Uterine Prolapse Treatment & Management

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.

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 S1 or S2 if it is strong and free of vessels.

The authors' biomechanical anatomic studies have demonstrated that the presacral fascia is strongest at the promontory.^[15] 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.

A variety of grafts have been used for sacropexy procedures (eg, harvested fascia lata abdominal fascia, cadaveric fascia lata, Marlex, Prolene, Gore-Tex, Mersilene, Vipro-II) with variable success rates. The ideal biocompatible material used should be chemically and physically inert, durable, noncarcinogenic, noninflammatory, readily available, and inexpensive.

The synthetic polypropylene mesh has been shown to be superior to autologous fascia lata.^[16] Multifilament mesh (ie, Gore-Tex, Mersilene) has been associated with chronic inflammation that can be detrimental compared to monofilaments, which produce an acute inflammatory reaction and formation of fibrous tissue.^[17] Moreover, mesh with large pore size (>75 micrometers) allows ingrowth of fibroblast, collagen and blood vessels, and allows for macrophage, and leukocyte infiltration and passage, thus decreasing the chance of mesh infection and mesh erosion.^[18]

On July 13, 2011, the FDA issued a statement that serious complications are not rare with the use of surgical mesh in transvaginal repair of pelvic organ prolapse. The FDA reviewed the literature from 1996-2011 to evaluate safety and effectiveness and found surgical mesh in the transvaginal repair of pelvic organ prolapse does not improve symptoms or quality of life more than nonmesh repair. The review found that the most common complication was erosion of the mesh through the vagina, which can take multiple surgeries to repair and can be debilitating in some women. Mesh contraction was also reported, which causes vaginal shortening, tightening, and pain.

The FDA’s update states, “Both mesh erosion and mesh contraction may lead to severe pelvic pain, painful sexual intercourse or an inability to engage in sexual intercourse. Also, men may experience irritation and pain to the penis during sexual intercourse when the mesh is exposed in mesh erosion.” The FDA is continuing to review the literature regarding surgical mesh in the treatment of stress urinary incontinence and will issue a report at a later date. See the full update regarding surgical mesh in pelvic organ prolapse here: FDA Safety Communication: Update on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse.

The graft is peritonealized to prevent any bowel entrapment. Some surgeons also 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. Grafts are placed from the vaginal cuff, or the amputated cervical stump, to the presacral fascia with permanent suture in a tension-free fashion. The graft is peritonealized and some surgeons obliterate the rectovaginal pouch (pouch of Douglas) to prevent future enterocele.

The Marion-Moschcowitz procedure entails a spiral suture placed around the rectovaginal pouch to close it circumferentially. The Halban procedure involves placement of several sutures in the sagittal plane that close the anterior and posterior leaves of the pouch of Douglas. Whether performing a total hysterectomy at the time of sacralcolpopexy increases the chance of vaginal exposure or erosions is debatable. Erosion rates vary from 6.9-27% with concurrent hysterectomy to 1.3-4.7% with a prior hysterectomy.^{[19, 20, 21]} At this time, no strong evidence shows that performing a supracervical hysterectomy at the time of sacrocolpopexy decreases the erosion rate; however, the authors favor this approach in patients with no evidence of cervical dysplasia.

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, high uterosacral ligament fixation, 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.^[22] 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.^[23]

The high uterosacral ligament fixation, which is a modification of the McCall culdoplasty may be used to correct apical descent or as prophylaxis against future prolapse.^[24] 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 proximal uterosacrals, 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.^[25] Alternatively, the authors have described placing the suture through the iliococcygeus and the periosteum at the ischial spine, where it is attached.^[26]

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 usually 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.^[27]

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. An unusual and rare complication of pyometra has also been reported after Le Fort colpocleisis, necessitating abdominal hysterectomy.^[28]

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.

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 culdoplasty may avoid the formation of an enterocele in the future.

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.

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 1-2 weeks 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.

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.^[29] Rarely, carcinoma at the site of contact has been reported.^[30]

Abdominal approach

Bleeding is the most serious complication of sacral colpopexy.^[31] Injuring the presacral venous plexus or the middle sacral artery while operating in the presacral space is possible. Other complications include ureteral injury, graft erosion, 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.^[32]

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 UP^[33] , 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.

For the first time in history, large numbers of women are living long enough to develop pelvic floor disorders. UP is one of the more common pelvic floor defects and is a challenge to the practicing gynecologist and reconstructive pelvic surgeon. A complete pelvic examination, with particular attention to pelvic support defects, is vital to accurate diagnosis and treatment. Close communication with the patient, her family, and her primary care physician is essential for optimal understanding, informed consent, and management.

Offer conservative treatments as the first option, and always try them before any surgical endeavor. Educating the patient and her family strengthens the doctor-patient relationship and improves compliance. When a surgical intervention is undertaken, the primary goals are to restore anatomy and to maintain normal function. Preoperatively, a thorough assessment of all risks or possible complications and a complete discussion of alternatives with the patient are key elements in the decision-making process. Age alone should not be a factor in the decision; rather, the patient's baseline function is an important guideline to selecting the treatment that will provide the best quality of life.

Abdominal approach

When operating on patients with UP, rationales for performing a concomitant hysterectomy include the long-term success of the surgery (which can theoretically be affected by the prolapsed uterus) and removal of a nonfunctioning organ in postmenopausal women. In addition, any uterine or cervical pathology (eg, large fibroid uterus, endometriosis, pelvic inflammatory disease, endometrial hyperplasia, carcinoma) may require removal of the uterus.

No evidence indicates that hysterectomy has any effect on long-term success of sacropexy. Furthermore, the efficacy of incontinence surgery, with complete pelvic floor reconstruction, is not affected by whether a hysterectomy is performed.^[34] The authors advocate deferring surgical treatment of UP for patients who desire future childbearing until completion of childbearing. Hysteropexy for those patients who elect to retain their uteri has been reported, but the data is limited.

If the uterus is too bulky, hysterectomy is preferable. The decision may be made intraoperatively, and the patient should be appropriately counseled. If the uterus is to be preserved, preoperative endometrial biopsy and/or ultrasound imaging is strongly recommended.

Vaginal approach

With a trend toward minimally invasive endoscopic surgery, procedures have been developed to accomplish repair of pelvic defects via laparoscopic approaches. Although results in short-term subjective reports are excellent, long-term randomized controlled trials are lacking. Few clinical trials have compared laparoscopic procedures with conventional open procedures. Consequently, the exact benefits and risks of operative laparoscopy for patients with pelvic floor defects are not known. The attractive advantages of laparoscopic vault suspension are shorter hospitalizations, better cosmetic results, less morbidity, and shorter postoperative recovery periods.

Any advanced laparoscopic reconstructive pelvic surgery requires good operative skills and determination on the part of the surgeon. Most experts agree that the learning curve is usually steep, and complications are more likely to occur in early experiences. A review of techniques for endoscopic repair of UP is beyond the scope of this article, but the goal of any laparoscopic approach is to perform the abdominal procedures through the laparoscope. Before any definitive recommendations are made, prospective randomized trials comparing laparoscopic approaches to open procedures are desirable. Nonetheless, many excellent surgeons have reported excellent results with laparoscopic Burch, paravaginal repair, and sacral colpopexy.