Uterine Prolapse in Emergency Medicine
- Author: Raafat S Barsoom, MD; Chief Editor: Pamela L Dyne, MD more...
Background
Definition
Uterine prolapse (also called descensus or procidentia) means the uterus has descended from its normal position in the pelvis farther down into the vagina. See image below.
Normal uterus versus a prolapsed uterus. Uterine prolapse is one type of pelvic organ prolapse (POP), and it is the second most common after cystourethrocele (bladder and urethral prolapse). Other types of pelvic organ prolapse are enterocele (prolapse of the small bowel), rectocele (prolapse of the rectum or large bowel), and vaginal vault prolapse.
History
Uterine prolapse was first recorded on the Kahun papyri (ancient Egyptian text discussing mathematical and medical topics) in about 2000 BC. Its many fragments were discovered by Flinder Petrie in 1889. Hippocrates described numerous nonsurgical treatments for this condition. In 98 BC, Soranus of Rome first described the removal of the prolapsed uterus when it became black.[1]
Pathophysiology
Normally, the uterus is held in place by the muscles and ligaments that make up the pelvic floor. Uterine prolapse 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 can be incomplete or, in more severe cases, complete when the uterus slips and drops outside of the vagina.
In 1996, a standardized terminology for the evaluation of pelvic organ prolapse (POP) was established by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons. That terminology replaced terms as cystocele, rectocele, enterocele, and urethrovesical junctions with precise descriptions relating to specific anatomic landmarks.
The first points are on the anterior vaginal wall and categorize anterior vaginal wall prolapse accordingly. Point (Aa) is a point located in the midline of the anterior wall 3 cm proximal to the urethral meatus and is roughly the location of the urethrovesical crease. Point (Ba) represents the most distal position of any part of the anterior vaginal wall. Point (C) represents either the most distal edge of the cervix or the leading edge of the vagina if a hysterectomy has been performed. Point (D) represents the location of the posterior fornix (pouch of Douglas) in a woman with a cervix. Point (Bp) is a point most distal of any part of the upper posterior vaginal wall, and point (Ap) is a point located in the midline of the posterior vaginal wall 3 cm proximal to the hymen.
To record measurements, these points should be expressed in centimeters above or below the hymen. It is important for the examining individual to express the position and other circumstances of the examination (eg, straining or not, patient flat on table or in examining chair).
Staging of Pelvic Floor Prolapse Using International Continence Society Terminology (POP Quantification)
- Stage 0: No prolapse is demonstrated. Points Aa, Ap, Ba, and Bp are all at -3 cm and either point C or D is between total vaginal length -2 cm.
- Stage I: Criteria for stage 0 are not met, but the most distal portion of the prolapse is >1 cm above the level of the hymen.
- Stage II: The most distal portion of the prolapse is less or equal to 1 cm proximal or distal to the plane of the hymen.
- Stage III: The most distal portion of the prolapse is >1 cm below the plane of the hymen but protrudes no further than 2 cm less than the total vaginal length in centimeters.
- Stage IV: Essentially complete eversion of the total length of the lower genital tract.
Epidemiology
Frequency
United States
Approximately half of all women older than 50 years complain of symptomatic prolapse.[2]
Studies have estimated that 50% of parous women have some degree of urogenital prolapse and, of these, 10-20% are symptomatic.[3]
International
Same as that in US Frequency.
Mortality/Morbidity
Significant morbidity can occur, usually secondary to alterations in bowel, bladder, or sexual function. No reliable data are available on mortality related directly to uterine prolapse.
Race
Studies show that white and Hispanic women have the highest rate of pelvic organ prolapse, followed by Asian and black women. Little information is available about the incidence of prolapse in women of other (or more specific) ethnic groups.
Sex
Uterine prolapse affects females only.
Age
The risk of uterine prolapse increases with age as pelvic muscles weaken and the natural reduction in estrogen at menopause also causes muscles to become less elastic.
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