Uterine prolapse

Generality

Uterine prolapse occurs in a woman when the uterus detaches from its seat and penetrates into the vagina. This happens due to a weakening of the pelvic floor, which supports and holds the pelvic organs in position. The symptoms of prolapse are numerous: the patient feels mainly pain and the sensation of a visceral movement.

The choice of therapy is based on the degree of severity of uterine prolapse. In milder cases, it is sufficient to implement simple control measures, in order to keep the situation stable.

In more serious cases, on the other hand, more invasive remedies should be used, including surgery.

Preventive measures, as usual, are fundamental.

Short anatomical reference: the pelvic floor

To understand what happens in the uterine prolapse, it is appropriate to make a brief anatomical review, concerning the pelvic floor.

The pelvic floor is the set of muscles, ligaments and connective tissue, located at the base of the abdominal cavity, in the so-called pelvic area . These structures cover a fundamental and indispensable function: they serve to support and maintain in their positions the urethra, the bladder, the intestine and, in women, the uterus.

If the pelvic floor weakens and no longer offers the same support, disorders of a different nature, both physical and sexual, may appear.

THE POSITION OF THE UTERUS

The uterus is the female genital organ, which serves to welcome the fetus during a pregnancy. It is found in the small pelvis, precisely between bladder (anteriorly), rectal intestine (posteriorly), intestinal loops (superiorly) and vagina (inferiorly).

The shape of the uterus resembles that of an upturned pear, in which two areas can be identified: a wider portion, called the uterus body, and a narrower portion, called the cervix or uterine cervix . The uterine cervix protrudes, to a minimum extent, inside the vagina. This ledge is also called tench snout .

What is uterine prolapse

The uterine prolapse, or prolapse of the uterus, is the sliding down of the uterus and its consequent protrusion inside the vagina. This occurs due to a weakening of the pelvic floor support structures.

Uterine prolapse can occur in more or less severe forms. The greater the protrusion of the uterus within the vagina, the greater the severity of the prolapse. A first classification involves three stages:

1st degree uterine prolapse, or mild . Characteristics: only a small portion of the uterus is lowered into the vagina.
2nd or moderate uterine prolapse . Characteristics: the uterus reaches the opening of the vagina.
3rd degree uterine prolapse, or severe . Characteristics: the pelvic floor has weakened so much, that the uterus can even escape from the vagina.

A second, simpler classification establishes the existence of only two stages:

Incomplete uterine prolapse, if the uterus is partially lowered into the vagina.
Complete uterine prolapse, if the uterus has slipped completely from its original position, until it exits from the vagina.

NB: the term prolapse, in medicine, has a precise meaning. It indicates the lowering, or the release, of an organ from its natural cavity, due to a relaxation or injury of the tissues surrounding the organ itself.

Epidemiology

Uterine prolapse can occur in women of any age. However, postmenopausal women and those who have had more vaginal parts are more affected. The reason will be explained in the chapter dedicated to causes and risk factors.

Causes of uterine prolapse

The causes of a uterine prolapse are different:

Vaginal delivery or complications (long labor)
Large fetus
Chronic bronchitis
Incorrect lifting of heavy objects
Obesity
Constipation

What exactly does these events determine within the pelvic floor?

PATHOPHYSIOLOGY

When one of the above conditions occurs, the structures of the pelvic floor (muscles, ligaments and connective tissue) undergo a stretch, or a trauma, which weakens and tears them. It is unlikely that the occurrence of the single circumstance (for example, a birth) causes a uterine prolapse; however, the probability increases, when events repeat themselves or overlap one another, acting in concert.

RISK FACTORS

Several risk factors have been observed.

The first, in importance, is the number of vaginal parts : a woman who has given birth several times is more prone to uterine prolapse. This is caused by the sum of the contractions of several troubles.
The second factor concerns aging . A woman, after menopause, produces less estrogen and this weakens the pelvic floor musculature.
The third factor is related to previous surgery on the pelvic organs. Women, who have been subjected to it, have a weaker pelvic floor.
The fourth factor is genetic . Some women suffer from congenital diseases (that is, present since birth) of collagen (collagenopathies), which make the pelvic floor more loose and subject to tearing.
The last factor is related to chronic obstructive pulmonary disease . In fact, it causes chronic cough, which is one of the main causes of uterus prolapse.

NB: collagen is a fundamental protein of connective tissue.

Symptoms, signs and complications

The prolapses of the 1st degree uterus are often free of symptoms and obvious signs, so much so that they can go unnoticed. However, the symptoms and signs of a moderate-severe uterine prolapse are clear. In these situations, the patient complains:

Sensation of heaviness in the pelvis
More or less evident leakage of the uterus from the vagina
Urine leakage
Urinary retention and subsequent bladder infection
Abdominal pain
Sensation of a bowel movement when sitting down
Pain during sexual intercourse
Bleeding and increased vaginal secretion

WHEN TO REFER TO THE SPECIALIST?

The lack of explicit symptoms, in 1st degree prolapses, leads to underestimate the problem. However, the situation can progressively degenerate. It is therefore recommended to consult a gynecologist as soon as the symptoms become more evident. This is to prevent any complications and surgical operations.

COMPLICATIONS AND ASSOCIATED DISEASES

The prolapse of the uterus includes two complications, which can occur for different reasons. They consist of vaginal ulcers and prolapse of other pelvic organs.

The vaginal ulcer occurs in cases of more severe prolapse, in which the leaked uterus irritates, by rubbing, the walls of the vagina. Although rarely, the ulcer can also become infected.
The prolapses of other pelvic organs, such as the bladder ( cystocele ) or the rectal portion of the intestine ( rectocele ), occur, instead, due to the fragility of the pelvic floor. Often, these disorders are considered to be associated pathologies, since the triggering causes are the same.

Diagnosis

The diagnosis of uterine prolapse is performed with a pelvic exam . Furthermore, for further information, the gynecologist can refer patients to an evaluation questionnaire, concerning the symptoms tested, and to instrumental examinations ( ultrasound and nuclear magnetic resonance ).

PELVIC EXAMINATION

Pelvic examination is essential to determine if it is a prolapse of the uterus or another pelvic organ. Using a speculum and with the patient lying down, the gynecologist examines the vaginal canal and the position of the uterus. Moreover, he asks the sufferer if, sitting down, he feels a bowel movement. This detail is important to understand if it is a serious uterine prolapse.

The specialist also evaluates the muscular strength of the pelvic floor. This analysis consists in making the pelvic muscles contract to the patient, as if to block the flow of urine; if the answer is negative, it means that the pelvic floor has weakened.

ASSESSMENT QUESTIONNAIRE

Using a specific questionnaire, the specialist further investigates the data collected with the pelvic exam. The questions concern the degree of pain felt and how much this conditions the lives of the patients.

ECOGRAPHY AND NUCLEAR MAGNETIC RESONANCE

Ultrasonography and magnetic resonance imaging are two examinations performed very rarely, since they are not necessary. Indeed, the pelvic exam is more than exhaustive.

However, the doctor may advise you to carry them out if doubts remain about the degree of severity of uterine prolapse or if prolapses of other pelvic organs are suspected.

Therapy

The choice of the most appropriate therapy for a uterine prolapse depends mainly on:

Severity of the case under consideration
Prolapse of other pelvic organs, particularly bladder and rectum

In mild cases, no specific treatment is required; vice versa, in the most serious cases, therapeutic intervention becomes indispensable. In such circumstances, a non-surgical treatment is initially chosen and the results are observed; if no benefits emerge, surgery is required, particularly if the patient is prone to complications.

TREATMENT OF THE UTERINE PROLASSO OF 1 DEGREE

A 1st degree uterine prolapse does not require special treatment. The specialist recommends, only, to put into practice some countermeasures, able to keep the disorder stable or, in the most fortunate cases, to make him regress.

The main remedy recommended is the constant practice of Kegel exercises, which serve to strengthen the pelvic floor muscles.

The other remedies consist in the reduction of body weight, in the case of overweight women, and in avoiding the lifting of heavy objects.

The implementation of these behaviors is fundamental if the situation is to be kept constant. Otherwise, the chances of a worsening of uterine prolapse increase considerably.

NON-SURGICAL TREATMENT OF MODERATE-SERIOUS CASES

If the prolapse is moderate to severe, the two main non-surgical remedies are pessary and estrogen- based hormone therapy (indicated for menopausal women).

Non-surgical remedies	What is it and what is it for?
The pessary	It is a ring of rubber, or plastic, which must be inserted into the vagina. It serves to block the prolapse of the pelvic organs, which dominate the vagina. The specialist teaches the patient how to clean it and how to apply it. There are pessaries of different sizes, depending on the needs.
Estrogens	Menopause causes a reduction in estrogen production. Their decline weakens the pelvic musculature. Therefore, with the assumption of synthetic estrogens, the pelvic floor muscles are strengthened in order to block the prolapse of the pelvic organs.

These therapeutic countermeasures serve to alleviate the symptoms, but their use is temporary. Very often, in fact, they are used for a defined time, waiting for the resolving surgery, because they could have side effects. For example, prolonged use of the pessary irritates the inner cavity of the vagina.

It is advised, even in these circumstances, to practice Kegel exercises, control body weight and avoid lifting heavy loads.

SURGICAL TREATMENT

Surgery is indispensable when the pain felt by the patient is unbearable and signs of prolapse evident; or when prolapses of other pelvic organs are found (bladder and rectum).

There are two possible intervention procedures:

Hysterectomy
Suspension of the uterus

Hysterectomy is the removal of the uterus. It can be done in three different ways. A first method involves incision of the abdomen. A second method is achieved through the vaginal route. Finally, the third and final approach takes place through minimally invasive laparoscopic procedures.

The suspension of the uterus, on the other hand, consists in bringing the uterus back to its original position and reinforcing the ligaments of the weakened pelvic floor through a tissue transplant or synthetic material.

The choice of one procedure, rather than the other, depends on the case under examination and on the experience of the surgeon in the practice of the different operating techniques.

SURGERY AND PREGNANCY

Clearly, a woman with uterine prolapse who wishes to have children or who is pregnant cannot undergo hysterectomy. In these situations, pending a pregnancy or the latter being completed, the use of the pessary is used.

Prognosis and prevention

The prognosis of a uterine prolapse depends on each case.

For 1st grade prolapses, the prognosis is positive, provided the situation is not underestimated and the Kegel exercises are practiced consistently. Neglect can be decisive in aggravating the symptoms and the painful sensation.

The circumstances are different, however, with regard to severe prolapses (2nd and 3rd degree). Under these conditions, the pessary is a temporary remedy, while surgery becomes a necessity. The intervention, however, like any operation, is not without complications: in fact, if the suspension of the uterus is applied, it is possible that another future prolapse may occur; while, if the uterus is removed, the patient (if age still allows it) must renounce having children for years to come. In light of this, the prognosis is certainly worse, compared to non-severe uterine prolapses.