Uterine and Vaginal Prolapse
Uterine prolapse is descent of the uterus toward or past the introitus. Vaginal prolapse is descent of the vagina or vaginal cuff after hysterectomy. Symptoms include vaginal pressure and fullness. Diagnosis is clinical. Treatment includes reduction, pessaries, and surgery.
Uterine prolapse is graded based on level of descent:
Vaginal prolapse may be 2nd or 3rd degree.
Symptoms tend to be minimal with 1st-degree uterine prolapse. In 2nd- or 3rd-degree uterine prolapse, fullness, pressure, dyspareunia, and a sensation of organs falling out are common. Lower back pain may develop. Incomplete emptying of the bladder and constipation are possible.
Third-degree uterine prolapse manifests as a bulge or protrusion of the cervix or vaginal cuff, although spontaneous reduction may occur before patients present. Vaginal mucosa may become dried, thickened, chronically inflamed, secondarily infected, and ulcerated. Ulcers may be painful or bleed and may resemble vaginal cancer. The cervix, if protruding, may also become ulcerated.
Symptoms of vaginal prolapse are similar. Cystocele or rectocele is usually present.
Urinary incontinence is common. The descending pelvic organs may intermittently obstruct urine flow, causing urinary retention and overflow incontinence and masking stress incontinence. Urinary frequency and urge incontinence may accompany uterine or vaginal prolapse.
Diagnosis of uterine or vaginal prolapse is confirmed by speculum or bimanual pelvic examination.
Vaginal ulcers are biopsied to exclude cancer.
Simultaneous urinary incontinence requires evaluation.
Asymptomatic 1st- or 2nd-degree uterine prolapse may not require treatment.
Symptomatic 1st- or 2nd-degree prolapse can be treated with a pessary if the perineum can structurally support a pessary; surgical repair is an option for women who do not wish to use a pessary.
Severe or persistent symptoms and 3rd- or 4th-degree prolapse require surgery, usually hysterectomy with surgical repair of the pelvic support structures (colporrhaphy) and suspension of the top of the vagina (suturing of the upper vagina to a stable structure nearby). Surgical options include a vaginal approach (for sacrospinous ligament suspension or sacrospinous colpopexy) and an abdominal approach (sacrocolpopexy). Robot-assisted laparoscopy is most often used with an abdominal approach.
For 3rd- and 4th-degree prolapse, an abdominal approach (using laparotomy or laparoscopy) results in greater structural support than a vaginal repair and a lower risk of complications than mesh placed vaginally. Laparoscopic repair of prolapse poses less risk of perioperative morbidity than laparotomy. Using mesh may lower the risk of prolapse recurrence after a vaginal repair, but complications may occur more frequently. Patients should be advised that all mesh may not be removed completely so that they can make an informed decision.
Surgery is delayed until all ulcers, if present, have healed.
Vaginal prolapse is treated similarly to uterine prolapse.
The vagina may be obliterated if women are not good candidates for prolonged surgery (eg, if they have serious comorbidities). Advantages of vaginal obliteration include short duration of surgery, low risk of perioperative morbidity, and very low risk of prolapse recurrence. However, after vaginal obliteration, women are no longer able to have sexual intercourse.
Urinary incontinence requires concurrent treatment.
The descending pelvic organs may intermittently obstruct urine flow, causing urinary retention and overflow incontinence and masking stress incontinence.
Third-degree uterine prolapse (cervix outside the introitus) may spontaneously reduce before patients present.
Confirm the diagnosis by examination, but biopsy vaginal or cervical ulcers to exclude cancer.
Treat with a pessary if prolapse is 1st or 2nd degree and symptomatic and the perineum can support a pessary, or treat with surgery if women prefer it to a pessary.
Treat surgically if prolapse is 3rd or 4th degree or if symptoms are severe or persistent.