Uterus

Uterine Prolapse

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Uterine Prolapse, Genital Prolapse, Uterine Descensus, Pelvic Organ Prolapse, Cystocele, Uterocele, Rectocele

  • Definition
  1. Pelvic organs (Bladder, Uterus, vagina) protrudes out of vaginal canal
    1. Herniation of anterior vaginal wall (2-3 fold more common than posterior and apical prolapse)
    2. Herniation of posterior vaginal wall
    3. Herniation of vaginal apex (Uterus, Cervix, vaginal cuff)
  2. Pelvic Organ Prolapse replaces older terms (Cystocele, Uterocele, Rectocele)
    1. Reflects uncertainty on examination of which organs are actually prolapsing
  • Epidemiology
  1. Prevalence increases with age and peaks at 5% for those over age 60 years old
  • Pathophysiology
  1. Levator ani Muscle
    1. Normally supports the vagina from prolapse in the face of increased intraabdominal pressure
    2. When levator ani loses tone, vaginal opening widens, allows pelvic organs to prolapse
    3. Levator ani is injured in 21-36% of vaginal deliveries in Nulliparous women
      1. Dietz (2005) Obstet Gynecol 106(4): 707-12 [PubMed]
  2. Other factors
    1. Connective tissue weakening
    2. Pudendal nerve injury from child birth
  • Grading
  • Braden-Walker System (with quatification system)
  1. Evaluate when patient performing valsalva or straining
  2. Grade 0: No prolapse
  3. Grade 1: Descent halfway to hymen (or greater than 1 cm above hymen)
  4. Grade 2: Descent to the hymen (within 1 cm of hymen)
  5. Grade 3: Descent halfway passed the hymen (>1 cm below the hymen, but not completely protruding)
  6. Grade 4: Maximal possible descent
  • Grading
  • Older system
  1. First-degree: On pressing on perineum, Cervix visible
  2. Second-degree: Cervix protrudes via vaginal introitus
  3. Third-degree: Entire Uterus is external to introitus
  • Symptoms
  1. Asymptomatic in most patients
  2. Peristent pelvic pressure provoked by straining, standing, lifting, coughing or physical exertion
  3. Patient notes protruding tissue or bulging from introitus (most specific for prolapse)
  4. Spotting or bleeding per vagina
  5. Vaginal Discharge (typically with complete Uterine Prolapse)
  6. Patients may apply pressure to perineum or posterior vagina to aid stool evacuation
  • Signs
  1. Exam is variable
    1. Prolapse findings vary by day, Bladder fullness, rectal fullness
    2. Observe for prolapse with speculum
      1. Observe Cervix or vaginal cuff on valsalva
      2. Observe anterior and posterior vaginal walls on valsalva
  2. Uterine Prolapse on provocative maneuvers
    1. Valsalva
    2. Standing
  • Imaging
  1. Bedside Ultrasound
    1. Measure post-void residual
    2. Evaluate for Hydronephrosis
  • Labs
  1. Urinalysis
    1. Urinary Tract Infection
    2. Hematuria
  • Risk Factors
  1. Decreased support of pelvic organs
    1. Multiparous women (most commonly associated risk factor)
      1. Vaginal deliveries
      2. Prolonged labor, instrumented delivery, episiotomy
    2. Advanced age (esp. Menopause)
    3. Prior Hysterectomy
    4. Connective Tissue Disorders (Ehlers-Danlos Syndrome)
  2. Increased intraabdominal pressures
    1. Overweight or obese
    2. Constipation
    3. Heavy lifting
    4. Ascites
  3. Nerve disorders (especially affecting pudendal nerve)
    1. Spina Bifida Occulta
  • Complications
  1. Urinary Incontinence
    1. Stress Incontinence (40%)
  2. Voiding dysfunction
    1. Overactive Bladder (37%)
    2. Bladder outlet obstruction
  3. Rectal dysfunction
    1. Fecal Incontinence (50%)
    2. Incomplete Defecation
  4. Sexual Dysfunction
  • Management
  1. General Measures
    1. Treat Constipation
    2. Weight loss in Obesity
    3. Tobacco Cessation
    4. Avoid heavy lifting
  2. Indications for more aggressive management
    1. Hydronephrosis from ureteral kinking
    2. Recurrent Urinary Tract Infections
    3. Bladder outlet obstruction with ureteral reflux
    4. Severe cervical or vaginal erosions
  3. Mechanical Support
    1. Kegal Exercises (Pelvic Floor Exercises)
      1. Improves Stress Incontinence and Urge Incontinence
      2. Does not treat or reverse Pelvic Organ Prolapse
    2. Pessary
      1. First choice intervention for two thirds of Pelvic Organ Prolapse patients
      2. High level of compliance (77% continue Pessary beyond 1 year)
      3. Effective for all levels of prolapse stages
  4. Medications
    1. Consider Estrogen Replacement Therapy
  5. Surgery
    1. Hysterectomy or hysteropexy
    2. Trasvaginal sacrospinous fixation (sacrocolpopexy)
      1. Placed abdominally or transvaginally
      2. However, transvaginal mesh is associated with complications and no longer recommended for most patients
    3. Colpocleisis
      1. Obliterative surgery for high risk patients with multiple comorbidity
      2. Highest cure rate with lowest morbidity
      3. Only applicable to women who no longer wish to have vaginal intercourse
  • References
  1. (2007) Obstet Gynecol 110(3): 717-29 [PubMed]
  2. Iglesia (2017) Am Fam Physician 96(3): 179-85 [PubMed]
  3. Kuncharapu (2011) Am Fam Physician 81(9): 1111-7 [PubMed]