuing low back pain with difficulty in walking, urination, and defecation.

  • Seek medical care immediately if you experience the following:

  • Obstruction or difficulty in urination and/or defecation

  • Complete uterine prolapse (your uterus comes out of your vagina)


When is it not appropriate to treat a Uterine Prolapse? 

Surgical treatment should never be considered in a woman with prolapse who recently had a baby. Tissues damaged during childbirth, once given the chance to heal, often improve. Many women panic when they discover that, in addition to all the other new surprises that come with motherhood, they are unable to make it to the bathroom without losing urine. Before running out and buying diapers in both newborn and adult sizes, it is important not to overreact. A symptomatic prolapse in the first few weeks after delivery, especially in breastfeeding moms who have lower than normal estrogen levels, is not an indication of a long-term problem. There is always improvement after nursing is concluded and hormones return to pre-pregnancy levels. Often, the problem completely resolves.


Treatment of Uterine Prolapse

Treatment is not necessary unless the symptoms are bothersome. Most women seek treatment by the time the uterus drops to the opening of the vagina.

  • Exercise – Special exercises, called Kegel exercises, can help strengthen the pelvic floor muscles. This may be the only treatment needed in mild cases of uterine prolapse. To do Kegel exercises, tighten your pelvic muscles as if you are trying to hold back urine. Hold the muscles tight for a few seconds and then release. Repeat 10 times. You may do these exercises anywhere and at any time (up to four times a day).

  • Vaginal pessary – A pessary is a rubber or plastic doughnut-shaped device that fits around or under the lower part of the uterus (cervix), helping to prop up the uterus and hold it in place. A health care provider will fit and insert the pessary, which must be cleaned frequently and removed before sex.

  • Estrogen replacement therapy (ERT) – Taking estrogen may help to limit further weakness of the muscles and other connective tissues that support the uterus. However, there are some drawbacks to taking estrogen, such as an increased risk of blood clots, gallbladder disease and breast cancer. The decision to use ERT must be made with your doctor after carefully weighing all of the risks and benefits.

  • Lifestyle Change - Weight loss is recommended in women with uterine prolapse who are obese. Heavy lifting or straining should be avoided, because they can worsen symptoms. Coughing can also make symptoms worse. Measures to treat and prevent chronic cough should be tried. If the cough is due to smoking, smoking cessation techniques are recommended.


Uterine Prolapse Surgery

If lifestyle changes fail to provide relief from symptoms of uterine prolapse, or if you'd prefer not to use a pessary, surgical repair is an option. Surgical options for patients with uterine and/or vaginal prolapse is dependent upon:

  • Degree or severity of prolapse

  • Areas specific for prolapse

  • Desire to maintain fertility (maintain uterus)

  • Desire to maintain sexual function

  • Patient's age

  • Patient's overall general health

  • Patients desire and opinion


Surgery may be needed for severe uterine prolapse. These procedures are usually not done until you have finished having children. Options include:

  • Hysterectomy —This is the removal of the uterus through the vagina. This will permanently resolve uterine prolapse, but it also results in infertility.

  • Vaginal repair —This is usually done with a hysterectomy. The repair can be done with sutures and with insertion of mesh or slings.

  • Colpocleisis — This involves closing the vagina. It is done only in women who are elderly and who are no longer sexually active.


Recovering from Surgery

Most repair operations take about an hour and you may need to stay in hospital for three to five days, depending on the type of procedure that you have. With some newer techniques you may be able to go home on the same day as the procedure or on the following day.

While you are in hospital, you may have a drip in your arm to provide fluids and a thin plastic tube called a catheter to drain urine from your bladder. Some gauze will be placed inside your vagina to act as a bandage for the first 24 hours. This may be slightly uncomfortable. Your stitches will usually dissolve on their own after a few weeks. 

For the first few days after your operation you may have some vaginal bleeding which is similar to a period. You may also have some vaginal discharge. This may last three or four weeks. During this time you should use sanitary towels rather than tampons


Prevention of Prolapsed Uterus

You may not be able to prevent uterine prolapse, but the following might help reduce your risk:

  • Always aim to keep your weight in the ideal range for you height, regardless of other health issues you may have.

  • NEVER strain to empty your bowels - always take your time!

  • One incidence of straining can be enough to cause prolapse. Always aim to keep your bowel actions soft. You may need to add some extra fibre into your diet, increase your water intake and do some general physical activity, such as walking, every day.

  • If you have respiratory problems, use your preventer and treatments to limit coughing and sneezing episodes.

  • Always avoid heavy lifting at home and at work. That one move of the freezer or repetitive lifting of young grandchildren may be enough to cause problems.

  • It shouldn’t be necessary to strain to empty your bladder and don’t ‘hover’ over public toilets. Sit down!

  • Be aware if you know that you have an unusually high degree of flexibility or if you have a mother or sister who has had a prolapse.

  • Choose low impact forms of physical activity such as power walking or dancing rather than running. Chose the ‘low impact’ classes at your gym.

  • If you need to stand for long periods of time, use breaks to sit down whenever possible to partially relieve the pressure of gravity. Women who have a prolapse are advised to lie down for up to 30 minutes in the middle of the day. Lying down eliminates gravity.


Prevention Techniques

Some women are at increased risk of uterine prolapse. Simple preventive measures include:

  • Pregnancy – pelvic floor exercises throughout the duration of pregnancy

  • Vaginal childbirth – post-partum pelvic floor exercises

  • Post-menopause – oestrogen cream to boost flagging hormone levels, and pelvic floor exercises

  • Obesity – loss of excess abdominal fat with dietary modifications and regular exercise exercises

  • Other conditions – treat underlying disorders (such as asthma, chronic bronchitis or chronic constipation) in consultation with your doctor

  • Chronic constipation – you need to have big, soft and formed stools. Usually, eating lots of fruit, vegetables and fibre will help. Don’t strain when using your bowels.


Complications

Ulceration and infection of the cervix and vaginal walls may occur in severe cases of uterine prolapse.

Urinary tract infections and other urinary symptoms may occur because of a cystocele. Constipation and hemorrhoids may occur because of a rectocele.

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