Uterine prolapse occurs when the uterus descends from its normal position into the vaginal canal due to weakened pelvic floor muscles and ligaments.

A uterine prolapse is a condition where the internal supports of the uterus become weak over time and the uterus sags out of position, descends downwards into the vagina.

Uterine prolapse (also called descensus or procidentia) means the uterus has descended from its normal position in the pelvis further down into the vagina.

Causes and Risk Factors of Uterine Prolapse

Uterine prolapse occurs when the pelvic floor muscles and ligaments, which normally support the uterus and other pelvic organs, become weakened or damaged. This allows the uterus to descend into or even protrude from the vagina.

Common causes include pregnancy, childbirth, hormonal changes after menopause, obesity, severe coughing and straining on the toilet.

1. Pregnancy and Childbirth:
   • Vaginal Delivery: The strain of pushing during labor, especially with large babies, can weaken the pelvic floor muscles.
   • Multiple Pregnancies: Repeated pregnancies can further stretch and weaken these muscles.
2. Age and Menopause:
   • Advanced Age: As we age, our tissues naturally lose elasticity and strength, including the pelvic floor.
   • Menopause: The decline in estrogen levels during menopause can contribute to tissue thinning and weakening.
3. Other Factors:
   • Chronic Cough: Conditions like bronchitis, asthma, or even persistent coughing can put strain on the pelvic floor.
   • Constipation: Straining during bowel movements can weaken the pelvic floor.
   • Major Pelvic Surgery: Procedures like hysterectomy or pelvic tumor removal can damage the supporting structures.
   • Smoking: Smoking reduces estrogen levels and can negatively impact tissue elasticity.
   • Excess Weight Lifting: Heavy lifting can strain the pelvic floor muscles.
   • Obesity: Excess weight puts added pressure on the pelvic floor.
   • Pelvic Tumors: While rare, pelvic tumors can displace the uterus and contribute to prolapse.
   • Spinal Cord Injuries: Conditions like muscular dystrophy, multiple sclerosis, or spinal cord injuries can weaken the pelvic floor muscles.
   • Family History: A family history of uterine prolapse increases the risk.

Pathophysiology:

The pelvic floor muscles and ligaments act as a hammock, supporting the uterus, bladder, and rectum. When these structures are weakened, the uterus can descend into the vagina.

Staging of Uterine Prolapse

Uterine prolapse is staged based on how far the cervix has descended:

• First Degree: The cervix drops into the vagina.
• Second Degree: The cervix descends to the level just inside the opening of the vagina.
• Third Degree: The cervix protrudes outside the vagina.
• Fourth Degree: The entire uterus is outside the vagina.

Clinical Features:

Symptoms of uterine prolapse vary depending on the severity but can include:

• Feeling of fullness or pressure in the pelvis
• Low back pain
• Sensation of something coming out of the vagina
• Bulging in the vagina
• Painful sexual intercourse
• Discomfort walking
• Uterine tissue protruding from the vaginal opening
• Unusual or excessive vaginal discharge
• Constipation
• Recurrent UTIs
• Symptoms may worsen with prolonged standing or walking
• Urinary problems (incontinence, frequency)
• Difficulty with bowel movements

Diagnosis:

History taking: A detailed medical history about symptoms and risk factors.

Physical examination:

• Abdominal exam: To assess the size and position of the uterus.
• Pelvic exam: To examine the vagina and cervix.
• Bimanual exam: To assess the pelvic floor muscle strength and support.

Laboratory studies:

• CBC, urinalysis, and cervical cultures: May be performed if infection is suspected.
• Pap smear cytology or biopsy: To rule out cervical cancer.
• Pelvic ultrasound: To visualize the uterus and surrounding structures.
• MRI: May be used for staging and to assess the extent of prolapse.

Differential Diagnoses:

• Urinary Tract Infection (UTI) and Cystitis (Bladder Infection) in Females: Symptoms can be similar to prolapse.
• Early Pregnancy: A growing uterus can also cause pelvic pressure and a feeling of fullness.
• Neoplasm: Tumors in the pelvic area can also cause prolapse-like symptoms.
• Ovarian Cysts: Cysts on the ovaries can cause pressure and discomfort.
• Vaginitis: Vaginal inflammation can lead to discharge and discomfort.

Management of Uterine Prolapse

The management of uterine prolapse depends on the severity of the prolapse, the patient’s symptoms, and their overall health. It can range from conservative measures to surgical interventions.

Conservative Management:

• Exercise: Kegel exercises, which involve contracting and relaxing the pelvic floor muscles, can strengthen the supporting muscles and help alleviate symptoms.
• Estrogen Replacement Therapy (ERT): For postmenopausal women, ERT can improve tissue elasticity and strength, potentially preventing further weakening of pelvic floor structures.
• Pessary: A pessary is a removable device inserted into the vagina to support the uterus and hold it in place. It is a non-surgical option suitable for women who want to avoid surgery or are not candidates for it. Pessaries come in various shapes and sizes, and they need to be fitted from the facility.
• Lifestyle modifications:
  
  • Weight Management: Maintaining a healthy weight reduces strain on the pelvic floor.
  • Dietary changes: Consuming a high-fiber diet can help prevent constipation and minimize straining.
  • Avoiding heavy lifting and prolonged standing: These activities can worsen prolapse symptoms.

Definitive Management (Surgery):

Surgery is considered when conservative options fail to provide relief or for severe prolapses.

• Vaginal Hysterectomy: This involves removing the uterus through the vagina. It is a common procedure for uterine prolapse, especially in women who are done having children.
• Abdominal Hysterectomy: This involves removing the uterus through an incision in the abdomen. It may be preferred in cases of severe prolapse or when there are other pelvic issues.
• Colpocleisis: This procedure involves surgically narrowing the vaginal opening, which provides support and eliminates the prolapse. It is considered for women who are not interested in sexual activity.
• Sacrospinous Fixation: This procedure involves attaching the uterus to the sacrospinous ligament, a strong ligament in the pelvis. This provides support to the uterus and prevents prolapse.
• Sacrohysteropexy: This procedure involves using a mesh patch to attach the uterus to the sacrum, a bone in the lower back. It is considered a more permanent solution than sacrospinous fixation.

Prevention:

• Maintaining a healthy weight: Obesity increases the risk of uterine prolapse.
• Regular exercise: Kegel exercises are especially helpful for strengthening the pelvic floor muscles.
• Healthy diet: High-fiber diet prevents constipation.
• Avoid straining: This includes straining during bowel movements and heavy lifting.
• Quit smoking: Smoking contributes to tissue weakening.
• Proper lifting techniques: Use your legs, not your back, to lift heavy objects.
• Minimizing vaginal deliveries: Multiple vaginal deliveries can weaken the pelvic floor.

Additional notes : Uterine Prolapse 

It is divided into three main categories: 2. Apical Prolapse:

• Uterine Prolapse: This is a prolapse of the uterus itself into or out of the vagina. It is graded based on how far the cervix (the lower part of the uterus) has descended:
  
  • Stage 0: No prolapse.
  • Stage 1: Cervix descends less than 1 cm above the hymen.
  • Stage 2: Cervix is at or within 1 cm of the hymen.
  • Stage 3: Cervix descends more than 1 cm below the hymen.
  • Stage 4: Complete uterine prolapse, the entire uterus is outside the vagina (procidentia).