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Treatment and management of uterine prolapse via conservative and surgical procedures. Conservative management of uterine prolapse is crucial to prevent worsening of prolapse that may require surgical intervention.

Uterine Prolapse is the bulging or slipping of the uterus into the vagina. Sometimes, the prolapse can be so severe that the uterus protrudes out of the vagina. Uterine prolapse can be a very uncomfortable condition affecting women of any age. However, uterine prolapse most commonly affects women who are postmenopausal and who gave birth vaginally at least once [1].

Uterine prolapse is ultimately caused by weakening pelvic muscles that are no longer able to support the uterus. Therefore, any factor that can potentially cause damage to the pelvic muscles can increase the risk of uterine prolapse.

The US Women's Health Initiative conducted a large study among almost 30.000 women with the aim to describe the prevalence of pelvic and uterus prolapse. The study showed some degree of prolapse in staggering 44 percent of women, with 14 percent of those women had uterine prolapse. A follow-up of the study showed a successful outcome: by controlling body mass index and other lifestyle habits uterine prolapse regressed in almost 48 percent of women who enrolled in the study. The study also demonstrated that women of African American showed the lowest risk for uterine prolapse, while women of Hispanic descent had the highest. [2]

Uterine Prolapse Risk Factors

Risk factors that cause weakening of pelvic muscles include the following:

  • Delivering a large baby, complications during labor and birth, or repeated childbirth.
  • The effects of gravity pulling on the pelvic organs.
  • Loss of estrogen that leads the pelvic supporting muscles and tissues to lose tone.
  • Activities that cause repeated straining, leading to raised intra-abdominal pressure over years (constipation, chronic cough in COPD and other chronic lung diseases, smoking)

Identifying the risk factors can help us understand ways to prevent uterine prolapse and also the rationale behind treatment approach for uterine prolapse.

Uterine prolapse can be categorized into different grades based on the level of uterine descent. Treatment recommendations are based on the severity of the prolapse [3].

  • 1st degree: descent of the uterus into the upper vagina
  • 2nd degree: descent of the uterus in the introitus
  • 3rd degree: descent until the cervix is outside the introitus
  • 4th degree: (sometimes referred to as procidentia): the uterus and cervix are entirely outside the introitus.

Clinical Presentations Of Uterine Prolapse

Some of the symptoms of uterine prolapse include pain and discomfort. Dyspareunia (pain during sexual intercourse), and urinary incontinence are common symptoms that typically occur together with uterine prolapse.

Treatment And Management Of Uterine Prolapse

Conservative Approach to Uterine Prolapse [4,5]

1. Preventive management of Uterine prolapse:

  • Avoid engaging in heavy lifting to prevent an increase of intra-abdominal pressure that can worsen uterine prolapse. This approach is recommended for all grades of prolapse. For patients who have mild prolapse and refuse any form of surgery or intervention like a pessary, this approach is highly recommended.
  • Avoid constipation by incorporating high-fiber foods into daily diet and drinking plenty of fluids. Studies have shown that increasing fluid intake is essential to optimizing the effect of fiber in reducing constipation.
  • Controlling persistent cough. Patients with medical conditions associated with chronic cough symptoms, such as COPD in smokers and other chronic lung diseases, are at an increased risk of uterine prolapse due to increase in intra-abdominal pressure.
  • Overweight and obesity are also associated with increased intra-abdominal pressure and contribute to uterine prolapse. Losing weight can, therefore, reduce the risk that your condition will get worse.

2. Pessaries:

  • Pessaries come in different shapes and sizes and can be used temporarily or permanently depending on how comfortable the patient feels. A pessary may require frequent cleaning and can be cumbersome to some patients. While a pessary can be helpful, it is not without complications. Constant insertion and removal can cause irritation of vaginal tissue. This can cause ulcers and affect sexual activities.

3. Exercise that helps strengthen pelvic floor muscles: supporting the uterus via Kegel exercises:

  • Although routine Kegel exercises in patients with uterine prolapse have been shown to improve pelvic floor muscle tone and stress urinary incontinence, the evidence is mainly related to limiting the damage of existing uterine prolapse. There has been no solid evidence from randomized clinical trials that show an improvement of pelvic muscle tone, causing regression of uterine prolapse.

4. Topical estrogen

  • Topical estrogen application in patients with uterine prolapse is an essential adjunct to other conservative management. It is essential to note that estrogen is usually only applied topically [6]. Systemic estrogen therapy is not encouraged solely for uterine prolapse purposes. Due to a need for chronic intake, there is a risk of breast malignancy. The presence of alternative conservative treatment also makes routine use of estrogen pills unsuitable as a primary treatment for uterine prolapse.

5. Surgical approach [7]:

  • Using procedures that repair the supporting pelvic floor muscle or suspension and fixation of the prolapsed uterus via a mesh or synthetic suspension medium.
  • A more radical approach would be a hysterectomy (removal of the uterus).
  • The exact method to use depends on the individual health status, preference for sexual intercourse, decision to get pregnant, severity (degree) of prolapse and results from other treatment modalities.

There are generally two types of surgical approach for patients with uterine prolapse [1]:

  • Obliterative surgery: This procedure narrows or sutures the vagina to create a support for the uterus. This procedure (colpocleisis) is typically done provided the patient is made aware that vaginal sexual intercourse will not be possible. It is more commonly done in patients who are in poor health and have failed other surgical procedures. 
  • Reconstructive surgery: This procedure is aimed at reconstructing and repairing the pelvic floor supporting structures. The surgical route to repair supporting structures can be from the vagina or via the abdomen (laparotomy or laparoscopy). Laparoscopic procedures involve the insertion of a lighted camera-type device. The types of reconstructive surgery include the following:
    • Sacrospinous Fixation: This procedure involves fixation and suspension of the uterus using the body’s own nearby tissues, typically using the uterosacral ligaments. This approach typically only requires procedures via the vagina and do not involve incision from the abdominal side. It prevents side effects such as urinary incontinence and requires less time to recover. These procedures involve the placement of a mesh through the vaginal wall. Usually for women who failed previously mentioned surgical procedures.
    • Sacrohysteropexy: Mesh is attached to the cervix and secured to the sacrum. Mesh may be placed vaginally or via an abdominal incision (open or laparoscopically). Each approach has its pros and cons. A vaginally placed mesh has an increased risk of complications including mesh erosion, infection, and discomfort and should be considered in those who failed other surgery (repair, abdominal surgery risky).
    • Hysterectomy: (removal of the uterus) may be recommended for patients who have completed childbirth and may be followed by surgical repair of the structures supporting pelvic organs (colporrhaphy). In the presence of ulcers in the vagina from pessary use, surgery is delayed until ulcers are healed.[8]
  • Contraindications to surgery:
    • Plan for pregnancy: If you plan future pregnancies, you might not be a good candidate for surgery to repair uterine prolapse. Pregnancy and delivery of a baby put a strain on the supportive tissues of the uterus and can undo the benefits of surgical repair. Also, for women with major medical problems, the risks of surgery might outweigh the benefits. In these instances, pessary use may be your best treatment choice for bothersome symptoms.
    • Health status and comorbid risk factors that make surgeries contraindicated.

Recommended Guidelines For Treatment

  • Asymptomatic mild (first or second degree) uterine prolapse is left alone and may not require treatment. However, conservative preventive measures can be adopted to avoid worsening of the uterine prolapse via Kegel exercise and active efforts to reduce risk factors such as a high fiber diet and quitting smoking to prevent a chronic cough from COPD.
  • Symptomatic mild (first or second degree) uterine prolapse can be managed with a vaginal pessary provided the perineum can support the pessary. Like patients with asymptomatic uterine prolapse, conservative measures are recommended together with the use of a pessary.
  • Severe prolapse (third and fourth degree prolapse) with persistent symptoms usually requires surgical treatment.[3].