• Uterine Prolapse

    (Pelvic Floor Hernia; Pudendal Hernia; Pelvic Relaxation)

    Definition

    Uterine prolapse occurs when the uterus slips out of place and into the vaginal canal. The severity of uterine prolapse is defined as:
    • First degree (mild)—the cervix (the lower opening of the uterus into the vagina) protrudes into the lower third of the vagina
    • Second degree (moderate)—the cervix protrudes past the vaginal opening
    • Third degree (severe)—the entire uterus protrudes past the vaginal opening
    Uterine Prolapse
    uterine prolapse
    Copyright © Nucleus Medical Media, Inc.

    Causes

    The uterus is normally supported by pelvic connective tissue. It is held in position by special ligaments. Weakening of the tissue causes the uterus to descend into the vaginal canal.

    Risk Factors

    These factors are associated with an increased risk of uterine prolapse:
    • Multiple pregnancies and vaginal deliveries
    • Retroverted uterus (positioned backwards from normal)
    • Age (especially after menopause)
    • Obesity—places additional strain on the supportive muscles of the pelvis
    • Large uterine or ovarian tumors
    • Activities that increase pressure on the abdomen and pelvis, such as:
    • Race: Caucasian

    Symptoms

    Mild cases of uterine prolapse may be symptom-free. Symptoms for more severe cases may include:
    • Sensation of fullness in the vagina
    • Sensation of pulling in the pelvis
    • Pain in the vagina, lower back, or lower abdomen
    • Vaginal discharge
    • Leakage of urine
    • Difficulty voiding urine
    • Frequent urinary tract infections
    • Protrusion of pink tissue from the vagina that may be irritated or itchy

    Diagnosis

    Your doctor will ask about your symptoms and medical history. A physical exam will also be done. This includes a pelvic exam.

    Treatment

    Treatment may include:

    Kegel Exercises

    Kegel exercises may be recommended for mild cases of uterine prolapse. The exercises strengthen the pelvic muscles. They are easy to do and can be done anywhere, at any time. To do Kegel exercises:
    • Squeeze the pelvic muscles as though you are trying to hold back urine.
    • Hold this position for a count of ten, then release slowly.
    • Repeat 10 times, four times daily.

    Medication

    Estrogen may help prevent further weakness of the pelvic floor. Talk to your doctor about the risks and benefits of this form of therapy.
    Your doctor may recommend that you take a stool softener or a laxative to treat constipation.

    Pessary Insertion

    This is a rubbery, doughnut-shaped device. It is inserted by your doctor into the upper part of the vagina. A pessary helps prop up the uterus and bladder. It temporarily prevents sagging into the vagina. It will need to be removed for cleaning. Depending on the type of pessary, you may be able to have sex with the device in place.
    If you have a pessary, follow these guidelines:
    • Periodically remove the device. To remove it, empty your bladder. Then insert two fingers into your vagina. Grab the pessary, slowly turn it, and pull down. Find a good position. Try lying down, squatting over a toilet, or with one leg lifted on a chair or toilet.
    • Clean the device with soap and water as directed. In some cases, you may need to go to your doctor's office to have your device cleaned.
    • To insert it, apply a lubricant (such as KY Jelly) to the tip of the pessary. Open your vagina with one hand. Then, insert the pessary with the other hand. Firmly push up.
    • Report any discomfort to your doctor.

    Surgery

    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. However, it also results in infertility.
    • Vaginal repair—This is usually done with a hysterectomy. The repair can be done with sutures or with insertion of mesh and slings.
    • Colpocleisis—This involves closing the vagina. It is done only in women who are elderly and who are no longer sexually active.

    Lifestyle Changes

    If you smoke, ask your doctor about strategies to quit. Smoking can cause a chronic cough. Coughing can further weaken your pelvic muscles.
    If you have to do a lot of heavy lifting, talk to your doctor about effective lifting techniques. Lifting may also weaken your pelvic muscles.

    Prevention

    To help prevent uterine prolapse:
    • Do Kegel exercises regularly, especially before and after childbirth.
    • Avoid constipation. Straining from constipation stresses the pelvic muscles.
    • Maintain a healthy weight through diet and exercise.
    • Quit smoking.
    • Limit heavy lifting.
    • If you are menopausal, ask your doctor if hormone replacement therapy is a good choice for you.

    RESOURCES

    American Congress of Obstetricians and Gynecologists http://www.acog.org

    Women's Health.gov http://www.womenshealth.gov

    CANADIAN RESOURCES

    The Society of Obstetricians and Gynaecologists of Canada http://www.sogc.org

    Women's Health Matters http://www.womenshealthmatters.ca

    References

    Colpocleisis (LeFort procedure). International Center for Laparoscopic Urogynecology website. Available at: http://www.miklosandmoore.com/lap%5Fproc11.php. Accessed August 10, 2012.

    Pelvic floor prolapse. EBSCO DynaMed website. Available at: https://dynamed.ebscohost.com. Updated July 31, 2012. Accessed August 10, 2012.

    Vaginal pessary. Family Doctor.org website. Available at: http://familydoctor.org/online/famdocen/home/women/reproductive/gynecologic/578.html. Updated August 2010. Accessed August 10, 2012.

    10/21/2008 DynaMed's Systematic Literature Surveillance https://dynamed.ebscohost.com/about/about-us: Shariati A, Maceda JS, Hale DS. High-fiber diet for treatment of constipation in women with pelvic floor disorders. Obstet Gynecol. 2008;111:908-913.

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