Uterine Prolapse

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Uterine Prolapse

Definition

Pelvic organ prolapse (POP) is the "descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy)," correlated with symptoms. Uterine prolapse specifically refers to the descent of the uterus through the urogenital diaphragm into or beyond the vaginal canal, caused by failure of the supportive cardinal-uterosacral ligament complex.

Normal pelvic anatomy (sagittal view):

Sagittal section of the pelvis showing normal female pelvic anatomy

Epidemiology

In the United States, 11% of women up to age 80 have surgery for POP or urinary incontinence; nearly one-third are repeat procedures.
Uterine prolapse accounts for 14.3% of POP in Women's Health Initiative data.
Women with at least one vaginal delivery are twice as likely to develop POP as nulliparous women.

- Berek & Novak's Gynecology, p. 1595

Anatomy & Pathophysiology

The uterus is supported by three levels of pelvic support:

Level	Structure	Function
Level I	Cardinal/uterosacral ligament complex	Suspends vaginal apex, maintains vaginal length and axis
Level II	Paravaginal attachments to arcus tendineus and levator fascia	Maintains midline position of vagina
Level III	Muscles and connective tissue around distal vagina and perineum	Supports vaginal introitus

The uterosacral ligaments originate at sacral vertebrae S2-S4 and insert at the upper vagina and cervix. The broad ligament does not provide significant support. When the cardinal-uterosacral complex attenuates (via tears, neuromuscular dysfunction, or both), uterine prolapse results.

Birth-induced injury to the pubococcygeal portion of the levator ani is seen in 55% of women with prolapse vs. 16% of women with normal support.

- Berek & Novak's Gynecology, p. 1596; Campbell Walsh Wein Urology, p. 3713

Risk Factors

Obstetric:

Vaginal delivery (strongest risk factor)
High parity
Prolonged labor, instrumental delivery

Non-obstetric:

Increasing age
Obesity
Constipation (chronic straining)
Chronic obstructive pulmonary disease (raised intra-abdominal pressure)
Prior hysterectomy
History of previous prolapse operations
Race (higher prevalence in White women than Black women)

- Berek & Novak's Gynecology, p. 1595

Classification / Staging (POP-Q System)

The Pelvic Organ Prolapse Quantification (POP-Q) system is approved by the International Continence Society. It identifies 9 anatomical locations in the vagina and vulva, measured in centimeters relative to the hymen.

Stage	Description
Stage 0	No prolapse
Stage I	Most distal portion >1 cm above the hymen
Stage II	Most distal portion between 1 cm above and 1 cm below the hymen
Stage III	Most distal portion >1 cm below the hymen but protrudes less than total vaginal length minus 2 cm
Stage IV	Complete eversion/procidentia

Older grading (still used clinically):

1st degree: cervix descends into vaginal canal but not to introitus
2nd degree: cervix reaches introitus
3rd degree: cervix protrudes beyond introitus
4th degree (procidentia): entire uterus and vaginal walls are everted

- Berek & Novak's Gynecology, p. 1609-1610

Clinical Features

Symptoms

Vaginal bulge - most specific symptom; vaginal descensus 0.5 cm distal to the hymen predicts bulge symptoms with 69% sensitivity, 97% specificity
Pelvic pressure or heaviness, worsened by prolonged standing
Lower urinary tract symptoms: urinary incontinence, urgency/frequency, obstructive voiding, retention
Women with more advanced prolapse are less likely to report stress incontinence and more likely to manually reduce the prolapse to void
Bowel symptoms: constipation, obstructed defecation, fecal incontinence
Low back and flank pain
Dyspareunia

Physical Examination

Examine in lithotomy position; encourage Valsalva maneuver to demonstrate full extent of prolapse
Use Graves speculum (apical), Sims or univalve speculum (anterior/posterior compartments)
Rectovaginal exam to distinguish posterior wall defect from enterocele
Standing straining exam if supine findings inconsistent with symptoms

- Berek & Novak's Gynecology, p. 1609

Treatment

1. Conservative / Non-surgical

Lifestyle modifications:

Weight reduction
Treat chronic constipation
Avoid heavy lifting

Pelvic floor muscle training (Kegel exercises):

Strengthens levator ani and puborectalis
Appropriate for mild-to-moderate prolapse

Pessaries (mechanical devices):

First-line non-surgical option for symptomatic prolapse in women who desire to avoid surgery or are poor surgical candidates
Provide mechanical support without addressing the underlying defect

Types of pessaries (Milex range A-X) used in the management of uterine prolapse and pelvic organ prolapse

Pessary types and uses:

Type	Notes
Ring with/without support	Most commonly used; easiest to insert/remove; 1st and 2nd degree prolapse
Gellhorn	Moderate-severe prolapse; stays in 6-8 weeks; harder to self-manage
Cube	Held by suction and space occupation; must be removed daily
Donut	Space-filling; for large vault prolapse / procidentia with reduced perineal support
Continence ring/dish	When stress incontinence coexists

Fitting protocol:

Digital exam to estimate size; ring forceps to reduce prolapse
Patient stands, performs Valsalva, and coughs - pessary must be retained
Proper fit: index finger sweeps between pessary and vaginal wall
Patient must void before leaving office
Follow-up at 1-2 weeks, then 4-6 weeks, then every 6-12 months
Monitor for vaginal ulceration, pressure sores, infection

- Berek & Novak's Gynecology, p. 1615-1619

2. Surgical Management

Surgery is indicated when symptoms are bothersome and not controlled by conservative measures. Treatment is individualized based on: compartment(s) involved, desire for future fertility, uterine preservation preference, health status, and whether obliterative or reconstructive approach is preferred.

Vaginal Procedures

Vaginal hysterectomy + apical suspension:

Standard for uterine prolapse in women not desiring fertility preservation
Vaginal hysterectomy alone is not adequate - apex must be suspended to prevent recurrent POP
McCall culdoplasty is the minimum addition: closes the peritoneal cul-de-sac, prevents enterocele, and provides apical fixation
Uterosacral ligament suspension (USLS) and sacrospinous ligament fixation (SSLF) are additional apical suspension techniques

Uterine-preserving procedures (Hysteropexy):

For women who desire fertility preservation or prefer uterine conservation
Manchester-Fothergill procedure: amputation of cervix + cardinal ligament plication
Sacrospinous hysteropexy
Comparable durability to hysterectomy-based repair in selected patients

Abdominal / Minimally Invasive Procedures

Abdominal/laparoscopic/robotic sacrocolpopexy:

Mesh attached from vaginal apex to sacral promontory
Considered the most durable repair for apical prolapse
Associated with lower prolapse recurrence rates vs. vaginal repairs in comparative trials

Uterosacral ligament suspension (USLS) - abdominal approach:

Native tissue repair; avoids mesh-related complications

Obliterative Procedures

Colpocleisis (Le Fort or total):

Partial or total closure of the vaginal canal
Reserved for elderly, frail patients who are sexually inactive and poor surgical candidates for reconstructive procedures
Very high success rates with low recurrence
During colpocleisis, at least 1.5 cm of the distal anterior vaginal wall adjacent to the urethral meatus should be preserved to avoid unmasking stress urinary incontinence

- Campbell Walsh Wein Urology, p. 3713; Berek & Novak's Gynecology, p. 1618-1625

Associated Conditions

Uterine prolapse frequently coexists with:

Cystocele (anterior vaginal wall prolapse) - most common associated defect
Rectocele (posterior vaginal wall prolapse)
Enterocele (small bowel herniation into posterior cul-de-sac)
Stress urinary incontinence (may be occult when prolapse is severe)

Any concomitant compartment defects should be addressed at the same surgical setting.

Special Considerations

Occult SUI: Women undergoing prolapse repair should be screened preoperatively; a concomitant anti-incontinence procedure may be offered
Mesh use: Transvaginal mesh for prolapse carries FDA safety concerns; abdominal sacrocolpopexy (where mesh is used abdominally) has a better safety profile than transvaginal mesh
Pregnancy: Uterine prolapse can complicate pregnancy; cervical prolapse is a known complication
Contraindications to vaginal hysterectomy: Endometriosis of unknown extent, obliterated cul-de-sac, large fibroids, pelvic/adnexal tumors, uterine/ovarian malignancy

Sources:

Berek & Novak's Gynecology, Chapter 30 (Pelvic Organ Prolapse), pp. 1593-1630
Campbell Walsh Wein Urology, Chapter 124 (Vaginal Reconstructive Surgery), pp. 3710-3715

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