Uterine Prolapse is the Herniation of the Uterus Into or Beyond the Vagina as a Result of Failure of the Ligamentous and Fascial Supports

8/20/2019 Uterine Prolapse is the Herniation of the Uterus Into or Beyond the Vagina as a Result of Failure of the Ligamento…

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Uterine prolapse is the herniation of the uterus into or beyond the vagina as

a result of failure of the ligamentous and fascial supports. It often coexists with

prolapse of the vaginal walls, involving the bladder or rectum. In the United

Kingdom, the disorder accounts for 20% of women waiting for maor

gynaecological surgery.!

How common is uterine prolapse?

"he exact prevalence is un#nown. $orty per cent of participants in the womens

health initiative &'(I) trial in the United *tates had some degree of prolapse.

Uterine prolapse was found in !+% of the 2 -+2 women enrolled in the

study.- nother U* study of !+/ + women found an !!% lifetime ris# of

surgery for prolapse or incontinence in the United *tates.+

"he 1xford $amily lanning ssociation study in the United Kingdom followed

more than ! 000 women aged 23-/. "he annual incidence of hospital admission

with prolapse was 20.+4!0 000, and the annual incidence of surgery for prolapse

was !5.24!0 000. 6any studies do not distinguish between prolapse of all pelvic

organs and prolapse of the uterus alone, which ma#es it difficult to determine the

true incidence.

$our hundred and twelve women originally enrolled in the '(I study were

followed up to assess progression of prolapse. *pontaneous regression was

common, especially for grade ! prolapse7the progression rate was !./4!00

women years and the regression rate was +84!00 women years.5 "hus, prolapse is

not always progressive.

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Why does prolapse occur?

Anatomy

*ome #nowledge of normal vaginal support is needed to understand the

pathophysiology of pelvic organ prolapse. 9elanceys three levels of support

&figure)&figure) are now accepted worldwide.

9elanceys three levels of pelvic support. :eprinted from ;arber,8 with permission

from the


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tendineous fascia pelvis and the fascia overlying the levator ani muscles

provide support to the middle part of the vagina.

• =evel -> "he urogenital diaphragm and the perineal body provide support

to the lower part of the vagina.

Risk factors

"he etiology of pelvic organ prolapse is multifactorial divided into

confirmed and possible ris# factor. "he confirmed ris# factor li#e older age, race,

family history, increased body mass index, higher parity, vaginal delivery,

constipation. "he possible ris# factor li#e Intrapartum variables &macrosomia,

long second stage of labour, episiotomy, epidural analgesia), increased abdominal

pressure andn menopause. "he pelvic organ support study found age to be a ris#

factor for pelvic organ prolapse ris# doubled with each decade of life. Increasing

parity was also associated with increasing severity of prolapse. 1f the ! 000

women in the 1xford family planning study, those with a history of two vaginal

deliveries were 8.+ times more li#ely to have surgery for prolapse than those with

no such history.

lthough vaginal delivery is clearly associated, specific obstetric ris#

factors remain controversial. 6acrosomia, prolonged second stage of labour,

episiotomy, anal sphincter inury, epidural analgesia, and the use of forceps and

oxytocin have all been proposed as ris# factors but have not been proved.

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'omen who are overweight &body mass index 23-0? odds ratio 2.!, /%

confidence interval !.!8 to .-) or obese &@-0? 2.5, !.2- to .-) are at high ris#

of developing prolapse.!0 (eritable or genetic factors might play a part. In a case

control study of !08 women with and without prolapse, a higher ris# of prolapse

was seen in women with a mother &-.2, !.! to .5) or sister &2.+, !.0 to .5)

reporting prolapse.!!

lthough menopause is often cited as a ris# factor for pelvic organ prolapse,

a study of 20 women from the '(I trial who had undergone hysterectomy found

no association between oestrogen status &use of hormone replacement therapy)

and prolapse.!2

Symptoms

6any symptoms have been attributed to prolapse &box 2), although none of them

are specific, except for seeing or feeling a vaginal bulge. study of +/ women in

the U* under annual review for prolapse !0 showed that the number of symptoms

and the problems these caused increased as the stage of prolapse increased from

stage 0 &no prolapse) to stage III &prolapse outside the vagina) &box -).

Box 2 Symptoms attributable to uterine prolapse

Vainal symptoms

• *ensation of a bulge or protrusion

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• *eeing or feeling a bulge

• ressure

• (eaviness

!rinary symptoms

• Incontinence, freAuency, or urgency

• 'ea# or prolonged urinary stream

• $eeling of incomplete emptying

• 6anual reduction of prolapse needed to start or complete voiding

&BdigitationC)

•


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• *plinting &pushing on or around the vagina or perineum) needed to start or

complete defecation &BdigitationC)

Sexual symptoms

• 9yspareunia &painful or difficult intercourse)

• =ac# of sensation

"xaminin the patient

pelvic examination should be done &using a *ims single bladed speculum) to

define the extent of the prolapse and establish the compartments of the vagina

affected &anterior, posterior, or apical). "he patient should be at rest and straining

during a Dalsalva manoeuvre. "he oestrogen status of the tissues &signs of vaginal

atrophy) and the siEe and mobility of the uterus and adnexae should be assessed.

*everal prolapse grading systems exist, but the only system that has been robustly

tested for both interobserver and intraobserver reliability is the pelvic organ

prolapse Auantification system.!- !+ "his system defines the extent of prolapse by

measuring the descent of anterior, posterior, and apical segments of the vaginal

wall relative to the vaginal hymen. full discussion is beyond the scope of our

review, but readers are referred to the original paper.!+"he score for each

compartment can be summarised into a staging system &box -).

Box # $he fi%e staes of prolapse &'

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034734/#ref13http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034734/#ref13http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034734/#ref14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034734/#ref14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034734/#ref14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034734/#ref13http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034734/#ref13http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034734/#ref14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034734/#ref13http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034734/#ref14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034734/#ref14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034734/#ref13http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034734/#ref14


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• *tage 0> Fo prolapse

• *tage I> "he most distal portion of the prolapse is @! cm above the level of

the hymen

• *tage II> "he most distal portion of the prolapse is G! cm proximal or

distal to the hymen

• *tage III> "he most distal portion of the prolapse is @! cm below the

hymen but protrudes no further than 2 cm less than the total length of the

vagina

• *tage ID>


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to loo# for development of new symptoms or disorders &such as obstructed

urination or defecation, vaginal erosion).

*onser%ati%e treatment

+el%ic floor muscle trainin

elvic floor muscle training is an effective treatment for urinary incontinence, but

its role in managing prolapse is unclear .!


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• "he goal is to fit the largest pessary that does not cause discomfort

• s# the patient to wal# around, bend, and micturate to ensure that the

pessary is retained

(anaement

• Fo consensus exists on how freAuently to see a patient after a pessary is

fitted successfully

• t each follow3up visit as# the patient about any new symptoms and

inspect for erosions, ulcers, or discharge

• $itting a pessary can unmas# symptoms of urinary incontinence

lthough evidence to support the use of pessaries is not robust, they are used by

85% of gynaecologists and /8% of urogynaecologists. !8 In a prospective study of

!00 consecutive women with symptomatic pelvic organ prolapse fitted with a

pessary, - women retained the pessary two wee#s later. fter two months, /2%

of these women were satisfied with the pessary? virtually all symptoms of

prolapse and 0% of urinary symptoms had resolved, although occult stress

incontinence was unmas#ed in 2!% of the women.!/

'e found ust one small prospective study that loo#ed at whether pessaries can

alter the natural history of prolapse. $ifty six women were prospectively evaluated

using the pelvic organ prolapse Auantification system. ll women had a pessary

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fitted for at least one year. 1f the !/ women who continued to use pessaries, the

stage of the prolapse improved in four.20

In 200+, a


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uterosacral ligament? sacrospinous or prespinous fixation for vaginal vault

prolapse? and sacrocolpopexy &performed via an open procedure or

laparoscopically). retrospective case control study compared 52 women having

sacrospinous fixation with 52 women having 6c

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Uterine Prolapse is the Herniation of the Uterus Into or Beyond the Vagina as a Result of Failure of the Ligamentous and Fascial Supports