PROLAPSED UTERUS
The uterus (or womb) is normally held in place inside the pelvis with various muscles, tissue, and ligaments. Because of pregnancy, childbirth or difficult labor and delivery, in some women these muscles weaken. Also, as a woman ages and with a natural loss of the hormone estrogen, her uterus can drop into the vaginal canal, this causes the condition known as a prolapsed uterus.
Muscle weakness or relaxation may allow the uterus to sag or come completely out of the body in various stages:
First degree: The cervix drops into the vagina.
Second degree: The cervix drops to the level just inside the opening of the vagina.
Third degree: The cervix is outside the vagina.
Fourth degree: The entire uterus is outside the vagina. This condition is also called procidentia. This is caused by weakness in all of the supporting muscles.
Other conditions are usually associated with prolapsed uterus. They also weaken the muscles that hold the uterus in place:
Cystocele: A herniation (or bulging) of the upper front vaginal wall where a part of the bladder bulges into the vagina. This may lead to frequent urination, urgency to urinate, urine retention, and incontinence (loss of urine).
Enterocele: This is the herniation of the upper rear vaginal wall where a small bowel portion bulges into the vagina. Standing upright leads to a pulling sensation and backache that is relieved when one lies down.
Rectocele: The herniation of the lower rear vaginal wall where the rectum bulges into the vagina. This makes bowel movements difficult, to the point that the individual may need to push on the inside of the vagina to empty the bowel.
TYPES OF PROLAPSE
The 4 main types of prolapse are:
- The bladder bulging into the front wall of the vagina (anterior prolapse)
- The womb bulging or hanging down into the vagina (uterine prolapse)
- The top of the vagina sagging down (this happens to some women after they have had surgery to remove their womb)
- The bowel bulging forward into the back wall of the vagina (posterior wall prolapse)
It's entirely possible for a woman to have more than 1 of these at the same time.
Pelvic organ prolapse will usually be classified on a scale of 1 to 4 to show how severe it is, with 4 being a severe prolapse.
STAGES
The uterus, also known as the womb, is held above the vagina by the pelvic floor muscles and ligaments.
Uterine prolapse can be categorized as incomplete or complete:
Incomplete uterine prolapse: The uterus is partially displaced into the vagina but does not protrude.
Complete uterine prolapse: A portion of the uterus protrudes from the vaginal opening.
The condition is graded by its severity, determined by how far the uterus has descended:
1st grade: descended to the upper vagina
2nd grade: descended to the introitus
3rd grade: cervix has descended outside the introitus
4th grade: cervix and uterus have both descended outside the introitus
In the early stages, exercises may help, but more severe cases may need surgery.
CAUSES
The following conditions can cause a prolapsed uterus:
- Weakness in the pelvic muscles with advancing age
- Pregnancy/childbirths with normal or complicated delivery through the vagina
- Major surgery in the pelvic area leading to loss of external support
- The loss of tissue tone and weakening after menopause and possibly the loss of natural estrogen
- All conditions that lead to increased pressure in the abdomen such as chronic cough (with bronchitis and asthma), straining (with constipation), pelvic tumors (rare), or an accumulation of fluid in the abdomen
- Being overweight or obese with its additional strain on pelvic muscles
- Smoking
Other risk factors include:
- Family history
- Excessive weight lifting
- Being a caucasian
SYMPTOMS
Mild cases of bladder or uterine prolapse would usually not cause any symptoms. A prolapse that is more advanced can cause any of the following symptoms:
- A moist discharge that soils undergarments
- Discomfort inside the vagina, pelvis, lower abdomen, groin or lower back. The discomfort associated with prolapse is often described as a pulling or aching sensation. It can be worse during sexual intercourse or menstruation.
- Leakage of urine, which is made worse with heavy lifting, coughing, laughing or sneezing
- Pain with sexual intercourse, urine leakage during sex, and/or the inability to have an orgasm
- Difficulty having a bowel movement
- Heaviness or pressure in the vaginal area. Some women reports feeling like something is about to fall out of the vagina.
- A bulge of moist pink tissue from the vagina. This exposed tissue may be irritated and cause itching or small sores that can bleed.
- Frequent urination and/or a frequent urge to urinate
- Frequent urinary tract infections, because the bladder fails to empty completely when urinating.
- The need to push one's fingers into the vagina, the rectum, or against the skin near the vagina to empty the bladder or have a bowel movement
RISK FACTORS
Risk factors include:
- Giving birth (the highest risk) - The ending of pregnancy where one or more babies leaves the uterus by passing through the vagina or by Caesarean section.
- Vaginal delivery (vs. C-section) - A vaginal delivery is the birth of offspring in mammals (babies in humans) through the vagina (also called the 'birth canal'). A C-section, or cesarean section, is the surgical delivery of a baby through incisions in the abdomen and uterus.
- Menopause - the time in a woman's life when her period stops because the woman's ovaries stop producing the hormones estrogen and progesterone
- Being Caucasian - Caucasian refers to a person who is from the region of Caucasus, which is in Europe bordering Turkey and Iran (e.g. Armenia, Azerbaijan, Georgia and Russia.)
- Being overweight - Being overweight or obese are both terms for having more body fat than what is considered healthy.
- Smoking - Smoking is a practice in which a substance is burned and the resulting smoke is breathed in to be tasted and absorbed into the bloodstream.
POSSIBLE COMPLICATIONS
Uterine prolapse is often associated with prolapse of other pelvic organs.
One might experience:
Anterior prolapse (cystocele). Weakness of the connective tissue separating the bladder and vagina may cause the bladder to bulge into the vagina. Sometimes this is referred to as prolapsed bladder.
Posterior vaginal prolapse (rectocele). Weakness of connective tissue separating the rectum and vagina may cause the rectum to bulge into the vagina. This might create difficulties with bowel movements.
A severe uterine prolapse can displace part of the vaginal lining, causing it to protrude outside the body. Vaginal tissue that rubs against clothing can lead to vaginal sores (ulcers). These sores can become infected though rarely.
WHEN TO SEE A DOCTOR
Prolapse of the pelvic organs is generally a non-threatening problem. People should contact their physician for an evaluation if they have symptoms that are worrisome, and if they suspect that they might have this problem. It is also important to report changes in urinary symptoms to their doctor, since urinary infections are a possible complication of prolapse.
DIAGNOSIS
Occasionally, an MRI (magnetic resonance imaging) test may be needed to confirm the diagnosis but an experienced physician usually can diagnose uterine or bladder prolapse with a pelvic examination.
In some cases, especially if the patient has frequent urinary infections or if she is having difficulty holding urine, the doctor may order one or more tests to evaluate the bladder function.
Urodynamic studies will test the bladder function and can show if the bladder empties completely. The pressure inside the bladder is measured as fluid is passed into it through a small tube. An X-ray video taken after dye is inserted through the urethra to fill the bladder can show whether its shape is distorted.
This test is known as a voiding cystourethrogram.
TREATMENT
There are several treatment options available for pelvic organ prolapse.
The most suitable will depend on:
- How severe the symptoms are
- Whether or not she plans to have children in the future
- The severity of the prolapse proper
- The age and general health of patient
Treatment may not be needed any if the prolapse is mild to moderate and is not causing any pain or discomfort.
Treatment options include:
- Lifestyle changes
- Pelvic floor exercises
- Hormone treatment
- Vaginal pessaries
- Surgery
The doctor should avail the patient with the full range of treatments and explain the possible benefits and risks of each option. This will help to choose the right treatment in conjunction with the doctor.
LIFESTYLE CHANGES
If a person does not have any symptoms or the prolapse is mild, making some lifestyle changes can ease the symptoms and stop the prolapse from getting worse.
They can also help reduce the risk of getting a prolapse in the first place.
They include:
- Maintenance of a healthy weight or losing weight if patient is overweight
- Eating a high-fiber diet to avoid constipation
- Refraining from lifting heavy objects
- Shunning high-impact exercise, such as trampolining
- Stopping smoking (smoking can cause coughing and make the prolapse worse)
Pelvic floor exercises
Engaging in pelvic floor exercises will strengthen the pelvic floor muscles and may well relieve a person's symptoms.
A General Practitioner or specialist doctor may recommend a programme of supervised pelvic floor muscle training for at least 16 weeks before moving on to other treatments or perhaps surgery.
Oestrogen Hormone treatment
If a person has a mild prolapse and have been through menopause, the doctor may recommend treatment with oestrogen to ease some of the symptoms, such as vaginal dryness or discomfort during sex.
Oestrogen is available as:
- A tablet that is inserted into the vagina
- A cream that is applied to the vagina
- An oestrogen-releasing vaginal ring
Vaginal pessaries
A device made of latex rubber or silicone is inserted into the vagina and left in place to support the vaginal walls and pelvic organs.
Vaginal pessaries allow a woman to get pregnant in the future. It can be used to ease the symptoms of moderate to severe prolapses. They are a good option if the patient cannot or would prefer not to have surgery.
Depending on a particular need, vaginal pessaries come in different shapes and sizes. With the most common being a ring pessary.
The patient may need to try a few different types and sizes to be able to determine the one that works best.
A gynecologist or a specialist nurse would be the one who usually fits a pessary. It may need to be removed, cleaned and replaced regularly.
Side effects of vaginal pessaries;
Vaginal pessaries can occasionally cause:
- Possible urinary tract infections
- Passing a small amount of urine when one coughs, sneezes or exercises (stress incontinence).
- An unpleasant smelling vaginal discharge. This may be a sign of an imbalance of the usual bacteria found in the vagina (bacterial vaginosis)
- Irritation and sores and possibly bleeding inside the vagina
- Some interference with sex (though most women can have sex without any problems)
All of these side effects can usually be treated.
Surgery
If non-surgical options have not worked, or if the prolapse is severe, then surgery becomes an option.
There are several different surgical treatments for pelvic organ prolapse.
They include:
- Vaginal mesh surgery
- Hysterectomy
- Surgical repair
- Closing the vagina
Doctors will usually discuss the benefits and risks of different treatments, and together with the patient, the best option will be co-opted.
Vaginal mesh surgery
Vaginal mesh surgery is where a piece of synthetic mesh, a plastic product that looks like a net, is inserted to hold the pelvic organs in place.
The mesh will remain in the body permanently.
The patient will be put to sleep during this operation and will usually need to stay in hospital for 1 to 3 days after the procedure.
Some women have unfortunately had serious complications after mesh surgery. Some, of these complications can also happen after other types of surgery.
The complications will include:
- Incontinence - Urinary incontinence means a person leaks urine by accident.
- Sexual problems - A sexual problem, or sexual dysfunction, refers to a problem during any phase of the sexual response cycle that prevents the man or couple from experiencing satisfaction from the activity.
- Long-lasting pain - Any pain that goes on for longer than would be expected after an injury or illness.
- Permanent nerve damage - A nerve injury can be caused by pressure, stretching, or cutting of the nerve. If the nerve is injured, one may feel numb, weak or painful in the injured area.
- Constipation - When bowel movements become less frequent and stools become difficult to pass.
- Mesh exposure - through vaginal tissues and occasionally injury to nearby organs, such as the bladder or bowel
If the patient has previously had vaginal mesh inserted and think they are having complications, they should speak to a doctor.
However, many women have had these types of surgery without developing any problems afterwards.
Hysterectomy
This is done for women with a prolapsed womb who have been through the menopause or do not wish to have any more children. A doctor may recommend surgery to remove the womb entirely (hysterectomy).
It can help to relieve pressure on the walls of the vagina and reduce the chance of a recurring prolapse.
One cannot get pregnant after having a hysterectomy, and sometimes it may cause patients to go through the menopause early.
A patient may need 6 to 12 weeks off work to recover.
Surgical repair
There are several different types of surgery that involve the lifting and supporting of the pelvic organs. This could either be by stitching them into place, or supporting the existing tissues to make them stronger. Surgical repairs are usually done by making cuts in the wall of the vagina under general anaesthetic. This means the patient be asleep during the operation and thus will not feel any pain.
If the patient will like to have children in the future, the doctors may suggest delaying the surgery because pregnancy can cause the prolapse to happen again. Typically, a person may need 6 to 12 weeks to recover, depending on the type of surgery.
Closing the vagina
Occasionally, an operation that closes part or all the vagina may be an option.
This treatment is only offered to women who have advanced prolapse. All other treatments have failed to work and they're sure they do not plan to have sexual intercourse again in the future.
This operation can only be a good option for frail women who would not be able to have more complex surgery.
Side effects of surgery
The risks and benefits of the 4 different types of surgery, including mesh surgery, must be discussed in-depth before a decision is taken together with the doctor whether one of
Possible side effects of all 4 types of surgery, including mesh surgery, include experiencing more prolapse symptoms, which may require further surgery
- Deep Vein Thrombosis, (blood clot forming in a vein, (such as in a leg) patient may be given medicine to help reduce this risk after surgery
Should a person have any of the following symptoms after surgery, the doctor will need to know as soon as possible:
- Heavy bleeding in the vagina
- Abnormal vaginal discharge (which may be an infection)
- A high body temperature
- A severe pain low in the tummy
- A stinging or burning sensation when urinating
PREVENTION
To reduce the risk of uterine prolapse, people must try to:
Perform Kegel exercises regularly. These exercises can strengthen the pelvic floor muscles which may especially be important after having a baby.
Treat and prevent constipation. Drink plenty of fluids and eat high-fiber foods, such as fruits, vegetables, beans and whole-grain cereals.
Avoid heavy lifting and lift correctly. When lifting, use the legs instead of the waist or back.
Control coughing. Get treatment for a chronic cough or bronchitis, and do not smoke.
Avoid weight gain. Talk with a doctor to determine an ideal weight and get advice on weight-loss strategies, if needed.