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Decubitus ulcer in uterus prolapse

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"Uterine Prolapse"[MeSH Terms] AND ulcer

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uterine prolapse decubitus ulcer clinical management guideline

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https://pmc.ncbi.nlm.nih.gov/articles/PMC1123216

A decubitus ulcer in uterine prolapse is a pressure-related ulcer, usually on the exposed cervix or vaginal wall in long-standing advanced uterovaginal prolapse (procidentia).

Why it occurs

The prolapsed part remains outside the vagina and undergoes:
  • Repeated friction and trauma from clothing/walking
  • Venous congestion and edema
  • Dryness and infection
  • Poor local blood supply
It may cause spotting or bleeding, foul-smelling discharge, pain, and secondary infection.

Examination

Assess:
  • Degree of prolapse and ulcer site/size
  • Bleeding, discharge, tenderness, necrosis, infection
  • Urinary symptoms and whether the prolapse can be reduced
  • Any irregular, hard, friable, or nonhealing lesion
Rule out cervical or vaginal malignancy. A suspicious ulcer, or one that does not heal after local treatment, needs biopsy. This is particularly important in older women with postmenopausal bleeding.

Management

  1. Local care and reduction
    • Keep the area clean and reduce the prolapse if possible.
    • Bed rest may help in severe cases.
    • Vaginal packing with topical estrogen may be used to reduce edema and allow ulcer healing, sometimes requiring short admission in complete procidentia.
  2. Treat contributing factors
    • Treat infection if clinically present, preferably guided by examination/culture when indicated.
    • Correct anemia, diabetes, malnutrition, constipation, or chronic cough where relevant.
    • In postmenopausal atrophy, topical vaginal estrogen may aid healing if not contraindicated.
  3. Definitive treatment after healing
    • Pessary for patients who do not want or are not fit for surgery, with regular follow-up.
    • Definitive prolapse repair, commonly vaginal hysterectomy with pelvic-floor repair in women who have completed childbearing, or a uterus-preserving prolapse procedure when appropriate.
Avoid inserting or retaining a pessary over an active ulcer until it has healed. Management should be individualized by a gynecologist or urogynecologist.
The BMJ review on prolapse care specifically notes that complete procidentia with a decubitus ulcer may require hospital care and estrogen vaginal packing, and that a suspicious or nonhealing ulcer warrants biopsy. A recent evidence search found no systematic review specifically addressing decubitus-ulcer treatment in prolapse; recent reviews focus on the choice of prolapse surgery rather than ulcer care (PMIDs: 41286733, 38269852, 38918960).
Seek prompt gynecologic assessment for heavy bleeding, fever, worsening pain, foul discharge, inability to pass urine, a black/necrotic-looking ulcer, or an ulcer that persists.
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