Uterine Prolapse

Introduction

• Description: Uterine prolapse is the loss of the normal support mechanism, resulting in descent of the uterus down the vaginal canal. In the extreme, this may result in the uterus descending beyond the vulva to a position outside the body (procidentia).

• Prevalence: Some degree of uterine descent is common in parous women.

• Predominant Age: Late reproductive age and older. Incidence increases with the loss of estrogen.

• Genetics: No genetic pattern.

Etiology and Pathogenesis

• Causes: Loss of normal structural support because of trauma (childbirth), surgery, chronic intraabdominal pressure elevation (eg, obesity, chronic cough, or heavy lifting), or intrinsic weakness. Most common sites of injury are the cardinal and uterosacral ligaments, and the levator ani muscles that form the pelvic floor, which may relax or rupture. Increased intraabdominal pressure from a pelvic mass or ascites may rarely weaken the pelvic support and result in prolapse. Injury to or neuropathy of the S1-S4 nerve roots may also result in decreased muscle tone and pelvic relaxation.

• Risk Factors: Birth trauma, chronic intraabdominal pressure elevation (eg, obesity, chronic cough, or heavy lifting), intrinsic tissue weakness, or atrophic changes, resulting from estrogen loss.

Signs and Symptoms

• Pelvic pressure or heaviness (a sense of “falling out”)

• Mass or protrusion at or beyond the vaginal entrance

• New-onset or paradoxical resolution of urinary incontinence

• Drying, thickening, chronic inflammation, and ulceration of the exposed tissues, which may result in bleeding, discharge, or odor

Diagnostic Approach