eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Uterine Prolapse: Treatment & Medication
Updated: Jun 12, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Emergency Department Care
Emergency department care consists of the following:
- Early diagnosis of uterine prolapse
- Patient education - Risk factors, how to prevent and early detect prolapse
- Early detection and treatment of complications
- Consultations - Obstetrician/gynecologist (OB/GYN) for definitive management of prolapse
Conservative
Many studies were implemented to determine the effect of conservative management (pelvic exercise and lifestyle interventions) for women with prolapse in comparison with no treatment or other treatment options such as mechanical devices or surgery. Three trials of relevance were identified; the conclusion was that pelvic floor muscle training in an outpatient setting may reduce severity of prolapse in mild-to-moderate cases, but further evidence is still necessary.4
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.
Vaginal pessary
A pessary is a rubber or plastic doughnut-shaped device that fits around or under the cervix, helping to support the uterus and hold it in place. Pessaries are available in different varieties (Smith-Hodge, donut, cube, or inflatable). They require the replacement of the uterus and cervix to their original position in the pelvis before placement of these devices. Pessaries are available in varying sizes and should be properly fitted to the patient. The perineum must be capable of holding the pessary in place, or the pessary will frequently fall out.
Currently, no evidence is available from randomized controlled trials on pessary use to direct the selection of the device or to compare pessaries with surgery. A recent prospective trial found 75% of 203 women fitted with a pessary device successfully retained the device at 2 weeks. Failure to retain the pessary was significantly associated with increasing parity and past hysterectomy. Forty-eight percent of the women completed a questionnaire at 4 months. The pessary device reduced symptoms of prolapse, including general symptoms of a vaginal bulge. It also relieved urinary symptoms such as voiding problems in 40% of women, urinary urgency in 38%, and urge incontinence in 29%. No improvement was noted in stress urinary incontinence. Bowel symptoms improved as well.5
Proper care includes regular removal and cleaning, removal before sex, as well as use of vaginal estrogen cream for postmenopausal women with vaginal atrophy.
Complications from vaginal pessaries are rare with proper use, but do include vaginal infections, bleeding, discomfort, vaginal erosion or ulceration, and impaction.
Estrogen replacement therapy (ERT)
Taking estrogen may help to limit further weakness of the muscles and other connective tissues that support the uterus. However, some drawbacks to taking estrogen include an increased risk of blood clots, gallbladder disease, and breast cancer.
Surgical
Vaginal hysterectomy with a vaginal vault suspension
The uterosacral and cardinal ligaments are preserved, so that they may be used in the support of the vaginal vault. The uterosacral ligaments should be sutured together so that the cul-de-sac is shortened or obliterated.
Abdominal hysterectomy
Under certain circumstances, like pelvic inflammatory disease or previous intra-abdominal operation for an inflammatory process, such as endometriosis, a vaginal hysterectomy is not advisable. Instead, an abdominal hysterectomy may be performed, followed by a vaginal anterior and posterior colporrhaphy, if needed. Under these circumstances, the cardinal and uterosacral ligaments should be treated as noted earlier.
Colpocleisis
In elderly women who are no longer sexually active, a simple procedure for reducing prolapse is a 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. This procedure may be performed with or without the presence of a uterus and cervix; when it is completed, a small vaginal canal exists on either side of the septum. Prognosis for a colpocleisis procedure to reduce the prolapse and prevent recurrence is generally excellent. Case series report 91-100% success rates.
Sacrospinous fixation
A special circumstance involves the treatment of women who wish to maintain their fertility despite the fact that they have a total uterine prolapse. In the procedure, uterosacral ligaments bilaterally could be sutured to the sacrospinous ligaments, thereby reversing the prolapse.
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. Recent publications suggest that synthetic meshes are promising for vaginal prolapse repair. Long-term controlled studies will have to confirm the effectiveness and safety of new meshes and will have to include more functional data on sexuality and quality of life, before transvaginal meshes can be accepted as routine surgery.6
Robotic-assisted abdominal sacrocolpopexy/sacrouteropexy (RASC) is another approach, used for stages III and IV prolapse, was found to be safe and efficacious. Its anatomical outcomes compare favorably to the reported results for open or laparoscopic sacrocolpopexy.7
The American College of Obstetricians and Gynecologists has developed guidelines on the treatment and management of pelvic organ prolapse as well.8
Consultations
Consult an obstetrician or gynecologist for definitive management of symptomatic prolapse in adults and for long-term follow-up in all children.
More on Uterine Prolapse |
| Overview: Uterine Prolapse |
| Differential Diagnoses & Workup: Uterine Prolapse |
 Treatment & Medication: Uterine Prolapse |
| Follow-up: Uterine Prolapse |
| Multimedia: Uterine Prolapse |
| References |
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References
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Progetto Menopausa Italia Study Group. Risk factors for genital prolapse in non-hysterectomized women around menopause. Results from a large cross-sectional study in menopausal clinics in Italy. Eur J Obstet Gynecol Reprod Biol. Dec 2000;93(2):135-40. [Medline].
Hagen S, Stark D, Maher C, Adams EJ. Conservative management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2008.
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Soderberg MW, Falconer C, Bystrom B, Malmstrom A, Ekman G. Young women with genital prolapse have a low collagen concentration. Acta Obstet Gynecol Scand. Dec 2004;83(12):1193-8. [Medline].
Swift S, Woodman P, O'Boyle A, et al. Pelvic Organ Support Study (POSST): the distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol. Mar 2005;192(3):795-806. [Medline].
Tan JS, Lukacz ES, Menefee SA, Powell CR, Nager CW. Predictive value of prolapse symptoms: a large database study. Int Urogynecol J Pelvic Floor Dysfunct. May-Jun 2005;16(3):203-9; discussion 209. [Medline].
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Further Reading
Keywords
prolapsed uterus, uterine prolapse, pelvic organ prolapse, procidentia, pregnancy trauma, uterus, vagina, treatment, symptoms, causes, descent of the uterus into the vagina, herniation of the uterus into the vagina, vaginal wall prolapse, weakness of the pelvic support, obstetrical trauma, lacerations during labor, lacerations during delivery, congenital weakness in the pelvic musculature, multiparous women, postmenopausal women, pelvic heaviness, pelvic pressure, protrusion of tissue, pelvic pain, impaired coitus, lower back pain, constipation, difficulty urinating, urinary frequency, urinary urgency, urinary incontinence, obstetrical trauma, congenital weakness of pelvic supports, decreased estrogen, increased intra-abdominal pressure, obesity, chronic lung disease, asthma, pelvic floor dysfunction, pelvic relaxation, urogenital prolapse, vaginal vault prolapse
