Uterine prolapse: what is it and how is it treated?

By Cristiano Antonino On Aug 30, 2023

When the uterus descends from the lesser pelvis, it is called uterine prolapse

It is a particular form of POP (pelvic organ prolapse), a condition that can lead to prolapse (and therefore descent) of the urethra, bladder, small intestine, rectum, vagina or uterus, due to excessive weakness of the pelvic muscles.

Usually caused by childbirth (especially if more than one), aging, an obesity condition, traumatic injury, or a habit of increasing pressure in the abdomen (for example, if you do a job that involves constantly lifting of weights), pelvic organ prolapse can vary in severity.

The real incidence is difficult to calculate as, in its mildest forms, the descent of one of these organs can be totally asymptomatic and the person does not require any medical advice.

According to the ICS (International Continence Society) first and second stage prolapse affects 48% of the female population, third and fourth degree prolapse 2% of women.

In the specific case of uterine prolapse, this occurs when the uterus descends until it occupies the vagina

Typically, the patient experiences pain and a feeling of encumbrance in the genital area.

This is why strengthening the pelvic floor, taking preventive action, becomes essential.

Uterine prolapse: what is it?

When uterine prolapse occurs, the uterus loses its physiological relationship and descends into the vagina.

The greater the protrusion into the vagina, the more severe the prolapse:

only a small portion of the uterus is involved in 1st degree uterine prolapse
in 2nd degree uterine prolapse, the uterus reaches the vaginal introitus,
in 3rd degree uterine prolapse, the uterus protrudes out of the opening of the vagina,
In 4th degree uterine prolapse, the uterus protrudes from the vagina.

But there is also a further distinction: the prolapse is said to be incomplete when the uterus is inside the vagina while it is complete if the slip is total and the organ comes out.

The main cause, in the case of the uterus, is the sagging of the pelvic floor

This, located in the pelvic area at the base of the abdominal cavity, includes muscles, connective tissue and ligaments and performs a primary function: in fact, it keeps the pelvic organs (uterus, urethra, bladder, intestine) in the correct position.

If it is injured or weakened, these slide downwards and give rise to numerous problems.

Deputy to house the fetus during pregnancy, the uterus is positioned between the bladder, the rectum, the intestinal loops and the vagina, in the small pelvis.

When the pelvic floor is healthy, only the cervix protrudes a few cm into the vagina.

Causes

Although the causes can be numerous, the main reason why uterine prolapse occurs is childbirth: the baby’s head, during the expulsion phase, passes along the vaginal canal and can damage both the connective and muscular structures.

Prolapse is more likely to occur in the event of a long labor or particularly complicated delivery and is much more frequent in multiparous women.

Another frequent cause of uterine prolapse is menopause, when the ovaries change their function and the muscles weaken due to the loss of elastic fibers caused by the new hormonal asset.

However, uterine prolapse can also occur in cases of

obesity
chronic constipation,
heavy work,
sport that involves the constant lifting of weights,
chronic bronchitis (due to cough that increases intra-abdominal pressure).

The underlying mechanism of uterine prolapse is a pelvic floor injury but, as a rule (unless it is too violent or the fetus is not too large), it is unlikely that a single delivery or a single event will cause uterine prolapse .

There are quite a few risk factors:

high number of parts,
aging,
surgery on the pelvic organs,
congenital collagen diseases,
chronic cough caused by chronic obstructive pulmonary disease.

Those who suffer from mild uterine prolapse usually do not experience any symptoms

The case of moderate and severe uterine prolapse is different, the primary symptom of which is given by a sense of encumbrance at the level of the vagina.

When the uterus comes out of the vagina, a feeling of heaviness is felt in the pelvis, as if there were a foreign body.

Often the woman has difficulty urinating, has involuntary leakage of urine (incontinence) or she may feel an urgent need to empty the bladder.

More rarely appears difficulty in defecation.

Among the main symptoms of uterine prolapse there is then the difficulty to have sexual intercourse, or a painful sensation during the same.

Incontinence is the symptom that most of all impacts on the patient’s quality of life.

If the urine leaks occur after an effort, whether it is lifting a weight or a cough, we try to solve them with exercises to strengthen the pelvic floor and – only at a later stage – we possibly proceed with an operation surgical.

If, on the other hand, the incontinence is due to urgency, and the losses are subsequent to a very strong voiding stimulus, surgery is almost never practiced since rehabilitation therapy is more effective.

To prevent the symptoms from becoming “chronic”, and from getting worse until they impede everyday life, it is necessary to contact your gynecologist as soon as these symptoms are felt.

Among the most serious complications of vaginal prolapse are vaginal ulcers (caused by rubbing between the extruded uterus and the walls of the vagina) and prolapse of other pelvic organs.

An eventuality, this, caused, in the same way, by the weakening of the pelvic floor.

Diagnosis

Uterine prolapse (as well as the prolapse of other pelvic organs) is diagnosed by the gynecologist, or urologist, through a pelvic exam: after listening to the patient’s symptoms, the specialist explores the vaginal canal and evaluates the position of the uterus using of the speculum. Finally, he asks the woman to contract the pelvic floor muscles to understand if this continues to perform her function or if it is not, instead, excessively weakened.

Only in rare cases may further investigation be necessary such as an ultrasound or a nuclear magnetic resonance: in general, the gynecologist chooses to carry them out only when it is not possible to establish with certainty the severity of the prolapse.

Uterine prolapse: possible therapies and cures

Treatment for uterine prolapse depends on the severity of the slip and whether other pelvic organs are involved.

In general, except in cases of extreme severity, conservative treatment is opted for, switching to surgery only in the event of its failure.

Grade 1 uterine prolapse does not need treatment

Your doctor will advise you to lose any excess weight and avoid heavy lifting.

He will also teach you how to perform some pelvic floor strengthening exercises known as “Kegel exercises”.

These consist of voluntary contractions of the muscles that support the pelvic organs: after emptying the bladder, the pelvic floor muscles are contracted for 5-10 seconds and released for the same amount of time.

The exercise should be repeated 2-3 times a day, doing series of 10 and taking care not to move the abdominal muscles, buttocks and legs.

In the case of 2nd, 3rd and 4th degree uterine prolapse, if the medical-rehabilitative therapy produces no effects, surgery is necessary.

In any case, attempts are made to avoid this path by setting up a specific conservative therapy.

Menopausal women are prescribed estrogens, since it is precisely their decrease that – in older patients – causes a weakening of the pelvic floor.

A revolutionary technique, then, is made up of ring or cube pessaries

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Made of silicone, they are replacing surgical operations.

The cube pessary is only worn during the day when the woman is standing and is removed in the evening before she goes to bed.

The ring pessary, used for women who find it difficult to put on and take off every day, is inserted by the doctor and kept for 6 months with a 20-30 day break between treatment cycles.

The pessary is inserted into the vagina and serves to prevent the pelvic organs from slipping: if the woman tolerates it well, this type of treatment can be effective even for life.

If these treatments do not give the desired results, surgery will be carried out.

There are many intervention techniques but, usually, hysterectomy and suspension of the uterus are used.

In the first case, reserved for women who no longer want/can have children, the uterus is removed through an abdominal incision, working vaginally or through a minimally invasive laparoscopy.

The suspension of the uterus, on the other hand, consists in bringing the organ back into position by strengthening the ligaments of the pelvic floor through the use of a synthetic material or the creation of a tissue transplant.

The risks of surgery include: