Uterine prolapse is one of a constellation of conditions collectively referred to as pelvic organ prolapse in which loss of pelvic support results in the protrusion of pelvic organs (uterus, bladder, or bowel) into the vagina. Uterine prolapse is a common problem for women and may occur concurrently with either bladder prolapse, bowel prolapse, or both.
Support of the pelvic organs is provided by an overlapping system of ligaments, fascia, and muscles. There may be many reasons for loss of this support. A combination of genetic factors, de-nervation or ischemic injury to the musculature, and mechanical failure of the connective tissue can lead to pelvic organ prolapse. Vaginal childbirth appears to be among the greatest risk factors for pelvic organ prolapse; the more children a woman has, the more it is associated with advancing prolapse. Damage to pelvic support tissue during childbirth is likely due to compression and extreme pressure from the fetal head and maternal expulsive efforts.
These high pressure can cause temporary or permanent stretch and tear injury (mechanical injury), as well as is chemic or neurological injury. In addition to vaginal childbirth, other risk factors include pregnancy, advancing age, low estrogen, obesity, chronic constipation, chronic cough, chronic obstructive pulmonary disease, cigarette smoking, and repetitive heavy lifting.
The therapeutic options to treat uterine prolapse are variable and are determined by age, health status, severity of symptoms, and degree of prolapse. No treatment is necessary with mild prolapse, especially if asymptomatic. For more severe degrees of prolapse or if the woman is suffering from symptoms, treatment options include both nonsurgical and surgical therapy.
The primary nonsurgical method involves placing a pessary in the vagina to support the pelvic organs. The traditional surgical treatment includes hysterectomy, then repair of the support mechanism, but uterine preservation with reconstruction of the support tissue is under investigation. Currently, focus is on prevention, such as elective cesarean section and aggressive treatment of chronic conditions that increase intra-abdominal pressure.
Pathophysiology of uterine prolapse
Although the exact etiology of pelvic prolapse has yet to be clearly defined, many risk factors have been proposed in the development of prolapse. Bump and Norton categorized these risk factors into four categories:
A. Predisposing factors are genetics, race, and gender;
B. Inciting factors are pregnancy and delivery, surgery, myopathy, and neuropathy;
C. Promoting factors are obesity, smoking, pulmonary disease, constipation, and recreational or occupational activities that cause chronic increases in intra abdominal pressure; and
D. Decompensating factors are aging, menopause, debilitation, and medications.
Any of the above risk factors can results in attenuation of the uterosacral cardinal ligament complex or breaks along the endo-pelvic fascia. Furthermore, muscle atrophy of the levator ani and coccyges can lead to a wider levator hiatus and a compromise in the excretory function of the bladder and rectum.
The loss of uterine support causes the cervix to move anteriorly, and the uterus then begins to shift posteriorly such that the intra- abdominal pressure is then directed on the anterior surface of the uterus. The uterus becomes progressively more Retroverted until the axis of the uterus is essentially vertical. This option allows uterine prolapse to occur.
Causes of uterine prolapse
Anything that exerts too much weight or pressure on the pelvic floor, or weakens it, will make a woman more likely to develop a prolapse: for example, coughing, heavy lifting, or regular straining on defecation. Frequent pregnancies, especially if the babies are large or if labor is prolonged, will weaken the mother’s pelvic floor, as will obesity in woman.
The supporting tissues seem to need a hormone called estrogen to retain their strength. This is released mainly from a woman’s ovaries. After menopause, the ovaries no longer secrete large amounts of estrogen. The pelvic floor becomes weaker and, as a result, the woman is in greater danger of developing a prolapse at this time.
Symptoms of uterine prolapse
The symptoms a prolapse produces depend on its severity and whether or not the bladder or intestine is involved. Many women have not symptoms; some simply experience a downward pressure in the vagina. Others feel a lump (the uterus) in the vagina or complain of feeling something coming down.
In a few cases, the entire uterus protrudes from the vagina. Obviously, this makes walking and sitting very uncomfortable, but it is very uncommon. If the intestine is involved in the prolapse, the woman may find it difficult to defecate without pushing the uterus back into the vagina. The same is true if the bladder is part of the prolapse. However, a much more common problem is that the woman finds that she leaks urine if she runs, laughs, or coughs. This is called stress incontinence.
A prolapse of the uterus does not cause any vaginal bleeding or pain, but occasionally women may notice a dull backache at the end of the day, which is relieved by lying down.
Prolapse are becoming less common, partly because women have better nutrition and tend to have smaller families, but largely owing to better prenatal preparation.
Prevention of uterine prolapse
It is important to try to prevent prolepses. The muscles of the pelvic floor can be strengthened by kegel exercise: women both at prenatal classes and in the maternity suite are taught these exercises. It is not always easy for a mother of a young baby to find the time to perform the exercises, but it is spare a few minutes daily. Weight loss often helps reduce the risk of prolapse. A high fiber diet will make bowel movements easier. Not partaking in activities that stress pelvic support muscles can also help.