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Uterine and Apical Prolapse

By

Charlie C. Kilpatrick

, MD, MEd, Baylor College of Medicine

Last full review/revision Apr 2019| Content last modified Apr 2019
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Uterine prolapse is descent of the uterus toward or past the introitus. Apical prolapse is descent of the vaginal vault or vaginal cuff after hysterectomy. Symptoms include vaginal pressure and fullness. Diagnosis is clinical. Treatment includes reduction, pessaries, and surgery.

Severity of these disorders can be graded by the Baden-Walker system which is based on level of protrusion:

  • 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

Although the Baden-Walker system is commonly used, it is an older classification system, that is not reproducible; thus, professional organizations recommend the Pelvic Organ Prolapse-Quantification (POP-Q) system. The POP -Q system is a more reliable and reproducible classification system that is based on predefined anatomic landmarks:

  • 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

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; the most common presenting symptom is a vaginal bulge. 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 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 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

  • 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 requires evaluation.

Treatment

  • 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])

In general, vaginal surgery causes less morbidity and a more rapid recovery time than abdominal surgery. 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 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 in symptomatic women if the perineum can support a pessary.

  • Treat surgically if women prefer surgery to a pessary or if the perineum cannot support a pessary.

Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
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