What is Uterine Prolapse & How is it Treated?

The uterus or the womb is a female reproductive organ. It is a pear shaped organ, located within the pelvic region in the female body. It is placed between the rectum (posteriorly) and the urinary bladder (anteriorly). Broadly it is divided into 3 parts: Fundus, body and cervix. It is driven by the female sex hormone and it helps in several reproductive functions. This includes gestation, labour, menstruation, implantation, delivery and child birth. The uterus adapts itself with the changes in a woman’s reproductive life. The uterus is supported by the pelvic diaphragm, perineal body and urogenital diaphragm. It is also supported by the peritoneum or the broad ligament of uterus. Excess strain on the uterus can lead to a condition called as uterine prolapse wherein the uterus shifts from its normal position. This can also result in a number of complications and hence knowing it in detail and preventing the condition is very important.

Uterine prolapse is a condition characterised by sagging or slipping of the uterus from its normal position into the vagina. The uterus is held in place by a network of muscles and ligament. Abnormal stretching and weakening of these muscles can cause uterine prolapse. It is also known by the term pelvic floor hernia.

Uterine prolapse are of 2 types: complete and incomplete. Complete uterine prolapse is characterised by complete sagging of the uterus with some tissues being outside the vagina. Incomplete uterine prolapse is partial sagging of the uterus.

Uterine prolapse proceeds in the following stages:

• First Degree Uterine Prolapse: Here the cervix sags into the vagina.
• Second Degree Uterine Prolapse: Here the cervix is at a level just at the opening of the vagina.
• Third Degree Uterine Prolapse: Here the cervix is seen outside the vagina.
• Fourth Degree Uterine Prolapse: This condition is also called as procidentia where the entire uterus is outside the vagina.

In the initial stages, uterine prolapse may go unnoticed as it is asymptomatic in the early stages. Symptoms start developing in the moderate or advanced stages. The most commonly encountered symptoms of uterine prolapse include:

• Persistent discomfort in the pelvic area with a constant feeling of sitting on a ball
• Vaginal bleeding
• Increased vaginal discharge
• Difficulty and pain with sexual intercourse
• Presence of tissue hanging out of the vagina
• Discomfort while walking, low back pain, urinary issues etc.
• Pulling sensation or a feeling of heaviness in the pelvic area
• Constipation and difficulty with urination
• Recurrent bladder infection
• Over a period of time, it can impair the patient’s sexual, bowel and bladder functioning.

There may be other conditions associated with uterine prolapse such as cystocele, enterocele and rectocele.

In mild cases, a treatment may not be required. Pessaries have yielded effective and good results. Surgical management also has good prognosis; however, it may require retreatment and re-surgery again.

The causes of uterine prolapse include:

• Multiple pregnancy or child birth can cause uterine prolapse
• Vaginal delivery or complicated delivery
• Weakness in pelvic muscles can also cause uterine prolapse
• Aging
• Weakness and loss of tonicity of muscles post menopause
• Reduced level of oestrogen
• Increased weight or obesity
• History of surgery in the pelvic region can cause uterine prolapse
• Smoking and alcohol consumption
• Increased abdominal pressure with coughing, straining while defecation, constipation, pelvic tumors, accumulation of fluid in the abdomen can lead to uterine prolapse.

The risk of developing uterine prolapse increases with aging as the estrogen levels decreases with aging in women. With fall in estrogen level, the strength of the pelvic muscles decreases leading to sagging of the uterus. The pelvic muscles may also get damaged with multiple pregnancy and childbirth. The risk also increases with history of multiple vaginal delivery and post menopause. Certain physical activities may also lead to weakness of the pelvic muscles causing uterine prolapse. Other risks factors include conditions such as obesity, chronic constipation and chronic coughing. Uterine prolapse is more common among the Caucasian ethnicity.

Possible complications of uterine prolapse include ulceration and infection of the cervix and also the vaginal wall. There can be recurrent urinary tract infections with other urinary issues. The risk of developing cystocele, rectocele and enterocele increases with the incidence of uterine prolapse. Uterine prolapse also causes constipation and haemorrhoids. In younger women, it poses a threat to child birth and pregnancy.

Diagnosis of uterine prolapse is done by an experienced physician or a gynaecologist. A detailed case history is obtained which is then followed with a physical examination. A pelvic examination is performed by the physician either is laying down or in standing position. A device called as the speculum is inserted through the vagina to visualize the vaginal canal and the uterus. The patient may be asked to push down like she is having a bowel movement to determine the extent of prolapse. Supportive studies may be done for further evaluation such as blood work for determining the estrogen and other hormonal levels. An ultrasound of the pelvic region is often helpful for further evaluation. In some cases, intravenous pyelogram or renal sonogram may be needed.

In certain cases, no active treatment is warranted for uterine prolapse. However, if the condition of uterine prolapse is severe, the following treatment can be considered based on the severity of the condition.

• Non-Surgical Treatments for Uterine Prolapse: The non-surgical treatment for uterine prolapse include –
  • Weight loss to reduce stress on the pelvic structure
  • Avoid activities such as heavy lifting
  • Exercises for strengthening of the pelvic muscles and pelvic floor. This includes Kegel’s exercises
  • Estrogen replacement therapy
  • Wearing a pessary. Pessary is a device that is inserted inside the vagina and placed under the cervix that may help is pushing and stabilizing the uterus and the cervix.
• Surgical Treatments for Uterine Prolapse: This includes uterine suspension or hysterectomy. Uterine suspension is a procedure where the uterus is pushed back into its original position by repairing the pelvic ligaments. Hysterectomy is a procedure where the uterus is removed out of the body through the abdomen or the vagina. Surgery is effective but it is not recommended in younger women who may plan to have a baby in future. Pregnancy and child birth post-surgical repair can lead to pressure over the pelvic ligaments which were repaired earlier and can lead to recurrence of the condition.

Uterine prolapse is a condition which cannot be prevented in certain situation. However, the following may help in reducing the risk of developing this condition:

• Being physically active and exercising on a regular basis
• Following a healthy diet
• Performing Kegel’s exercises
• Estrogen replacement therapy during menopause.

Uterine prolapse is a condition where the uterus moves downwards towards the vagina due to weakness in pelvic muscles and ligaments which hold and support the uterus. Based on the extent of sagging, the condition can be classified into complete and incomplete uterine prolapse and the treatment is determined. It is also more frequent among women who have a history of multiple pregnancies and child birth. Even young women can experience this condition; this can corrected through various treatment methods available. However, they might take caution to strengthen the pelvic muscles before pregnancy; extra caution must be taken during and after pregnancy to prevent recurrence of uterine prolapse.