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:

• 1st degree: To the upper vagina
• 2nd degree: To the introitus
• 3rd degree: Cervix is outside the introitus
• 4th degree (sometimes referred to as procidentia): Uterus and cervix entirely outside the introitus

Vaginal prolapse may be 2nd or 3rd degree.

Symptoms and Signs

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 or coccygeal pain may develop. Constipation is possible.

Third-degree uterine prolapse manifests as a bulge or protrusion of the cervix or 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 mass may intermittently obstruct urine flow, causing urinary retention and masking stress or overflow incontinence. Urinary frequency and urge incontinence may accompany vaginal prolapse.

Diagnosis

• Pelvic examination

Diagnosis is confirmed by speculum or bimanual pelvic examination. Vaginal ulcers are biopsied to exclude cancer. Simultaneous urinary incontinence requires evaluation.

Treatment

• Treatment of symptomatic or 3rd-degree prolapse, beginning with pessaries and Kegel exercises
• Surgical repair of supporting structures if necessary, usually with hysterectomy

Asymptomatic 1st- or 2nd-degree uterine prolapse does not require treatment. Symptomatic or 3rd-degree prolapse can be treated nonsurgically if the perineum can structurally support a pessary. Severe or persistent symptoms require surgery, usually hysterectomy with surgical repair of the pelvic support structures (colporrhaphy) and suspension of the vagina (suturing of the upper vagina to a stable structure nearby). The abdominal approach results in greater structural support than the vaginal approach, but risk of short-term morbidity and mesh-related complications is greater. Surgery is delayed until all ulcers, if present, have healed.

Vaginal prolapse is treated similarly to uterine prolapse. Urinary incontinence requires concurrent treatment.

Last full review/revision December 2008 by S. Gene McNeeley, MD