Uterine Prolapse & Vaginal Prolapse: Information, Symptoms, and Treatment

Uterine prolapse is the descent of the uterus from its normal position in the pelvis downward toward the vagina. It is usually caused by a weakening of the pelvic floor and the supporting connective tissue, often exacerbated by pregnancies, childbirth, or heavy physical strain.

The uterus is elastically attached to the pelvic wall by ligaments (ligamenta rotunda, ligamenta cardinalia). From below, it is supported by the ligamenta sacrouterinae and the pelvic floor. The pelvic floor consists of several layers of muscle and connective tissue. These are attached to the pelvic bones like a sort of “hammock.”

The urethra, vagina, and rectum pass through a natural opening in the pelvic floor. The uterus can also descend through this opening if it is no longer properly supported. This not only changes the position of the uterus but can also affect the positioning of other organs in the pelvis.

Illustration of a prolapsed uterus and the surrounding organs © Henrie / Fotolia

The primary cause of uterine prolapse is usually a weakening of the pelvic floor structures. There can be various reasons for this. Uterine prolapse is particularly likely to occur when several risk factors coincide. Risk factors include, for example:

• Age: After menopause, the elasticity of the tissue decreases. Muscle mass declines, and blood flow to the tissue decreases.
• Weak connective tissue: Weak connective tissue is usually hereditary or genetic. Other signs of this include varicose veins, hemorrhoids, or pronounced stretch marks.
• Pregnancy and childbirth: The firmness of the pelvic floor changes as early as during pregnancy—the tissue becomes softer. Vaginal delivery stretches the pelvic floor very significantly and can lead to muscle tears or tears in the tendinous muscle attachments to the pelvic wall. If other factors are involved, such as deliveries using a vacuum extractor or forceps, very heavy babies, or births occurring in quick succession, this can lead to permanent overstretching of the pelvic floor.
• Excess weight: Every kilogram of excess weight puts strain on the pelvic floor and leads to constant overloading.
• Lifting and carrying heavy loads significantly increases pressure on the pelvic floor over the long term.

A typical symptom of uterine prolapse is a “feeling of pressure” downward. A sensation of a foreign body in the vagina also frequently occurs with uterine prolapse. Some women experience pulling pain in the lower abdomen that radiates to the back after physical exertion. 

These symptoms are caused by the uterus pulling on the ligaments that support it. The discomfort is usually less severe in the morning and increases throughout the day. In cases of advanced prolapse, the pressure may be felt all the way into the vagina.

The altered position can also lead to urinary incontinence. If the pelvic floor is overstretched, the urethra is often no longer firmly anchored in the surrounding tissue. About half of those affected experience involuntary urine leakage during physical activity (stress incontinence). However, bladder emptying disorders involving incomplete bladder emptying may also occur. The urine remaining in the bladder (residual urine) increases the risk of bladder infections.

In severe cases, the rectum protrudes into the vagina. This can lead to difficulty with bowel movements.

If the vaginal lining or the cervix descends, this can lead to pressure sores on the skin. These sometimes cause bleeding or bacterial and fungal infections of the mucous membrane. This, in turn, can lead to vaginal discharge and an unpleasant odor.

Medically, uterine prolapse is classified by degree of prolapse:

• Grade I: Uterine prolapse extending below the upper third of the vagina but not reaching the vaginal opening (introitus).
• Grade II: Uterine prolapse extending to the vaginal opening.
• Grade III: Uterine prolapse extending beyond the vaginal opening (complete uterine prolapse).
• Grade IV: Total prolapse (the uterus protrudes through the vagina and pulls the vaginal wall downward with it)

Recurrent or chronic symptoms should always be evaluated by a doctor.

Be sure to see a gynecologist if you experience the symptoms described. Uterine prolapse can also affect bladder function, which is why a thorough evaluation is important.

Basic diagnostic procedures include a gynecological speculum examination and a pelvic exam. During these exams, the doctor can assess the position of the genital organs both at rest and when you bear down. In addition, the doctor checks the function of the anal sphincter when you clench your buttocks.

Using a cough test with a full bladder, the doctor can clinically confirm a relaxation of the urethra associated with stress incontinence.

Additional diagnostic options:

• In addition, an ultrasound assessment of residual urine volume as well as an ultrasound examination of the bladder and kidneys should be performed.
• An X-ray of the bladder is not necessary, as it does not provide any additional information regarding bladder prolapse compared to ultrasound.
• A defecography (imaging of bowel evacuation via MRI) can provide evidence of complex, higher-level anatomical or functional abnormalities of the rectum, as the bowel may also be affected.

Not every case of uterine prolapse causes symptoms in the affected women. However, if symptoms do occur, the uterine prolapse should be treated.

In general, treatment initially involves conservative, non-surgical measures. Surgery may be necessary only if these measures do not lead to improvement. The goal is to strengthen a weakened pelvic floor and alleviate symptoms.

These measures include, for example:

• Hormone suppositories or creams (“local estrogen therapy”): Estrogen deficiency in the urogenital tract leads to reduced tissue nourishment in postmenopausal women. This results in a more rapid breakdown of the so-called supporting structures. Therefore, treatment with estrogen-containing ointments or suppositories applied vaginally is often helpful for mild prolapse and/or incontinence symptoms.
• Pelvic floor exercises
• Biofeedback and electrostimulation therapy: These devices facilitate pelvic floor exercises. They provide feedback during muscle contraction or stimulate the muscles directly via electrical impulses.
• Pessaries: A pessary is shaped like a cup, ring, or cube and is made of hard rubber or silicone. They are inserted into the vagina and serve to expand and tighten the vaginal walls. This provides support for the uterus. However, pessaries are not effective for every type of uterine prolapse and can cause pressure sores (ulcers) and infections.

Pelvic floor exercises strengthen the pelvic floor muscles and can help with uterine prolapse or its prevention © Iryna | AdobeStock

If symptoms do not improve with conservative measures, surgery is necessary. The choice of surgical procedure depends on several factors:

• Severity of the uterine prolapse
• Any additional existing conditions (e.g., incontinence)
• The patient’s wishes regarding preservation of the uterus and the ability to have sexual intercourse

Surgery can be performed through the vagina, via an abdominal incision, or by laparoscopy. The following surgical options are available:

Hysterectomy: Removal of the prolapsed uterus through the vagina (vaginal), via laparoscopy, or through an abdominal incision.

Fixation of the vaginal end: The end of the vagina can be attached to connective tissue (supporting ligaments) in the area of the removed uterus or to a ligament in front of the spine (ligamentum longitudinale).

Plastic mesh is typically used for this purpose. However, since complications have repeatedly occurred with this method, tendon tissue from the thigh has recently begun to be used as well.

Vaginal tightening (vaginal plasty): Tightening of the prolapsed vaginal wall at the front and back. However, since the vagina is very elastic, the results are usually short-lived. In nearly 30 percent of cases, prolapse recurs within 5 years at the latest.

Insertion of a synthetic mesh under the vaginal wall (mesh insertion): This method results in a more stable vaginal correction. A synthetic mesh is used to reinforce the vaginal walls. At the same time, the surgeon secures the vaginal opening to the ligaments sacrospinalis or sacrotuberalis.

However, pain may occur after the surgery. Under certain circumstances, the synthetic mesh may protrude through the vaginal wall. Since the vagina grows into the mesh, complete removal of the mesh is then no longer possible. Accordingly, such a mesh should only be used in exceptional cases (for example, when other procedures have been unsuccessful). In some countries, such as the United States, the use of synthetic mesh is now banned.

Correction of stress incontinence: Existing incontinence may also improve following a prolapse repair. However, if incontinence persists after surgery, it can be corrected with a subsequent surgical procedure.

The pelvic floor loses stability over the course of a woman’s life. The best prevention is to avoid overloading the pelvic floor and to exercise it regularly (regular pelvic floor exercises).

Pelvic organ prolapse can recur even after surgical correction. Therefore, affected women should continue to focus on prevention even after surgery.

For women who are over 35 years old when giving birth to their first child, a planned cesarean section may be recommended. This helps protect the pelvic floor tissue.

After childbirth, it is important to treat birth injuries, particularly those involving the anal sphincter (musculus sphincter ani). Postpartum exercises and postnatal rehabilitation help strengthen the core. Ideally, these exercises should continue to be performed regularly after childbirth.

As a preventive measure, it is important to maintain a healthy weight and engage in moderate physical activity. Sports that are beneficial for strengthening the pelvic floor include

• hiking
• Walking
• Swimming
• Horseback riding
• Dancing

Sports involving sudden movements, such as

• tennis
• Trampoline jumping

Since the pelvic floor changes over the course of a woman’s life, ongoing exercise is worthwhile.

As part of the pelvis, the uterus is particularly dependent on stable supporting structures. The causes of uterine prolapse are usually a weakening of the connective tissue and the pelvic floor. It can be exacerbated by aging, pregnancy and childbirth, or heavy lifting.

Typical symptoms may include a feeling of pressure, difficulty urinating, or a sensation of a foreign object in the vagina. Stress incontinence and discomfort during sexual intercourse may also occur. Some women also experience pain during sexual intercourse.

The diagnosis is made through a gynecological examination, during which the doctor assesses the degree of uterine prolapse. Additionally, a cough test, ultrasound, or residual urine measurement may be helpful.

Treatment for uterine prolapse usually begins with targeted pelvic floor exercises or the use of a pessary. For mild uterine prolapse, a conservative approach is often sufficient. If symptoms persist, surgery may be necessary.