Uterine prolapse: Information and specialists

09.11.2023
Leading Medicine Guide Editors
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Leading Medicine Guide Editors

The uterus is held in position above the vagina by ligaments and tendons. The pelvic floor muscles also contribute to this. Due to natural aging processes, but also giving birth, the resilience of the supporting structures can decrease. Then the uterus may shift downward due to gravity. This process is called uterine prolapse or uterine descensus.

Below you will find more information and selected specialists in uterine prolapse.


ICD codes for this diseases: N81.2, N81.3, N81.4

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Brief overview:

  • What is uterine prolapse? When the uterus shifts downward in the abdominal cavity, it is called uterine prolapse. 50% of women are affected during their lifetime.
  • Causes: There is usually a weakness of the connective tissue. The pelvic floor muscles are also responsible. Risk factors include having heavy babies, regularly lifting heavy loads, and being overweight.
  • Symptoms: Symptoms do not always occur. Pain during intercourse, in the lower abdomen or lower back, a foreign body sensation in the vagina, urinary incontinence, and urinary tract infections are among the symptoms.
  • Diagnosis: A doctor can detect a uterine prolapse during a gynecological exam. Further investigations can pinpoint the exact causes.
  • Treatment: It can be treated conservatively at first or surgically later. The decision depends on several factors. Conservative therapies include pelvic floor exercises and the use of foreign bodies in the vagina (pessaries). Since conservative therapy is usually insufficient, several surgical therapies are available.
  • Prevention: It can be prevented by pelvic floor training, reducing excess weight, and gentle carrying techniques.

Article overview

Position of the uterus

The uterus is elastically attached to the pelvic wall by ligaments (round ligament, cardinal ligament). From below, it is supported by the uterosacral ligaments and the pelvic floor. The pelvic floor consists of several layers of muscles and connective tissue. They are fixed to the bones of the pelvis like a kind of "hammock".

The urethra, vagina, and rectum run through a natural opening in the pelvic floor. The uterus can also descend through this gap if it is no longer held properly.

Gebärmuttersenkung
Illustration of the descending uterus and surrounding organs © Henrie / Fotolia

Causes and risk factors for uterine prolapse

The reason for uterine prolapse is usually a weakening of the pelvic floor structures. There may be various reasons for this. Especially when several risk factors coincide, the uterus descends. Risk factors include:

  • Age: After menopause, the elasticity of the tissue decreases. The musculature breaks down and tissue perfusion decreases.
  • Weak connective tissue: A connective tissue weakness is mostly hereditary or genetic. Other signs are varicose veins, hemorrhoids, or pronounced stretch marks.
  • Pregnancies and births: Even during pregnancy, the strength of the pelvic floor changes and the tissue becomes softer. Vaginal birth stretches the pelvic floor a great deal and can cause muscle tears or avulsions of the sinewy muscle attachments to the pelvic wall. If other factors are added, such as births with a vacuum extractor or forceps, very heavy children, or births in rapid succession, this can lead to permanent overstretching of the pelvic floor.
  • Obesity: In obesity, every kilo puts more load on the pelvic floor and leads to it being constantly overloaded.
  • Lifting and carrying "heavy" objects also increases the chances of the female genital organs lowering.

Symptoms of uterine prolapse

A typical symptom of uterine prolapse is a downward "feeling of pressure". A foreign body sensation in the vagina is also common with uterine prolapse. Some women suffer from 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 from which it is suspended. The discomfort is usually less in the morning and increases over the course of a day.

When there is overstretching of the pelvic floor, often the urethra is also no longer firmly fixed in the tissue. About half of those affected experience involuntary leakage of urine during physical activity (stress incontinence). However, bladder emptying disorders with incomplete bladder emptying can also occur. The urine remaining in the bladder (residual urine) increases the chances of developing bladder infections.

In severe cases, the rectum bulges into the vagina. Then there may be difficulty defecating.

If the vaginal mucosa or cervix descends, this can cause pressure ulcers on the skin. These sometimes cause bleeding or colonization of the mucosa with bacteria and fungi. This, in turn, can lead to discharge and odor.

Medically, a distinction is made between four degrees of severity in uterine prolapse:

  • Grade I: Uterine prolapse that extends below the upper third of the vagina but not to the vaginal entrance (introitus).
  • Grade II: Uterine prolapse extends to the vaginal entrance.
  • Grade III: Uterine prolapse beyond the vaginal opening.
  • Grade IV: Total prolapse (the uterus pushes out through the vagina and pulls the vaginal wall down with it)

Diagnosing uterine prolapse

Be sure to go to the gynecologist if you experience the symptoms described above.

Basic diagnostics include a gynecological speculum and palpation examination. This allows the doctor to assess the position of the genital organs at rest and during pressing. In addition, they check the functioning of the sphincter muscle (anal sphincter) during contractions.

By means of a cough test with a full bladder, the physician can clinically confirm a loosening of the urethra with stress incontinence.

Other examination options:

  • In addition, residual urine should also be determined by an ultrasound and sonography of the bladder and kidneys.
  • An X-ray of the bladder is not necessary, as it does not provide any further indications with regard to bladder prolapse compared to ultrasound.
  • A defecography (visualization of the bowel movements in an MRI) can provide indications of complex higher positional or functional anomalies of the rectum.

Conservative treatment for uterine prolapse

Not every uterine prolapse leads to symptoms in the affected women. However, if symptoms occur, the uterine prolapse should be treated.

In general, the therapy initially provides for conservative, non-surgical measures. Surgery may only be necessary if these do not bring improvement.

These measures include, for example:

  • Hormone suppositories or creams ("local estrogenization"): Estrogen deficiency in the urogenital tract leads to reduced tissue nutrition in post-menopausal women. This results in a more rapid degradation of the supporting structures. Therefore, therapy with estrogen-containing ointments or suppositories applied through the vagina is often helpful for mild uterine descensus and/or incontinence symptoms.
  • Pelvic floor exercises
  • Biofeedback and electrostimulation treatment: These tools facilitate the exercises of the pelvic floor. They provide feedback during muscle activity or stimulate the muscles themselves via impulses.

Pessaries: Pessaries are bowl, ring, or cube-shaped and are made of hard rubber or silicone. They are inserted into the vagina and have the function of expanding and tightening the vagina, which supports the uterus. However, pessaries do not stay in place in every form of uterine prolapse and can cause pressure sores (ulcers) and infections.

Beckenbodentraining

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

Surgical treatment for uterine prolapse

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

  • Severity of uterine prolapse,
  • Possibility of an additional existing diseases (e.g., incontinence), and
  • Wishes of the patient with regard to the preservation of the uterus and preservation of the ability to have sexual intercourse.

Surgery can be performed from the vagina, through an abdominal incision, or via laparoscopy. The following surgical measures are possible:

Uterus removal (hysterectomy): Removal of the lowered uterus through the vagina, by laparoscopy or abdominal incision.

Fixing the end of the vagina: The end of the vagina may be attached to connective tissue (retaining ligaments) in the area of the removed uterus or to a ligament in front of the spine (longitudinal ligament).

Plastic mesh is usually used for this purpose. However, since there have been repeated complications with this, tendon tissue from the thigh has recently been used.

Narrowing of the vagina (vaginoplasty): Tightening of the lowered vaginal wall in front and behind. However, since the vagina is very stretchy, success is usually short-lived. In almost 30 percent of cases, a new prolapse occurs after 5 years at the latest.

Insertion of a plastic mesh under the vaginal skin (mesh insertion): This method produces a more stable vaginal correction. A plastic mesh is used, which reinforces the vaginal walls. At the same time, the surgeon fixes the end of the vagina to the sacrospinous ligament or sacrotuberous ligament.

However, pain may occur after the operation. Under certain circumstances, the plastic mesh may pass through the vaginal wall. As the vagina grows into the mesh, complete removal of the mesh is then no longer possible. Accordingly, such a mesh should be used only in exceptional cases (for example, when other methods have not been successful). In some countries, such as the USA, the use of plastic mesh is now banned.

Correcting stress incontinence: After a prolapse operation, existing incontinence may also improve. However, if incontinence persists after surgery, it can be corrected in another operation.

Preventing uterine prolapse

The pelvic floor loses stability in the course of life. The best prevention is not to overexert the pelvic floor and to exercise it regularly (pelvic floor training).

Sagging of the pelvic floor can recur even after surgical correction. Therefore, affected women should think about prevention even after surgery.

For women who are over 35 years of age when their first child is born, a planned cesarean section may be recommended. This protects the pelvic floor tissue.

After childbirth, it is important to care for birth injuries and especially sphincter muscle injuries (anal sphincter muscles). Postnatal and postpartum gymnastics lead to the strengthening of the body's core. Ideally, these exercises continue to be performed regularly after births.

Attention should be paid to normal weight and reasonable exercise as preventative measures. Sports that are advisable for strengthening the pelvic floor are

  • Hiking,
  • Walking,
  • Swimming,
  • Horse riding, and
  • Dancing.

Less beneficial are sports with abrupt movements such as

  • Tennis and
  • Trampolining.
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