�Diseases, Conditions and Injuries

Uterine Prolapse

(Pelvic Floor Hernia; Pudendal Hernia; Pelvic relaxation)

En Espa�ol (Spanish Version)

Definition

Uterine prolapse occurs when the uterus (womb) slips out of place and into the vaginal canal. The severity of uterine prolapse is defined as:

First degree (mild) � The cervix (the lower opening of the uterus into the vagina) protrudes into the lower third of the vagina.
Second degree (moderate) � The cervix protrudes past the vaginal opening.
Third degree (severe) � The entire uterus protrudes past the vaginal opening.

Other organs, such as the ovaries or bladder, may also be out of place.

Uterine Prolapse

Causes

The uterus is normally supported by pelvic connective tissue and the pubococcygeus muscle, and held in position by special ligaments. Weakening of these tissues causes the uterus to descend into the vaginal canal.

Risk Factors

A risk factor is something that increases your chance of getting a disease or condition. The following factors are associated with an increased risk of uterine prolapse:

Multiple pregnancies and vaginal deliveries--Uterine prolapse occurs most commonly in women who have had one or more vaginal births, and in Caucasian women. Tissue trauma sustained during childbirth, especially with large babies or difficult labor and delivery, is typically the cause of muscle weakness.
Retroverted uterus (positioned backwards from normal)
Age: Past menopause--The loss of muscle tone and the relaxation of muscles, which are both associated with normal aging and a reduction in the female hormone estrogen, are also thought to play an important role in the development of uterine prolapse.
Obesity--Obesity places additional strain on the supportive muscles of the pelvis,
Large uterine or ovarian tumors--Descent can also be caused by a pelvic tumor; however, this is fairly rare.
Activities increasing the pressure in the abdomen and pelvis
- Severe or long-standing constipation
- Chronic coughing
- Heavy lifting

Symptoms

There may be no symptoms for mild cases of uterine prolapse. Symptoms for more severe cases may include:

Sensation of fullness in the vagina
Sensation of pulling in the pelvis
Pain in the vagina, lower back, or lower abdomen
Vaginal discharge (particularly in premenopausal women)
Leakage of urine
Frequent urinary tract infections
Protrusion of pink tissue from the vagina that may be irritated or itchy

Diagnosis

Your health care provider will ask about your symptoms and medical history, and perform a physical exam, including a thorough pelvic exam.

Treatment

Treatment may include:

Kegel Exercises

For mild cases of uterine prolapse, Kegel exercises are recommended to strengthen the pelvic muscles. These exercises are easy to do and can be done anywhere, at any time. To perform Kegel exercises:

Squeeze the pelvic muscles as though you are trying to hold back urine.
Hold this position for a count of ten, then release slowly.
Do this ten times, four times daily.

Pessary Insertion

This is a rubbery, doughnut-shaped device. It is inserted by your doctor into the upper portion of the vagina. A pessary helps to prop up the uterus and bladder, and temporarily prevent sagging into the vagina. It will need to be removed for cleaning and before sexual intercourse.

Surgery

Surgery may be necessary to correct uterine prolapse. These procedures are generally not done until you have finished having children. Surgical procedures include:

Vaginal Hysterectomy �removal of the uterus through the vagina. This procedure will permanently resolve uterine prolapse, but also results in infertility.

Resuspension of the Uterus � this involves removal of the cervix. It allows you to keep your uterus, but is associated with high rates of infertility and premature labor. This is a less common procedure.

You and your doctor should discuss all risks and benefits when considering these surgical options.

Complications

Urinary tract infections and other urinary symptoms may occur due to the frequently associated cystocele, (a hernia-like disorder in women that occurs when the wall between the bladder and the vagina weakens, causing the bladder to drop or sag into the vagina). Constipation and hemorrhoids may also occur as a result of the associated rectocele (a similar condition to cystocele, only the rectum protrudes into the vagina). Ulceration and infection may occur in more severe cases of prolapse.

Prevention

To help prevent uterine prolapse:

Do Kegel exercises regularly, especially before and after childbirth.
Avoid constipation. Straining from constipation stresses the pelvic muscles.
Maintain a healthy weight through diet and exercise.
Don't smoke. If you smoke, quit. Smoking may cause chronic coughing, which weakens pelvic muscles.
Limit heavy lifting
Discuss hormone replacement therapy (HRT) with your doctor. HRT at menopause helps retain muscle tone, which may help prevent uterine prolapse. However, there are health risks associated with HRT. You should discuss all risks and benefits with your doctor.

RESOURCES:

American College of Obstetricians and Gynecologists
http://www.acog.org

The National Women's Health Information Center
http://www.4woman.gov

REFERENCES:

Harvard Guide to Women's Health, Harvard University Press, 1996.

Medline Plus
http://www.nlm.nih.gov/medlineplus/ency/article/001508.htm

Last reviewed September 2005 by Joan K. Lingen, MD, FACOG

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