Uterine prolapse, or Pelvic organ prolapse as we call it in the medical literature, is the descent of organs within the hip bone into the vagina due to connective tissue or muscle weakness. Pelvic organ prolapse is divided into 3 subcategories according to the region descending into the vagina.
Prolapse can occur from a single region or from several regions together. Although there are many causes of uterine prolapse, pregnancy and vaginal birth are the most important causes. Vaginal birth can directly lead to damage to the pelvic floor muscle and connective tissue that cover the bottom of the hip bone.
In this article, what is uterine prolapse? What is its frequency? Symptoms of uterine prolapse, how is it examined? You can find answers to your questions such as treatment and uterine prolapse surgery.
Uterine prolapse is the herniation of the uterus from its natural anatomical position into the vaginal canal, hymen or outside the vagina. This is due to the weakening of the surrounding support structures.
In its normal state, the uterus is located at the top of the pelvic organs. The uterus and vagina are suspended from the sacrum, the bone that forms the coccyx, and from the hip bone on the side wall, via the uterosacral and cardinal ligaments. The weakening of these ligaments causes the uterus to prolapse out of the vagina.
Although uterine prolapse is not life-threatening by nature, it can lead to sexual dysfunction, urinary and fecal incontinence and a lower quality of life.
It is generally difficult to calculate uterine prolapse rates separately from bladder and bowel prolapse. In general, the rate of pelvic organ prolapse is 9.7% in women aged 20-39 and 49.7% in women over 80. Approximately 50% of older women can expect to have a prolapse of the uterus, bladder or bowel. The rate of uterine prolapse is around 7%.
Symptoms of uterine prolapse include;
Symptoms appear gradually and may worsen over time as prolapse progresses. It has been shown that the number and degree of complaints increase with the worsening severity of prolapse. However, the specific complaints experienced by patients do not show a proportional relationship with the stage of prolapse, and most patients are completely asymptomatic in the early stages of uterine prolapse.
In addition to the complaints reported by patients, direct visualization of the prolapsed area during gynecological examination is very important for the diagnosis of uterine prolapse. Gynecological examination should be performed while the patient is resting and straining during the Valsalva maneuver. The degree of prolapse is staged according to the hymen or intraocular opening, which is the vaginal opening. The POP-Q staging method is used for staging.
Uterine prolapse is most often diagnosed with the patient's medical history and physical examination. Other possible diagnoses include urethral prolapse, cystocele, enterocele, rectocele, abscess, and masses of gynecological origin.
There is no laboratory test that helps diagnose uterine prolapse. The basic method for diagnosing uterine prolapse is the history given by the patient together with gynecological examination findings. However, the prolapsed area can be seen in multiple imaging methods such as computed tomography and MRI, and these methods can help confirm the diagnosis. However, it is not clearly seen on ultrasound.
There are many staging systems used to classify pelvic organ prolapse. However, there is no consensus on which system is best.
The Pelvic Organ Prolapse Grading (POP-Q) system was created in 2002. Measurements from the hymen to the vagina are expressed as negative numbers and measurements from the hymen to the outside of the vagina are expressed as positive numbers, and when the hymen is used as the reference point, the lowest part of the prolapsed organ is taken into account and the area near the hymen is given as the reference point 0.
Measurements are taken while the patient performs the Valsalva maneuver and strains. POP Q staging can be briefly seen in the table below.
Treatment of uterine prolapse depends largely on the degree of the patient's symptoms. Conservative treatments include pelvic floor muscle training and vaginal pessaries in the early stages. There are also many surgical options for treating advanced stages.
Accurate diagnosis and management of uterine prolapse can greatly affect the patient's quality of life and ensure long-term physical and mental health. Gynecologists should provide comprehensive counseling to patients with uterine prolapse so that they can make informed decisions and choose the treatment that is right for them.
Pelvic floor muscle training is typically taught to patients in conjunction with a physical therapist. Patients have shown improvement in symptoms as well as improvement in POP-Q staging.
Vaginal pessaries are devices, usually made of silicone, that are inserted into the vagina to provide support for prolapsed pelvic organs. Vaginal pessaries have been found to be a successful solution in 84% of cases of pelvic organ prolapse. Mild side effects were observed in 31% of cases.
Although pessaries do not definitively correct herniation of the pelvic organs, they can reduce symptoms and prevent progression of prolapse. The appropriate size pessary for the patient can be found after several attempts. The patient's bowels and bladder should be empty when a pessary is inserted.
The examiner should be able to slide one finger between the pessary and the vaginal walls. The patient should be able to walk, bend, and urinate comfortably without slipping the pessary. Complications of pessary insertion include vaginal irritation, ulceration, discharge, pain, bleeding, and odor.
Regular assessment of pessary fit should be performed to ensure that the pessary does not rub against the vaginal walls, as this can irritate the vaginal mucosa and predispose patients to infection.
Rare complications include movement of the pessary into the bladder or rectum, causing fistula, bowel obstruction, and urinary tract obstruction. If patients with dementia or inadequate follow-up do not pay enough attention to hygiene conditions and do not have the pessary position checked regularly to prevent complications, very difficult situations can occur. This group of patients are not suitable candidates for a pessary.
The decision for surgical treatment should be made after a detailed discussion with the patient about the patient's desire for future vaginal intercourse, the effects on body image, alternative treatments and possible complications.
Hysterectomy can be performed vaginally or transabdominal as a treatment for uterine prolapse. Vaginal approaches have been shown to be less invasive and provide an opportunity to repair pelvic floor defects. Additional surgical procedures can be performed at the same time to reduce the risk of prolapse of other pelvic organs.
We perform sacrospinous fixation, which is the vaginal suspension of the uterus, or vaginal removal of the uterus (vaginal hysterectomy-VAH) surgery on our elderly patients.
It can be applied to patients who want to maintain their fertility in the future and want to protect their uterus. If the uterus is preserved, reproduction is preserved and a natural transition to menopause is provided.
Patients who undergo uterine-preserving surgical treatments require continuous follow-up in terms of gynecological cancers; therefore, uterine preservation is not appropriate in patients with a history of uterine and cervical pathology. Laparoscopic Hysteropexy (suspension of the uterus) provides less blood loss, shorter operation time and faster recovery compared to removal of the uterus together with prolapse repair.
After the gynecological evaluation, laparoscopic sacrocolpopexy, or closed uterine suspension surgery, is applied to patients in the young age group.
It is an occlusive, non-invasive surgical option that involves sewing the vaginal walls together to completely occlude the vaginal canal and provide muscle support to the rest of the pelvic organs. This procedure is ideal for patients who have undergone hysterectomy who do not want vaginal intercourse in the future.
Uterine suspension surgery complications are very rare in the hands of experienced surgical teams.
The weakness of the pelvic floor connections that allow the apical compartment to prolapse can additionally allow the anterior and posterior compartments to prolapse, resulting in a cystocele, rectocele and/or enterocele. These conditions accompanying uterine prolapse can often result in urinary incontinence, fecal incontinence and long-term illness.
After making a diagnosis to our patients, we inform them that uterine prolapse is a common and well-known condition and select treatment
