Uterine Prolapse Disease

DESCRIPTION

Uterine prolapse occurs when the integrity of supporting structures is lost. This allows the uterus to descend into the vagina. In advanced cases, complete protrusion with inversion of the vagina occurs.

Prior to menopause, the degree and severity of prolapse is usually related to the number of children and the difficulty of childbirth. After menopause, atrophy and loss of tissue integrity further leads to prolapse.
System(s) affected: Reproductive, Renal/Urologic, Renal/Urologic, Gastrointestinal
Genetics:
- Common among Caucasian races
- Less common among Asians and African Americans, and particularly uncommon in South African Bantus and West Africans
Incidence/Prevalence in USA: Approximately 1 in 10 women will experience some degree of prolapse
Predominant age: Peri- and post-menopausal female
Predominant sex: Female only

SIGNS AND SYMPTOMS

Pelvic pressure and low back pain
As prolapse progresses, eventually a bulging is noticed as a result of protrusion
Dyspareunia
Difficulty with urination or defecation

CAUSES

Advancing age and vaginal childbirth are the most important factors
The incidence of prolapse increases with the frequency and difficulty of vaginal deliveries. Less than 2% of prolapse occurs in nulliparous women.
Other causes of prolapse include connective tissue disorders with lax tissue, i.e., Marfan's syndrome, and neurogenic disorders, i.e., multiple sclerosis, cloacal agenesis, chronic constipation, pelvic tumors or ascites, and chronic coughing from chronic lung disease
Patients who have undergone radical vulvectomy with loss of the external supporting structures have a higher rate of prolapse

RISK FACTORS

Childbirth, particularly multiple parity
Advancing age
Caucasian race
Various connective tissue and neurogenic disorders
Conditions resulting in increased intra-abdominal pressure, such as obesity, abdominal or pelvic tumors, pulmonary disease with chronic coughing, chronic constipation
Occupations requiring heavy lifting

LABORATORY

Evaluation of renal function to rule out ureteral obstruction
Urinalysis to rule out urinary tract infection

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Hyperkeratosis of the cervical and vaginal tissues occur with prolapse beyond the introitus due to chronic irritation and drying. As the irritation becomes more pronounced, bleeding and ulceration occur.
Degrees of prolapse:
- First degree prolapse - to the ischial spine
- Second degree prolapse - to the introitus
- Third degree prolapse - just beyond the introitus
- Fourth degree prolapse - complete uterine and vaginal inversion involving bladder and bowel

SPECIAL TESTS

N/A

IMAGING

Intravenous pyelogram to rule out ureteral obstruction in complete uterine prolapse (optional)
Pelvic ultrasound or CT scan to rule out other pelvic pathology, if suspected (optional)

DIAGNOSTIC PROCEDURES

If ulceration or bleeding is present, Pap smears and appropriate cervical and endometrial biopsies should be done to rule out concomitant malignancies

APPROPRIATE HEALTH CARE

Outpatient
Inpatient when surgery is necessary

GENERAL MEASURES

Treatment depends on multiple variables including the severity of prolapse, age, sexual activity, associated pelvic pathology and desire for future fertility
Treatment of first and second degree prolapse is expectant unless patient is symptomatic
Mildly symptomatic patients and poor surgical candidates - can be treated nonoperatively with perineal (Kegel) exercises, estrogen replacement and vaginal pessaries. Estrogen replacement restores healthy vaginal mucosa and promotes healing.

SURGICAL MEASURES

Surgically able patients without additional pelvic pathology - vaginal hysterectomy with or without enterocele, cystocele, rectocele repair and vaginal vault suspension
For patients who desire to maintain reproductive function - uterine suspension with vaginal repair is an option
Elderly, non-sexually active women - can be treated with a colpocleisis or vaginal obliteration procedure

ACTIVITY

Heavy lifting or significant increases in intra-abdominal pressure will lead to worsening of prolapse or recurrence after surgical correction. Lifting should therefore be restricted.

DIET

Unlimited. Avoid constipation.

PATIENT EDUCATION

Kegel exercises when applicable
American College of Obstetricians & Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188, (800)762-ACOG

PREVENTION/AVOIDANCE

Kegel exercises will increase the strength of the pelvic diaphragm muscles and may provide some pelvic support
Weight loss and proper management of conditions that would increase abdominal pressure help to prevent prolapse

POSSIBLE COMPLICATIONS

Ureteral obstruction and renal failure
Incarceration of bowel herniations
Pessary use - may not always be effective, and may cause discomfort, ulcers, infection

EXPECTED COURSE AND PROGNOSIS

It is expected that as patients age, the incidence and severity of prolapse will increase
Surgical correction usually successful

ASSOCIATED CONDITIONS

Cystocele, rectocele, enterocele and vaginal vault prolapse are often associated with uterine prolapse

AGE-RELATED FACTORS

Pediatric: Prolapse in newborn has been reported, but is rare and usually associated with congenital disorders and neuropathies
Geriatric: This is largely a disease of aging and will be much higher as the population ages
Others: N/A

PREGNANCY

This disorder in large part results from vaginal childbirth and the distention and distortion of supporting tissues with childbirth

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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