Uterine Prolapse in Emergency Medicine Treatment & Management

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

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.

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]

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.

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]

Consult an obstetrician or gynecologist for definitive management of symptomatic prolapse in adults and for long-term follow-up in all children.