Severity of vaginal wall prolapse can be graded by the Pelvic Organ Prolapse-Quantification (POP-Q) system:
Stage 0: No prolapse
Stage I: Most distal prolapse is more than 1 cm above the hymen
Stage II: Most distal prolapse is between 1 cm above and 1 cm below the hymen
Stage III: Most distal prolapse is more than 1 cm below hymen but 2 cm shorter than total vaginal length
Stage IV: Complete eversion
The POP-Q system is recommended by professional organizations because it is a reliable and reproducible classification system that is based on predefined anatomic landmarks.
The Baden-Walker system, which is based on level of protrusion, is sometimes used. However, it is an older classification system that is not reproducible:
Grade 0: No prolapse
Grade 1: Halfway to the hymen
Grade 2 : To the hymen
Grade 3 : Halfway past the hymen
Grade 4: Maximal possible
Symptoms and Signs of Uterine and Apical Prolapse
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; the most common presenting symptom is a vaginal bulge. Lower back pain may develop. Incomplete emptying of the bladder Urinary Retention Urinary retention is incomplete emptying of the bladder or cessation of urination. Urinary retention may be Acute Chronic Causes include impaired bladder contractility, bladder outlet obstruction... read more and constipation Constipation Constipation is difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation. (See also Constipation in Children.) No bodily function is more variable and... read more 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 occasionally 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 Urinary Incontinence in Adults Urinary incontinence is involuntary loss of urine; some experts consider it present only when a patient thinks it is a problem. The disorder is greatly underrecognized and underreported. Many... read more 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 and Apical Prolapse
Pelvic examination
Diagnosis of uterine or vaginal prolapse is confirmed by speculum or bimanual pelvic examination.
Rarely, vaginal ulcers require a biopsy to exclude cancer.
Simultaneous urinary incontinence Evaluation Urinary incontinence is involuntary loss of urine; some experts consider it present only when a patient thinks it is a problem. The disorder is greatly underrecognized and underreported. Many... read more , difficulty voiding, or urinary retention Diagnosis Urinary retention is incomplete emptying of the bladder or cessation of urination. Urinary retention may be Acute Chronic Causes include impaired bladder contractility, bladder outlet obstruction... read more requires evaluation.
Treatment of Uterine and Apical Prolapse
For mild symptomatic prolapse, pessaries
Surgical repair of supporting structures if necessary, usually with hysterectomy
Uterine prolapse
Asymptomatic prolapse does not require treatment, but patients should be followed clinically for progression.
Symptomatic 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 or the perineum cannot support a pessary.
Surgery for uterovaginal prolapse can be done through the vagina or through an incision in the abdomen using various techniques. Factors determining choice of techniques include surgeon experience and patient desires. Techniques may include one or a combination of the following:
Hysterectomy
Surgical repair of the pelvic support structures (colporrhaphy)
Suspension of the top of the vagina (suturing of the upper vagina to a stable structure nearby)
Colpocleisis (closure of the vagina after removal of the uterus or with the uterus in place [Le Fort procedure])
Procedures are done using a transvaginal or abdominal route. Regardless of the surgical route, symptoms often recur, especially along the anterior vaginal wall.
Surgery is delayed until all ulcers, if present, have healed.
Vaginal apical prolapse
Vaginal prolapse is treated similarly to uterine prolapse.
The vagina may be stitched close (colpocleisis) if women are not good candidates for prolonged surgery (eg, if they have serious comorbidities). Advantages of vaginal closure include short duration of surgery, low risk of perioperative morbidity, and very low risk of prolapse recurrence. However, after vaginal closure, women are no longer able to have vaginal intercourse.
Urinary incontinence requires concurrent treatment.
Key Points
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.
Treat women with prolapse if they have troublesome symptoms.
Treat with a pessary if women have symptoms and the perineum can support a pessary.
Treat surgically if women prefer surgery to a pessary or if the perineum cannot support a pessary.
