Prolapse refers to the sinking or slipping of the uterus from its normal position in the pelvis into the vagina.
The uterus sinks when the pelvic floor muscles and ligaments become weak and give way, so they cannot give the uterus sufficient support.
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Anatomy of the uterus
The uterus is a female reproductive organ, which has the shape of an upside-down pear and is located in the pelvis.
The uterus, bladder and intestines are supported by a layer of muscle that extends between the coccyx and pubic bone.
These muscles are known as pelvic floor muscles or elevator ani muscles.
Through ligaments and connective tissue, the uterus is firmly anchored in place. However, if these tissue structures are weakened or damaged, the uterus can sink down into the vagina.
The feeling of a uterus emerging from the vagina is, to say the least, extremely bizarre.
One of my patients once said to me: “You can’t imagine what it’s like to have something hanging between your legs all the time!”
Classification of uterine prolapse
Pelvic floor weakness can result in varying degrees of severity, from a slight lowering to complete prolapse of the uterus from the vagina.
A uterine prolapse can be divided into the following stages:
- First degree: The cervix sags into the vagina.
- Second degree: The cervix descends to the vaginal opening.
- Third degree: The cervix emerges from the vagina.
- Fourth degree: The entire uterus has emerged from the vagina, one speaks of a uterine prolapse. It is caused by the weakness of the supporting muscles.
Concomitant complaints of uterine prolapse
As a rule, with a uterine prolapse, further complaints occur, whereby the muscles that hold the uterus in its position are weakened:
Cystocele: A protrusion of the bladder into the anterior-upper vaginal wall can lead to frequent urination, urinary urgency, urinary retention and incontinence.
Enterozele: Prolapse of the posterior-upper vaginal wall, parts of the small intestine protrude in the vagina. When standing, draught feeling and back pain can arise, while lying down the symptoms subside.
Rectocele: Bulge or prolapse of the rectum (rectum) into the posterior-lower vaginal wall. This causes difficulties with bowel movements, so that the woman may have to press against the vaginal wall to empty the intestine.
Causes of uterine prolapse
The causes lie in muscles, ligaments and other structures that form the supporting apparatus of the uterus in the pelvis.
In pelvic floor weakness, the uterus sinks into the birth canal.
This phenomenon is called uterine prolapse or uterine prolapse.
Lowering the uterus is more common in women who have undergone at least one natural birth.
Other causes of uterine prolapse:
- normal aging process,
- estrogen deficiency after menopause,
- everything that puts pressure on the pelvic floor muscles, including obesity and chronic cough,
- tumor in the pelvic area,
- Persistent constipation and the strain of bowel movements can aggravate the situation.
Risk factors for uterine prolapse
Some factors can increase the risk of uterine prolapse:
- One or two pregnancies, after childbirth increases the probability;
- After the birth of very large children;
- Advanced age, an older woman is much more at risk;
- Frequent lifting of heavy loads;
- Chronic cough;
- Previous operation in the pelvic area;
- Frequent pressing and pressing when emptying the intestine;
- Congenital connective tissue weakness.
Health problems such as obesity, chronic constipation and chronic obstructive pulmonary disease (COPD) can also put pressure on muscles and connective tissue of the pelvic floor and play a role in the development of uterine prolapse.
What are the symptoms of uterine prolapse?
Women with mild or moderate uterine prolapse often do not feel any discomfort. However, if the uterus sinks further, it may press on other organs, such as the bladder or intestines, causing a number of symptoms, such as:
- pressure and bloating in the lower abdomen,
- pelvic or abdominal pain,
- pain during sexual intercourse,
- a protrusion can be felt through the vaginal opening,
- recurrent (recurrent) urinary tract infections,
- unusual or excessive discharge,
- Constipation
- Difficulty urinating, including unwanted loss of urine (urinary incontinence), frequent urination and urge to urinate.
The symptoms can become stronger when standing and walking because of greater pressure on the pelvic floor muscles due to gravity.
What are the complications and consequences of uterine prolapse?
If left untreated, uterine prolapse can conflict with the bowel, bladder, and sexual activity.
Diagnosis of uterine prolapse
For diagnosis, it is necessary to perform a gynecological examination.
The doctor, usually a gynecologist, will inquire about the medical history and check the signs of uterine prolapse as part of a complete abdominal examination. The examination can be carried out lying down or standing.
Diagnostic imaging techniques such as ultrasound or magnetic resonance imaging (MRI) can also be used to evaluate uterine prolapse.
What are the treatment options for urogenital prolapse?
Controlled waiting
In the case of mild complaints, the doctor may advise after the examination to wait to see how the symptoms develop. However, the patient must keep an eye on the situation and carry out the necessary checks.
Pessary
A uterine prolapse can be well controlled with a vaginal pessary. This tool is an alternative for women who do not want to have surgery, who are still of fertile age, who are waiting for surgery or for women for whom surgery would be too risky due to other diseases.
The pessary is usually ring-shaped and is usually made of plastic or silicone.
The ring is inserted into the vagina.
A pessary supports the vagina and uterus. It can easily be used by the doctor, even many family doctors are able to do so. It must be replaced at regular intervals.
If pain becomes noticeable after insertion or if the flow of urine is impeded, this should be discussed with the doctor as soon as possible.
It may be necessary to use a pessary in a different size.
Vaginal pessaries usually do not cause problems, but in very rare cases they can affect the skin in the vagina in such a way that it forms ulcers.
Some women feel discomfort during sexual intercourse.
Estrogen cream
With a slight uterine prolapse, the doctor may prescribe an estrogen-containing cream, which will be used to treat the vagina for 4-6 weeks.
This can alleviate the symptoms associated with uterine prolapse.
However, symptoms may recur when ointment treatment stops.
Pelvic floor exercises
All women with birthing butter lowering should train their pelvic floor muscles, even if they do not feel any symptoms.
At an early stage, pelvic floor exercises can prevent the uterus from sinking further; it is the best measure to prevent prolapse.
The exercises can also relieve symptoms such as back pain and abdominal discomfort.
However, not all existing uterine prolapse can be improved with the targeted pelvic floor exercises.
Operation
The aim of the procedure is a permanent treatment of uterine prolapse.
There are various surgical options, which are selected depending on the form and degree of severity of the lowering.
Some of these procedures can be performed as minimally invasive surgery or using laparoscopy. The surgeon knows which treatment method is suitable for the patient.
When is surgery necessary?
The decision to operate is made by the patient after consulting with the surgeon and weighing up the daily problems and symptoms.
There are the following surgical procedures:
Vaginal gathering. This procedure is performed to strengthen and fix the vaginal walls; this is usually done by placing a fold in the vaginal wall and holding the walls in place with a few stitches.
The operation is usually performed from the vagina, so an abdominal incision is not necessary.
In some cases, a mesh or special tape can be sewn into the vaginal walls.
Note: There are several procedures for tightening the vagina.
With some of these methods, there are doubts about the long-term treatment success of using a mesh and there is a risk of complications, such as erosion of the mesh through the vaginal wall.
This can mean another intervention, which can cause sexual complaints and problems.
The advantages and disadvantages of the various surgical procedures should be discussed and weighed in detail with the surgeon before taking the next step.
Hysterectomy (Hysterectomy). This is a common form of treatment for uterine prolapse.
Especially for women over 50, this method is often used.
Sometimes the removal of the uterus is performed together with a vaginal gathering.
Raising of the uterus or vagina. There are several methods here, including:
Sacral hysteropexy: A special mesh is used to support the uterus and hold it in position. One end of the mesh is attached to the cervix, the other to the posterior pelvic bone, to the sacrum.
This operation is usually performed by means of an abdominal incision.
Sacral colpopexy. In this procedure, the vagina is fixed to the sacrum.
With the help of a net or other material, the vagina is held in its natural position.
At the same time, a hysterectomy can be performed.
As a rule, this operation is performed by means of an abdominal incision.
Infracoccygeal hysteropexia or colpopexy (new). These are new surgical techniques in which the mesh is inserted through the vagina rather than through an abdominal incision, which presumably means faster recovery.
Sacrospinal fixation. In this operation, the vagina is fixed to a ligament of the pelvis, the sacrospinal ligament.
Usually, the procedure is performed through the vagina, so an abdominal incision is not necessary.
After the operation, a hospital stay of about two days is planned.
Full recovery will take six to eight weeks. During this period, lifting heavy loads and sexual intercourse should be avoided.
There is a small probability that a further reduction will occur after the procedure.
Can complications occur?
Possible complications and discomfort in the surgical treatment of vaginal prolapse include pain, infection, perforation of the rectum or bladder, injury to the ureters, return of symptoms such as urinary incontinence or difficulty urinating, uterine prolapse and sexual pain.
In addition, there are general risks associated with any surgery, including the dangers of anesthesia, bleeding and any necessary blood transfusion, pelvic or wound infections, and the risk of deep vein thrombosis (DVT) in the legs.
Recovery
The length of hospitalization is 3 to 5 days for most women. If the patient feels well and urination does not cause any problems, she can be discharged.
It is important that the body is sufficiently spared after the operation so that the treated area can heal.
In the first 2 weeks:
- Limit everyday activities.
- As much peace and quiet as possible.
- The discharge from the vagina is weak, has a light pink color and lasts about two weeks.
In the first 2-4 weeks:
- Light and simple everyday activities can be carried out, walks are allowed.
- Do not lift heavy objects (no more than 4 kg), including shopping bags, laundry baskets and children.
- No sports, such as swimming, or activities that cause impact movements, such as running and jumping, for 4 weeks.
- In the first few days, sudden discharge of moderate intensity may occur, which should subside after 8-10 days.
- The sutures of the surgical suture dissolve within about 10 days (max. 3 weeks) and do not need to be removed.
In the first 6 weeks:
No sexual intercourse.
After two weeks, the patient is allowed to sit behind the wheel again, but you should talk to the car insurance.
Pain relief Doctors usually recommend acetaminophen (e.g. Ben-u-ron), taken for two weeks, every four hours (codeine-containing drugs cause constipation).
It is important to schedule sufficient time to rest every day.
Healthy eating habits
- Every day about 1.5 liters of liquid should be consumed.
- Pay attention to a healthy diet.
- To regulate bowel movements, Metamucil or a similar remedy from the pharmacy can be used.
