UTERINE PROLAPSE - Causes and Risk Factors, Pathophysiology, Clinical Manifestations, Diagnostic Evaluations and Management

Uterine prolapsed is a condition in which a woman’s uterus sags or slips out of its normal position. Uterine prolapsed occurs when pelvic floor muscles and ligaments stretch and weaken, providing inadequate support for the uterus. The uterus then descends into the vaginal canal.

Uterine prolapse often affects postmenopausal women who have had one or more vaginal deliveries. Damage to supportive tissues during pregnancy and childbirth, effects of gravity, loss of estrogen, and repeated straining over the years all can weaken pelvic floor and lead to uterine prolapse.

 

CAUSES AND RISK FACTORS

Pregnancy and trauma incurred during childbirth, particularly with large babies or after a difficult labor and delivery, are the main causes of muscle weakness and stretching of supporting tissues leading to uterine prolapse. Loss of muscle tone associated with aging and reduced amounts of circulating estrogen after menopause also may contribute to uterine prolapse. In rare circumstances, uterine prolapsed may be caused by a tumor in the pelvic cavity.

Other factors such as obesity,chronic coughing or straining, an accumulation of fluid in the abdomen and chronic constipation all place added tension on the pelvic muscles, and may contribute to the development of uterine prolapse. Radical surgery in the pelvic area leads to loss of external support. Genetics also may play a role in strength of supporting tissues. Women with a genetic collagen deficiency (Marfan syndrome or Ehlers-Danlos syndrome) have an increased risk of prolapse even if they do not have any of the other risk factors. Women who have large fibroids or pelvic tumors are at an increased risk of prolapse.

Previous pelvic surgery, for example bladder repair procedures, may damage nerves and tissues in the pelvic area increasing the risk of prolapsed. Spinal cord injury and conditions such as muscular dystrophy and multiple sclerosis increase the risk of prolapsed. If the pelvic muscles are paralyzed or movement is restricted, the muscles weaken and cannot support the pelvic organs.

        Women of Northern European descent have a higher incidence of uterine prolapsed than do women of Asian and African descent.

 

PATHOPHYSIOLOGY

        Prolapse refers to a collapse, descent, or other change in the position of the uterus in relation to surrounding structures in the pelvis. Normally, the uterus is held in place by the muscles and ligaments that make up the pelvic floor. Uterine prolapsed occurs when the pelvic floor muscles and ligament stretch, become damaged and weakened, so they can no longer support the pelvic organs, allowing the uterus to fall into the vagina.

        Prolapsed refers to a collapse, descent, or other change in the position of the uterus in relation to surrounding structures in the pelvis

                                               

Normally, uterus is held in place by the muscles and ligaments that make up the pelvic floor

                                               

Uterine prolapsed occurs when the pelvic floor muscles and ligaments stretch become damaged and weakened

                                               

So they can no longer support the pelvic organs, allowing the uterus to fall into the vagina

Prolapse of the uterus may be one of three types, depending on severity:

1. First-degree prolapse occurs when the uterus sags downward into the upper vagina.
2. Second-degree prolapse occurs when the cervix is at or near the outside of the vagina.
   
3. Third-degree prolapsed (total prolapsed) occurs when the entire uterus is outside the vagina.
   

 

CLINICAL MANIFESTATIONS

    Women with mild cases of uterine prolapse may have no obvious symptoms. However, as the uterus slips further out of position, it can place pressure on other pelvic organs – such as the bladder or bowel – causing a variety of symptoms, including:

• A feeling of heaviness or pressure in the pelvis
• Pain in the pelvis, abdomen or lower back
  
• Painful sexual intercourse
  
• A protrusion of tissue from the opening of the vagina
  
• Recurrent bladder infections
  
• Low back pain
  
• Unusual or excessive discharge from the vagina
  
• Constipation
  
• Difficulty with urination, including loss of urine (incontinence), or urinary frequency or urgency
  
• Symptoms may be worsened by prolonged standing or walking; this is due to the added pressure placed on the pelvic muscles by gravity
  

 

DIAGNOSTIC EVALUATIONS

        Health care provider can diagnose uterine prolapsed with a medical history and physical examination of the pelvis. Doctor will perform a complete pelvic exam to check for signs of uterine prolapse. The doctor may need to examine patient in standing position as well as while lying down and ask to cough or strain to increase the pressure in abdomen.

        Specific conditions, such as ureteral obstruction due to complete prolapse, may need an intravenous pyeloggram (IVP) or renal sonography. Dye is injected into vein, and a series of x-rays are taken to view its progress through bladder. Ultrasound may be used to rule out other pelvic problems. In this test, a wand is passed over abdomen or inserted into vagina to create images with sound waves.

MANAGEMENT

        There are surgical and non- surgical options for treating uterine prolapsed. The treatment chosen will depend on the severity of the condition, as well as the woman’s general health, age and desire to have children. Treatment generally is effective for most women. Treatment options include the following:

Non-Surgical Options

1. Exercise – Special exercises, called Kegel exercises, can help strengthen the pelvic floor muscles. This may be the only treatment needed in mild cases of uterine prolapse.  To perform Kegel exercises, ask the patient to tighten the pelvic muscles as if she is trying to hold back urine for few seconds and then release, to be repeated 10 times, up to 4 times a day. Patient may do these exercises anywhere and at any time. (Up to four times a day).
2. Vaginal pessary – a pessary is a rubber or plastic doughnut-shaped device that fits around or under the lower part of the uterus (cervix), helping to support the uterus and hold it in place. The pessary can be a temporary or permanent form of treatment.
   
3. Estrogen replacement therapy – taking estrogen may help to limit further weakness of the muscles and other connective tissues that support the uterus.​
   

SURGICAL OPTIONS

1. Hysterectomy – Uterine prolapse may be treated by removing the uterus in a surgical procedure called hysterectomy. This may be done through an incision made in the vagina (vaginal hysterectomy) or through the abdomen (abdominal hysterectomy). Hysterectomy is major surgery, and removing the uterus means pregnancy is no longer possible.
2. Colpocleisis – The classic procedure was described by Le Fort and involves the removal of a strip of anterior and posterior vaginal wall, with closure of the margins of the anterior and posterior wall to each other.
   
3. Sacrohysteropexy – This procedure uses a strip of synthetic mesh to hold the uterus in place. The operation is performed abdominally, either through a 15-cm incision or laparoscopy. One end of the mesh is attached to the cervix and top of the vagina and the other to a bone (sacrum or sacral bone). Once in place, the mesh supports the uterus.
   
4. Uterine suspension – This procedure involves putting the uterus back into its normal position. This may be done by reattaching the pelvic ligaments to the lower part of the uterus to hold it in place. Another technique uses a special material that acts like a sling to support the uterus in its proper position. Recent advances include performing this with minimally invasive techniques and laparoscopically that decrease post operative pain and speed recovery.
   

NURSING MANAGEMENT

1. Lifestyle changes may be the first step to ease symptoms of uterine prolapse:

• Encourage the patient to achieve and maintain a healthy weight, to minimize the effects of being overweight on supportive pelvic structures.
• Instruct the patient to perform Kegel exercises regularly, to strengthen pelvic floor muscles
  
• Encourage the patient to avoid heavy lifting and straining to reduce abdominal pressure  on supportive pelvic structures
  

2. Encourage the patient to stop smoking and getting proper treatment for contributing medical problems, such as lung disease with coughing, may slow the progression of uterine prolapse.
3. Encourage the patient to a healthy diet balanced in protein, fat and carbohydrate. Also, eat food that is high in dietary fiber (such as whole grain cereals, legumes and vegetables). A healthy diet can help maintain weight and prevent constipation
Instruct the patient that the pessary must be cleaned frequently and removed before sex
4. Educate the woman regarding complications of the vaginal pessary such as pelvic discomfort, vaginal discharge, vaginal ulceration, and bleeding. Such complications may require at least temporary discontinuance of use, as recommended by physician.
5. Encourage the patient to avoid prolonged standing or walking. Because the added pressure placed on the pelvic muscles by gravity may be worsened symptoms.
Administer hormone replacement therapy for at least 30 days in the form of systemic estrogen to improve the integrity of the pelvic tissue and may slow the progression of pelvic organ prolapse

 

UTERINE PROLAPSE - Causes and Risk Factors, Pathophysiology, Clinical Manifestations, Diagnostic Evaluations and Management