eMedicine Specialties > Obstetrics and Gynecology > Prolapse and Incontinence
Uterine Prolapse: Treatment
Updated: Aug 14, 2007
Treatment
Medical Therapy
Patients with mild uterine prolapse do not require therapy because they are usually asymptomatic. However, when symptoms occur, many patients initially opt for conservative treatment. In addition, patients who are poor surgical candidates or are strongly disinclined to surgery can be offered pessaries for symptom relief. Topical estrogen is an important adjunct in the conservative management of patients with UP. When operative repair for prolapse of the uterus is chosen, a clear surgical plan must be formulated. The pelvic surgeon should consider surgical risks, coital activity, and normal vaginal anatomy. The correct operation must be tailored to the individual patient (see Indications).
Other questions that must be answered include whether the operation is performed abdominally, vaginally, or laparoscopically and whether a hysterectomy should be performed. A hysterectomy is not necessarily a mandatory part of the surgical repair for UP because various types of uterine suspensions can be performed via the abdominal or vaginal route. However, for practical reasons, the uterus is often removed to provide better access to the apical reattachment points, particularly the uterosacral, cardinal, sacrospinous, and anterior sacral ligaments.
Conservative treatment
Pelvic exercises and pessaries are the current mainstays of nonsurgical management of patients with UP. Although routine Kegel exercises can improve pelvic floor muscle tone and stress UI, no evidence in any prospective, blinded, randomized trials indicates that improvement of pelvic floor muscle tone leads to regression of UP.
Vaginal support devices are excellent options for treating patients with UP conservatively, and pessary use has few contraindications aside from acute pelvic inflammatory disease and pain after insertion. Recurrent vaginitis is a relative contraindication and may require removal of the pessary. An important adjunct is application of topical estrogen to the everted vagina, particularly if signs of hypoestrogenism exist.
Many different types of pessaries can be used, and pessary fitting is far from an exact science. Trial and error is the rule. Initially, the authors try the two most common types, ie, the ring with support and the donut pessary, depending on concomitant pelvic floor defects. Other types are the inflatable ball, cube, and Gehrung pessaries. The Gellhorn is most often used for patients with significant UP and a large introital diameter who have not obtained relief with other pessaries. The Smith-Hodge and Risser pessaries facilitate retrodisplacement of the uterus and should be used for patients with a well-defined pubic notch and adequate vaginal width.
Surgical Therapy
The primary management strategy for severe UP is surgical. For patients in whom conservative management has failed, a variety of surgical approaches are available to correct POP.
Abdominal approach
If an abdominal approach is selected for the correction of UP, the authors' preferred operations are abdominal sacral colpopexy or sacral uteropexy. Both operations allow the upper vagina to regain its normal anatomic axis (sitting upon and parallel to the pelvic floor) by securing the apical vagina or the uterus to the sacrum with sutures through the presacral fascia at the promontory or at S3 if it is strong and free of vessels.
The authors' biomechanical anatomic studies have demonstrated that the presacral fascia is strongest at the promontory.14 If the promontory is chosen, the intervening material must be applied loosely so that there is no tension on the vagina during straining and the vagina rests on the levator plate. These abdominal forces can be hypothetically tested intraoperatively by means of gentle downward traction on the vagina and graft material before trimming the material and securing the suture. The abdominal approach generally allows higher fixation in the pelvis and provides durable repair with sufficient vaginal length.
Sacropexy procedures use grafts of harvested fascia lata15 , abdominal fascia, dura mater, Marlex, Prolene, Gore-Tex, Mersilene16 , or cadaveric fascia lata. Grafts are placed from the vaginal cuff, the amputated cervical stump, or the uterine corpus to the presacral fascia. The authors prefer to attach the graft to a large area of both the anterior and posterior vaginal walls, which reduces large mid-to-high cystoceles and rectoceles in many instances. Permanent suture is used, and the graft is peritonealized to prevent any bowel entrapment. As mentioned previously, the authors routinely perform a culdoplasty. This procedure involves obliterating the cul-de-sac by suturing the peritoneal surfaces together, usually incorporating the uterosacral ligaments in the repair.
Vaginal approach
Most commonly, vaginal surgery is preferred because the patient usually has a shorter recovery time with this approach. In addition, it is selected if a vaginal approach is planned for the correction of incontinence (eg, for placement of a suburethral sling) or when concomitant vaginal reconstruction is indicated.
The 3 common vaginal procedures to suspend the prolapsed vaginal apex are sacrospinous ligament fixation, modified McCall culdoplasty, and iliococcygeus fascia suspension. As originally described by Amreich and modified by Richter and Nichols, sacrospinous ligament fixation is usually performed on the patient's right side to avoid the rectosigmoid.17 The vaginal apex is attached, using permanent sutures, to the sacrospinous ligament. A thorough knowledge of pelvic anatomy is critical to avoid complications. Take care to place the sutures 1-2 cm medial to the ischial spine to avoid injury to the pudendal bundle and the inferior gluteal vessels. Place the suture through—rather than around—the ligament. Excellent results have been reported for correcting vaginal vault prolapse using fixation to the sacrospinous ligament. However, in 1992, Shull and colleagues reported a predisposition for recurrence of anterior vaginal wall relaxation after sacrospinous ligament fixation.18
The McCall culdoplasty may be used to correct apical descent or as prophylaxis against future prolapse.19 This procedure uses the uterosacral ligaments, which, if strong, are shortened and reattached to the vaginal cuff after completion of the vaginal hysterectomy. In the authors' opinion, attaching the prolapsed vagina to stretched prolapsed uterosacral ligaments is of little value. The surgeon must be bold enough to grasp the uterosacrals near the sacrum, where they are usually strong and undetached, but careful enough to respect and avoid the neighboring ureters. Intraoperative cystourethroscopy is therefore essential to be sure the ureters have not been ligated or kinked.
The iliococcygeus fascia suspension provides effective cuff suspension, since it attaches the apex to the obturator internus fascia and iliococcygeus fascia with less risk of neurovascular damage than does the sacrospinous ligament fixation.20 Alternatively, the authors have described placing the suture through the iliococcygeus and the periosteum at the ischial spine, where it is attached.21
If an enterocele is encountered after removing the uterus, the sac is separated from the vagina. This redundant "hernia sac" is ligated at its neck and excised. Take care to avoid any loops of small bowel, which may also prolapse into the cul-de-sac between the vagina and the rectum. If the enterocele is not adequately repaired, the patient may have recurrence of apical, posterior, or anterior defects, with prolapse of the vagina vault.
For patients who cannot undergo long surgical procedures and who are not contemplating sexual activity, obliterative procedures, such as the Le Fort colpocleisis or colpectomy and colpocleisis, are viable options. With the Le Fort colpocleisis, a patch of anterior and posterior vaginal mucosa is removed. The cut edge of the anterior vaginal wall is sewn to its counterpart on the posterior side. As the approximation is continued on each side, the most dependent portion of the mass is progressively inverted. A tight perineorrhaphy is also performed to help support the inverted vagina and prevent recurrence of the prolapse. The authors have described and reported a procedure for denuding the anterior and posterior vaginal mucosa with a dermatome.22
The main problem specific to these obliterative operations is that they limit coital function. Neither corrects an enterocele because they are both extraperitoneal procedures. Also, there is a 25% incidence of postoperative urinary stress incontinence caused by induced fusion of the anterior and posterior vaginal walls and flattening of the posterior urethrovesical angle. In addition, if the uterus is retained, the patient can later bleed from many causes, including carcinoma.
Preoperative Details
Although the choice of procedure largely depends on the surgeon's preference and experience, also consider factors such as the patient's general health status, degree and type of POP, need for preservation or restoration of coital function, concomitant intrapelvic disease, and desire for preservation of menstrual and reproductive function.
When deciding on the type of surgery to correct UP, the pelvic surgeon should remember that UP is the result and not the cause of POP. Therefore, performing a hysterectomy does not correct the apical defect. A careful preoperative evaluation should identify all concomitant defects associated with UP, which should be repaired in order to avoid recurrence of POP.
Intraoperative Details
The challenge to the pelvic surgeon is to recreate normal anatomy while maintaining normal function. Experienced gynecologic surgeons can reevaluate the anatomy intraoperatively, noting the strength and consistency of the various support structures (eg, uterosacral ligaments). If these structures are found to be weak, it may be necessary to use other, stronger reattachment sites, such as the sacrospinous ligament or the presacral fascia, for the correction of the defect. In addition, make every attempt to prevent a recurrence of POP. For example, when performing a retropubic urethropexy for UI, a concomitant colpocleisis may avoid the formation of an enterocele in the future.
Postoperative Details
If a vaginal approach is used, instruct the patient to avoid any exercise or heavy lifting and to refrain from intercourse for 6 weeks after her discharge from the hospital. Subsequent to the 6-week follow-up visit, the patient is instructed to progressively return to her usual daily activities. Stress the need to avoid causes of increased intra-abdominal pressure, such as constipation, weight lifting, and cigarette smoking, for at least 3 months. This facilitates adequate healing and prevents surgical failures. For postmenopausal patients, the authors routinely recommend continuation of estrogen therapy in order to maintain the integrity of pelvic tissues and to maximize surgical success.
Follow-up
If conservative treatment is used, depending on symptoms, instruct patients to remove and clean the pessary and/or to douche weekly with a weak vinegar solution to lessen the chances of complications (see Complications). After fitting the patient with the appropriate size and type of pessary, instruct her to return for a follow-up examination at 1 week to assess any inflammatory response, ulceration, or urinary or defecatory problems. If the patient cannot clean and replace the pessary satisfactorily, the provider should clean and replace it every 8-12 weeks.
For excellent patient education resources, visit eMedicine's Women's Health Center. Also, see eMedicine's patient education article Prolapsed Uterus.
Complications
Conservative treatment
Pessaries may cause vaginitis, bleeding, ulceration, UI, urinary obstruction with retention, fistula formation, and erosion into the bladder or rectum. Most complications are from a long-forgotten pessary.23 Rarely, carcinoma at the site of contact has been reported.24
Abdominal approach
Bleeding is the most serious complication of sacral colpopexy.25 Injuring the presacral venous plexus or the middle sacral artery while operating in the presacral space is possible. Other complications include ureteral injury, graft rejection, and suture pullout (causing recurrence of the prolapse). Erosion of synthetic grafts through the vagina has been reported at a rate of 3% in a series of 370 patients who had undergone sacral colpopexy.26
Vaginal approach
Surgical correction of UP has a low complication rate. Reported complications (other than the risks associated with general anesthesia) include pelvic infection, hemorrhage, and injury to the ureters or lower urinary tract with fistula formation, bowel injury, sacral osteomyelitis, and graft rejection. The two most serious complications from sacrospinous ligament fixation are hemorrhage and nerve injury from the pudendal neurovascular bundle. Despite the reported long-term success rates after correction of UP27 , surgical failure does occur. For patients who have recurrent POP, a careful evaluation is warranted in order to determine the cause of failure. Most surgical failures are probably related to surgical technique or inaccurate preoperative diagnosis of other concomitant defects.
More on Uterine Prolapse |
| Overview: Uterine Prolapse |
| Workup: Uterine Prolapse |
 Treatment: Uterine Prolapse |
| Follow-up: Uterine Prolapse |
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References
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Further Reading
Keywords
UP, prolapsed uterus, pelvic organ prolapse, POP, urinary incontinence, UI, genitourinary prolapse, procidentia, pelvic relaxation, pelvic floor defects, multiparity, genital atrophy, hypoestrogenism, pelvic tumors, sacral nerve disorders, diabetic neuropathy, obesity, Marfan syndrome, lower urinary tract dysfunction, hydronephrosis, obstructive nephropathy, urinary retention, hysterectomy, sacral colpopexy, sacral uteropexy, sacropexy, hysteropexy, sacrospinous ligament fixation, modified McCall culdoplasty, iliococcygeus fascia suspension, Kegel exercises, pessary, pessaries
