28 Aug Uterine Prolapse

• Uterine prolapse: is a condition mostly of women past or nearly past childbearing age in which the suspending uterine ligaments have stretched and the perineal muscles have weakened so that the uterus falls through the vagina and sometimes reaches the outside.
• Stages of uterine prolapse:
  • Range:
    • mild sagging of the uterus made worse by coughing or bearing down,
    • uterine prolapse present all the time.
  • Not dangerous,
  • Very symptomatic.
• Incidence and Prevalence
  • Extremely common
  • US: 16 percent of all reasons for hysterectomy
  • Millions of women, of childbearing age and beyond, suffer from some sort of pelvic organ prolapse, including uterine prolapse.
• Predisposing Factors
  • Childbirth is the greatest risk factor,
  • More pregnancies, greater ris,
  • Vaginal delivery of large babies: greater chance,
  • Obesity and advancing age,
  • Previous pelvic surgery,
  • Genetic predisposition
  • an ethnic predisposition to Caucasian and Hispanic
  • Chronic and severe constipation will cause straining with bowel movements that will drive the uterus downward.
• Signs and Symptoms
  • Mild uterine prolapse:
    • No signs or symptoms
    • Identified at the time of a pelvic examination.
  • Moderate to severe disease:
    • Sensation of drawing or pulling in the lower abdomen and pelvis (as if something is pushing on the perineum),
    • The cervix may protrude from the vagina with coughing, sneezing, or bearing down (or all the time),
    • Urinary retention or urinary leakage (stress incontinence),
  • Severe Uterine Prolapse (Procedentia):
    • Difficulty sitting down
      • Sensation that they are sitting on something (which is the cervix protruding from the vagina).
    • Sex can be painful or nearly impossible
      • Uterus and cervix have filled the vaginal cavity, making it impossible to have any penile penetration during sex.
    • Symptoms are less annoying in the morning and worsen throughout the day as gravity kicks in and causes further sagging of the uterus.
  • Clinical Presentation
    • Sexual concerns:
      • Prolapse affects the ability to have sex without pain and difficulty.
    • Fullness in the pelvis
    • Presence of cervical structural tissue through the vagina
      • Temporary,
      • Permanent: Irritation of the cervix and frank cervicitis from chronic air exposure.
    • Etiology
      • Gyn causes:
        • Weakness of the supportive ligaments of the uterus and the pelvic/perineal musculature.
        • Causes of muscle weakness: Pregnancy-related.
          • Due to child birth trauma:
            • Forceps delivery,
            • Large baby delivered vaginally,
            • Prolonged labor,
            • Tearing of the perineal muscles, or
            • Vacuum extraction.
          • Non-Gyn Causes:
            • Chronic constipation: Chronic straining and increased intrapelvic pressure.
            • Chronic bronchitis or COPD: Prolonged coughing and increase in intraabdominal/intra-pelvic pressure.
          • Occupational causes:
            • Job that increases the amount of time spent doing heavy: An increase in intrabdominal and intra-pelvic pressure, worsening uterine prolapse.
          • Pathology
            • No histologic changes
            • Cervicitis from chronic air-exposure of the cervix.
            • Clinical evidence of perineal muscle weakness on physical examination.
            • Severe cases with urinary tract problems may need to have urodynamic testing.
          • Treatment and Management
            • Depends on severity:
              • Self-care measures,
                • Kegel exercises,
                • Stool softener to prevent constipation, and
                • Losing weight.
              • Nonsurgical option:
                • Pessary:
                  • Rigid doughnut-shaped rubber ring inserted into the vagina and worn all the time (between cleanings),
                  • Serves the function of holding up the vaginal and pelvic tissues, and
                  • Help with urinary incontinence symptoms.
                • Surgical option:
                  • Women who don’t desire a pregnancy:
                    • Vaginal hysterectomy, sparing the ovaries.
                    • Vaginal muscles tightened up so the rest of the pelvic structures stay intact.
                  • In women who desire to get pregnant again,
                  • Uterine suspension
                  • Pelvic floor muscles tightening
                    • Adding a synthetic mesh to the tissues, or
                    • Grafting tissues from inside the body to the perineal musculature.
                  • Complications
                    • Uterine prolapse not dangerous
                    • Linked to the prolapse of other organs in the pelvis:
                      • Cystocele or anterior prolapse:
                        • Bladder falls through the vaginal wall and bulges into the vagina
                        • Can be so severe: Bladder tissue prolapses through the vagina.
                      • Rectocele: Posterior vaginal prolapse:
                        • Weakness or thinning of the muscles and tissue that normally separate the vagina and the rectum.
                        • Causes stool to fill up the vaginal space during bowel movements, making bowel movements extremely difficult.