Uterine Prolapse

Uterine prolapse is the descent of the cervix and uterus into the vagina and beyond. It's caused by relaxation of the uterosacral and cardinalligaments. Three degrees of uterine prolapse have been described. In first degree uterine prolapse, the cervix is still within the vagina. In second degree uterine prolapse, the cervix is at the vaginal introitus. In third degree uterine prolapse, the cervix and uterus are outside of the vaginal introitus.

Uterine prolapse is more common in older women who have had one or more vaginal births. It's also more common in white women. It may be seen in nulliparous women, children, and infants. In these cases, it's usually due to defects innervation and the basic uterine supports.

What causes uterine prolapse?

The most common cause of uterine prolapse is trauma related to childbirth, especially if a woman has delivered large infants or had difficulties with labor and delivery. Genetics may predispose some women to develop uterine prolapse. In addition, advancing age contributes to the loss of muscle tone and the relaxation of the pelvic muscles. The loss of hormonal support with estrogen in postmenopausal women is another contributing factor. Additional strain on the uterine muscles may be caused by obesity, thereby contributing to uterine prolapse. The same theory applies to patients who suffer from excessive coughing, such as associated with chronic bronchitis and asthma, or straining due to chronic constipation.

Signs and symptoms of uterine prolapse

Patients with uterine prolapse commonly complain of a bulge or lump in the vagina. Other symptoms may include:

• pain
• pelvic pressure
• backache
• difficulty or pain with sexual intercourse
• disruption of bladder and bowel function
• bleeding if the cervix is ulcerated.

Uterine prolapse may be associated with cystocele and rectocele. Patients with concurrent cystocele may complain of frequent urinary tract infections or other urinary symptoms such as incontinence. Patients with concurrent rectocele may also suffer from hemorrhoids and constipation.

Diagnosis information

Uterine prolapse is diagnosed during pelvic examination. The clinician should have the patient bear down and observe for protrusion of the cervix into the vagina or beyond. It may be necessary to examine the woman in the standing position to observe the prolapse. Cystocele and rectocele may also be observed and the ovaries and the bladder may be palpated in lower positions than normal.

Other diagnostic procedures include:

• hysterosalpingography
• hysteroscopy
• endometrial biopsy (to rule out endometrial cancer in patients over age 35 with abnormal uterine bleeding)
• laparoscopy.

Treatment of uterine prolapse

Usually, uterine prolapse is only treated if a woman is symptomatic. A pessary is inserted into the vagina to hold the uterus in place. Pessaries come in different shapes and sizes and must be fitted to the individual patient. They can be used as a temporary or permanent form of treatment. A pessary requires cleaning by the patient and may irritate the vaginal mucosa. Some patients may complain that it interferes with intercourse because it affects the depth of penetration. Patients must be aware of signs and symptoms of vaginal infections because the presence of a foreign object in the vagina will increase their risk.

Vaginal hysterectomy is the surgical method of choice for effective treatment of uterine prolapse. At the time of hysterectomy, the surgeon can also usually repair sagging vaginal walls, urethra, bladder, or rectum.

Another surgical procedure, laparoscopic suture hysteropexy, may also be used to treat uterine prolapse. It involves plication of the uterosacral ligaments and reattachment of them to the cervix. It's effective and safe, and enables preservation of the uterus.

Special considerations and Prevention

Nursing care of the patient with uterine prolapse encompasses emotional support and teaching regarding the disorder and treatments:

• Patients may suffer from problems with body image, daily activities, and sexuality.
• Sexual intercourse may produce challenges before and after surgery. The use of lubricants may be suggested.
• The patient should be instructed to avoid lifting or straining, which may worsen the prolapse.
• Give emotional support and guidance to obese patients in their attempt to lose weight.
• Prevention techniques, such as prenatal and postnatal Kegel exercises, can be taught to reduce the risk of uterine prolapse by strengthening the pelvic floor muscles.
• Estrogen replacement therapy in postmenopausal women may be prescribed to help maintain muscle tone; however, the increased risk of endometrial cancer from unopposed estrogen therapy must be discussed with the woman's primary care provider or gynecologist.