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Uterine prolapse is a form of pelvic organ prolapse in which the uterus and a portion of the upper vagina protrude into the vaginal canal and, in severe cases, through the opening of the vagina.[1] Symptoms may include vaginal fullness, pain with sexual intercourse, difficulty urinating, and urinary incontinence.[1][2] Risk factors include older age, pregnancy, vaginal childbirth, obesity, chronic constipation, and chronic cough.[2] Diagnosis is based on physical examination, including pelvic examination.[1]

Preventive efforts include managing chronic lung conditions, smoking cessation, and maintaining a healthy weight.[2] Management of mild cases of uterine prolapse include pelvic floor therapy, pessaries, or estrogen therapy. More severe cases may require surgical intervention, including removal of the uterus or surgical fixation of the upper portion of the vagina to a nearby pelvic structure.[1]

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Signs and Symptoms

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While uterine prolapse is rarely life-threatening, the symptoms associated with uterine prolapse can have a significant impact on quality of life.[3] The severity of prolapse symptoms does not necessarily correlate with the degree of prolapse, and one may experience little to no bothersome symptoms with even advanced prolapse.[3][4] Additionally, different forms of pelvic organ prolapse often present with similar symptoms.[3]

Most women do not have symptomatic pelvic organ prolapse.[3] When symptoms are present, the most common and most specific symptoms for uterine prolapse—and organ prolapse in general—into the vagina are bulge symptoms, such as pelvic pressure, vaginal fullness, or a palpable vaginal bulge, and these symptoms are often more common and more severe if the prolapse reaches the vaginal hymen.[3][4] Urinary symptoms, such as uncontrollable loss of urine or difficulty urinating, may also be present.[4] Complete uterine prolapse in which the uterus protrudes through the vaginal hymen is known as procidentia.[5] In the absence of treatment, symptoms of procidentia may include purulent vaginal discharge, ulceration, and bleeding.[6][5] Complications of procidentia include urinary obstruction.[5]

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People may also report sexual dysfunction symptoms, such as pain with sexual intercourse and decreases libido.[7][3] There is conflicting data concerning the effect of pelvic organ prolapse on sexual function.[3][4] The severity of the symptoms associated with prolapse seem to have a negative affect on sexual activity and reported satisfaction. Mild or asymptomatic prolapse does not seem to be associated with sexual complaints while more symptomatic prolapse is associated with more negative sexual symptoms.[8]

Causes

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The causes of uterine prolapse are generally the same as the causes of other forms of pelvic organ prolapse. The most common risk factor associated with uterine prolapse is vaginal childbirth.[9][10][11] The risk of prolapse increased with each vaginal delivery, and people who have had multiple vaginal deliveries are more likely to develop prolapse compared with those who have had a single vaginal delivery.[9] Operative vaginal delivery, such as when forceps are used, has been found to increase the odds of pelvic organ prolapse when compared to non-operative vaginal delivery.[9][11]

Age also plays a significant role in uterine prolapse, with prevalence increasing with each decade of life due in part to age-related changes to pelvic support structures and estrogen depletion during menopause.[9] Additionally, conditions that chronically increase the pressure within the abdomen can also predispose people to uterine prolapse.[12][9][11] This includes chronic obstructive pulmonary disease (COPD), obesity, chronic cough, straining due to chronic constipation, and repetitive heavy lifting.[9][11] Tobacco smoking has been found to be correlated to pelvic organ prolapse both due to the risk of developing lung conditions that lead to chronic cough or COPD as well as the negative effects of tobacco chemicals on connective tissue.[9]

Pathophysiology

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The uterus is normally held in place by the combined effort of pelvic floor muscles, various ligaments, pelvic fascia, and the vaginal wall.[13][14] The levator ani muscle play the most significant role in pelvic organ support by acting as a basket that keeps the pelvic organs suspended.[13] The uterosacral ligaments are especially important in providing support to the uterus by suspending and anchoring the uterus, cervix, and upper vagina to parts of the pelvic wall.[13][15]

Uterine prolapse occurs when there is a disruption to any of the structures mentioned above that help hold the uterus in place.[13][14] Weakening of the levator ani muscles can occur during vaginal childbirth, in which portions of the muscle can detach from the bony pelvis, or through age-related changes to musculature, and this can lead to a loss of support for the uterus.[13] Pregnancy, vaginal childbirth, or injury can also stretch and weaken the uterosacral ligaments, leading to poor suspension or positioning of the uterus so that it is no longer supported by pelvic floor muscles.[15] Problems with the vaginal wall, such as through trauma or loss of smooth muscle support in the wall, can lead to the uterus collapsing downward due to a loss of support.[13]

Additionally, the pelvic musculature and connective tissues are estrogen sensitive and respond to changes in estrogen level.[13] Estrogen deficiency, such as during menopause, can affect the production of collagen that is needed to build connective tissue that makes up ligaments and fascia, which can contribute to uterine prolapse.[13] This is also a reason that connective tissue disorders can predispose certain people to uterine prolapse.[13]

Diagnosis and management

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Diagnosis
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Diagnosis of uterine prolapse is based on a history of symptoms, which may include symptom questionnaires, and a physical exam.[2][9] Usually, the physical exam involves a vaginal exam, often with a speculum, and a pelvic exam to help determine the strength of the pelvic floor musculature.[5][9] The findings of the physical exam are commonly documented using the Pelvic Organ Prolapse Quantification (POP-Q) system in which the extent and severity of prolapse is measured using the hymen as an anatomic landmark.[2][5]

Management
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The management of uterine prolapse may be conservative or surgical, depending on factors such as personal preference, symptom severity, and extent of prolapse.[9] Additionally, management of existing medical conditions that can contribute to prolapse, such as chronic lung conditions, chronic constipation, and obesity, are important to prevent progression of uterine prolapse and reduce symptom burden.[5]

Conservative

Conservative options include pelvic floor muscle strengthening exercises and pessaries.[5][3] Pelvic floor muscle training (PFMT), also known as Kegel exercise, has been found to improve the bulk and urinary symptoms associated with pelvic organ prolapse and improve quality of life when performed consistently and correctly.[9][16] Pessaries are a mechanical treatment that supports the vagina and elevates the prolapsed uterus to its anatomically correct position. Pessaries are frequently offered as a first-line management option for uterine prolapse, especially amongst people who cannot or do not wish to undergo surgery, due to their affordability and low-risk profile compared to more invasive procedures.[10] When properly fitted, pessaries have been found to improve bulk and pressure symptoms associated with prolapse and improve quality of life measures.[4][17]

Surgical

There are many surgical options available for the treatment of uterine prolapse, which may be performed through a vaginal procedure or through the abdomen.[9][18] Generally, vaginal procedures are considered to be less invasive, offer a quicker recovery, and have a shorter operative time compared to abdominal procedures, but abdominal procedures offer longer-term results and potentially reduce risk of postoperative vaginal pain with intercourse.[9] Laparoscopic and robotic approaches to abdominal procedures in prolapse surgery have become more common as they require smaller incision sites, result in less blood loss, and have shorter hospital stays.[3][18]

Vaginal vault suspension (known as colpopexy), in which the upper portion of the vagina is surgically connected to another structure in the pelvis, is commonly performed in the treatment of uterine prolapse.[3][18] Forms of colpopexy include sacrocolpopexy, in which the vaginal vault is attached to the sacrum using a mesh; sacrospinous ligament fixation, in which the upper vagina is attached to the sacrospinous ligaments; and uterosacral ligament vaginal vault suspension, in which the upper vagina is attached to the uterosacral ligaments.[9] Colpopexy can be performed with or without a hysterectomy. If performed without a hysterectomy, the procedure is known as a hysteropexy, and includes procedures such as sacrohysteropexy and sacrospinous hysteropexy.[9]

In severe cases of prolapse where the person no longer desires vaginal intercourse and has contraindications to more invasive surgery, vaginal closure procedures may be offered. These include LeFort partial colpocleisis and complete colpocleisis, in which the vagina is sutured closed.[18]

Also taken into consideration prior to surgery is use of native, or one's own, tissue versus a synthetic mesh. Mesh may be considered in instances where the connective tissue is weak or absent, if there is an empty space at the surgical site that needs to be bridged, or if there is a high risk of prolapse recurrence.[9] Synthetic mesh is indicated and used for sacrocolpopexy and sacrohysteropexy procedures.[9] However, the use of synthetic mesh transvaginally, or within the vaginal tissue itself, is not indicated and is not routinely used due to a lack of safety and efficacy data, higher rate of mesh erosion compared with native tissue repair, and lack of data regarding long-term outcomes and complication rates.[4][9][18]

Outcomes

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Overall, it appears that quality of life was found to be significantly improved for people with pelvic organ prolapse after surgical or pessary management.[17]

It can be difficult to determine success when discussing the outcomes of surgical intervention for pelvic organ prolapse due to multiple factors that can define success, such as anatomic success versus patient-reported outcome measures.[18] Improvement of vaginal bulge symptoms after surgery appears to be more of a measure of success for patients themselves than does anatomic success alone.[4]

Success may be defined as reoperation after prolapse surgery.[4] The rates of reoperation following pelvic organ prolapse surgery ranges from 3.4% to 9.7%.[4] The rate of pelvic organ prolapse recurrence following surgery depends on several factors, the most significant being patient age (patients younger than 60 years have higher likelihood of recurrence), POP-Q stage (POP-Q greater than 3 has higher likelihood of recurrence), surgeon's experience performing the procedure, and prior history of pelvic surgery.[19][20] Additionally, the type of surgery, for instance vaginal versus abdominal, also affects recurrence rate.[4][21] For apical prolapse specifically, a meta-analysis found the reoperation rates for traditional vaginal vault suspension (meaning sacrospinous ligament fixation and uterosacral ligament vaginal vault suspension), sacrocolpopexy, and transvaginal mesh procedure were 3.9%, 2.3%, and 1.3% respectively.[4] However, the transvaginal mesh procedure group had the highest rate of total reoperations when complications were taken into consideration.[4]

Epidemiology

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Numerical values regarding prevalence of uterine prolapse differ based on if the epidemiologic study in question uses a physical exam or a symptom questionnaire to determine the presence or absence of prolapse.[4][22] Prevalence of pelvic organ prolapse was found to be consistently higher when physical exam was used (for uterine prolapse, this was 14.2% in one study[23] and 3.8% in another study[4]) compared to a symptom-based determination in which the prevalence of any degree of prolapse, including uterine prolapse, was 2.9% to 8% in the US.[4] Using Women's Health Initiative data, the incidence of grades 1 to 3 uterine prolapse was approximately 1.5/100 women-years and progression of uterine prolapse was found to be about 1.9%.[4]

History

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The first mention of uterine prolapse in medical literature was on the Kahun papyrus, dated circa 1835 B.C.E, which read, "of a woman whose posterior, belly, and branching of her thighs are painful, say thou as to it, it is the falling of the womb."[24] The treatment at the time, documented on the Ebers papyrus, was to rub the afflicted person with a mixture of "oil of the earth [and] fedder",[24] or petroleum and manure.

Throughout history, the management of uterine prolapse has been hampered by a poor understand of female pelvic anatomy. During the Hippocratic era, approximately 460 B.C.E., it was thought that the uterus was similar to an animal.[24] Common treatments were fumigation, placing a foul-smelling object near the uterus to convince it to move into the vagina; the use of topical astringents, such as vinegar; and succussion, in which a woman was tied upside-down and shaken until the prolapse reduced.[24]

During the first century C.E., the Greek physician Soranus would disagree with many of these practices and recommend the use of wool, dipped in vinegar or wine and inserted into the vagina, to lift the uterus back into place. He would also go on to recommend surgical of gangrenous portions of a prolapsed uterus.[24] However, these ideas did not become commonly accepted practices during that era, and the Middle Ages brought about a return to previous beliefs and practices for uterine prolapse.[24] In 1603, for instance, it was recommended that burning the prolapsed uterus with a hot iron would frighten it back into the vagina.[24]

Towards the end of the 16th century, pessaries became more common in the management of uterine prolapse, due in part to advances in anatomic knowledge of the female genitourinary tract earlier in the century.[24] Pessaries were usually made out of wax, metal, glass, or wood. Charles Goodyear's invention of volcanized rubber in the mid 1800s made it possible to produce pessaries that would not decompose.[24] However, even into the 1800s, alternative practices were still used, such as use astringents, sea-water douches, postural exercises, and leeching.[24]

Although the use of surgery in the the treatment of uterine prolapse had been described previously, the 19th century saw advances in surgical techniques.[24] During the mid to late 1800s, surgical attempts to manage uterine prolapse included narrowing the vaginal vault, suturing the perineum, and amputating the cervix.[24] in 1877, LeFort described the process of a partial colpocleisis.[24] In 1861, Choppin in New Orleans reported the first instance in which vaginal hysterectomy was performed for uterine prolapse. Prior to that, vaginal hysterectomies were mainly performed for malignancies.[24]

Following Alwin Mackenrodt's 1895 publication of a comprehensive description of the female pelvic floor connective tissue, including the cardinal ligaments, Fothergill began working on the Manchester-Fothergill surgery with the belief that the cardinal and uterosacral ligaments were key support structures for the uterus.[24] In 1907, Josef Haban and Julius Tandler theorized that the levator ani muscles were also very important for uterine support.[24] Combined with a better understanding of female pelvic floor connective tissue, these ideas would go on to influence surgical approaches for the treatment of uterine prolapse.[24]

By the early 20th century, different techniques for vaginal hysterectomies had been described and performed. As a result, post-hysterectomy vaginal vault prolapse became more common and a growing concern for some surgeons, and new techniques to correct this complication were attempted.[24] In 1957, Arthure and Savage of London's Charing Cross Hospital, suspecting that uterine prolapse could not be cured with hysterectomy alone, published their surgical technique of sacral hysteropexy. Their technique is still used in modern practice with the addition of a graft.[24]

Society and culture

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Vaginal mesh kits were introduced to the market in 2004 through the US Food and Drug Administration (FDA) pathway that did not require companies to demonstrate both safety and efficacy of the product if they were able to demonstrate that their product was similar to previous products already in the market.[4] However, due to the increased rates of mesh-related complications, lack of proof that transvaginal mesh products were superior to other forms of surgical intervention, and the expedited process which the vaginal mesh kits were introduced to the market, the FDA released a Safety Communication in 2011 that described serious complications associated with transvaginal mesh as "not rare".[4] In 2019, the FDA ordered manufacturers to cease production and distribution of transvaginal mesh intended for repair of pelvic organ prolapse.[4][25] This does not include surgical mesh used during sacrocolpopexy, sacrohysteropexy, or transurethral sling procedures.[25]

A number of class action lawsuits have been filed and settled against several manufacturers of transvaginal mesh after people developed complications following surgery.[26]

References

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  1. ^ a b c d Kilpatrick, Charlie C. "Uterine and Apical Prolapse - Gynecology and Obstetrics". Merck Manuals Professional Edition. Retrieved 2023-01-16.
  2. ^ a b c d e Ferri, Fred F. (2015-05-28). Ferri's Clinical Advisor 2016 E-Book: 5 Books in 1. Elsevier Health Sciences. ISBN 978-0-323-37822-2.
  3. ^ a b c d e f g h i j Hoffman, Barbara L.; Bradshaw, Karen D.; Schaffer, Joseph I.; Halvorson, Lisa M.; Corton, Marlene M. (2020). Williams Gynecology (Fourth ed.). New York: McGraw-Hill Education. ISBN 978-1-260-45687-5. OCLC 1120727710. Retrieved Jan 17, 2023.
  4. ^ a b c d e f g h i j k l m n o p q r s t Barber, Matthew D.; Bradley, Catherine S.; Karram, Mickey M.; Walters, Mark D. (2022). Walters and Karram urogynecology and reconstructive pelvic surgery (Fifth ed.). Philadelphia, PA: Elsevier. ISBN 9780323697835. OCLC 1286723474.
  5. ^ a b c d e f g Hacker, Neville F.; Gambone, Joseph C.; Hobel, Calvin J. (2016). Hacker & Moore's Essentials of Obstetrics & Gynecology (Sixth ed.). Philadelphia, PA: Elsevier. ISBN 978-0-323-38852-8. OCLC 929903395.
  6. ^ Ferri, Fred F. (2015-05-28). Ferri's Clinical Advisor 2016 E-Book: 5 Books in 1. Elsevier Health Sciences. ISBN 978-0-323-37822-2.
  7. ^ Kilpatrick, Charlie C. "Uterine and Apical Prolapse - Gynecology and Obstetrics". Merck Manuals Professional Edition. Retrieved 2023-01-16.
  8. ^ Barber, Matthew D.; Bradley, Catherine S.; Karram, Mickey M.; Walters, Mark D. (2022). Walters and Karram urogynecology and reconstructive pelvic surgery (Fifth edition ed.). Philadelphia, PA: Elsevier. ISBN 9780323697835. OCLC 1286723474. {{cite book}}: |edition= has extra text (help)CS1 maint: date and year (link)
  9. ^ a b c d e f g h i j k l m n o p q r Hoffman, Barbara L.; Bradshaw, Karen D.; Schaffer, Joseph I.; Halvorson, Lisa M.; Corton, Marlene M. (2020). Williams Gynecology (Fourth ed.). New York: McGraw-Hill Education. ISBN 978-1-260-45687-5. OCLC 1120727710. Retrieved Jan 17, 2023.
  10. ^ a b Hacker, Neville F.; Gambone, Joseph C.; Hobel, Calvin J. (2016). Hacker & Moore's Essentials of Obstetrics & Gynecology (Sixth ed.). Philadelphia, PA: Elsevier. ISBN 978-0-323-38852-8. OCLC 929903395.
  11. ^ a b c d Weintraub, Adi Y.; Glinter, Hannah; Marcus-Braun, Naama (2020). "Narrative review of the epidemiology, diagnosis and pathophysiology of pelvic organ prolapse". International Braz J Urol: Official Journal of the Brazilian Society of Urology. 46 (1): 5–14. doi:10.1590/S1677-5538.IBJU.2018.0581. ISSN 1677-6119. PMC 6968909. PMID 31851453.
  12. ^ Ferri, Fred F. (2015-05-28). Ferri's Clinical Advisor 2016 E-Book: 5 Books in 1. Elsevier Health Sciences. ISBN 978-0-323-37822-2.
  13. ^ a b c d e f g h i Hoffman, Barbara L.; Bradshaw, Karen D.; Schaffer, Joseph I.; Halvorson, Lisa M.; Corton, Marlene M. (2020). Williams Gynecology (Fourth ed.). New York: McGraw-Hill Education. ISBN 978-1-260-45687-5. OCLC 1120727710. Retrieved Jan 17, 2023.
  14. ^ a b Hacker, Neville F.; Gambone, Joseph C.; Hobel, Calvin J. (2016). Hacker & Moore's Essentials of Obstetrics & Gynecology (Sixth ed.). Philadelphia, PA: Elsevier. ISBN 978-0-323-38852-8. OCLC 929903395.
  15. ^ a b Barber, Matthew D.; Bradley, Catherine S.; Karram, Mickey M.; Walters, Mark D. (2022). Walters and Karram urogynecology and reconstructive pelvic surgery (Fifth ed.). Philadelphia, PA: Elsevier. ISBN 9780323697835. OCLC 1286723474.
  16. ^ Espiño-Albela, Andrea; Castaño-García, Carla; Díaz-Mohedo, Esther; Ibáñez-Vera, Alfonso Javier (2022-05-17). "Effects of Pelvic-Floor Muscle Training in Patients with Pelvic Organ Prolapse Approached with Surgery vs. Conservative Treatment: A Systematic Review". Journal of Personalized Medicine. 12 (5): 806. doi:10.3390/jpm12050806. ISSN 2075-4426. PMC 9142907. PMID 35629228.{{cite journal}}: CS1 maint: PMC format (link) CS1 maint: unflagged free DOI (link)
  17. ^ a b Ghanbari, Zinat; Ghaemi, Marjan; Shafiee, Arman; Jelodarian, Parivash; Hosseini, Reihaneh Sadat; Pouyamoghaddam, Shahla; Montazeri, Ali (2022). "Quality of Life Following Pelvic Organ Prolapse Treatments in Women: A Systematic Review and Meta-Analysis". Journal of Clinical Medicine. 11 (23): 7166. doi:10.3390/jcm11237166. ISSN 2077-0383. PMC 9738239. PMID 36498740.{{cite journal}}: CS1 maint: PMC format (link) CS1 maint: unflagged free DOI (link)
  18. ^ a b c d e f de Tayrac, Renaud; Antosh, Danielle D.; Baessler, Kaven; Cheon, Cecilia; Deffieux, Xavier; Gutman, Robert; Lee, Joseph; Nager, Charles; Schizas, Alexis; Sung, Vivian; Maher, Christopher (2022-10-17). "Summary: 2021 International Consultation on Incontinence Evidence-Based Surgical Pathway for Pelvic Organ Prolapse". Journal of Clinical Medicine. 11 (20): 6106. doi:10.3390/jcm11206106. ISSN 2077-0383. PMC 9605527. PMID 36294427.{{cite journal}}: CS1 maint: PMC format (link) CS1 maint: unflagged free DOI (link)
  19. ^ Schulten, Sascha F.M.; Claas-Quax, Marieke J.; Weemhoff, Mirjam; van Eijndhoven, Hugo W.; van Leijsen, Sanne A.; Vergeldt, Tineke F.; IntHout, Joanna; Kluivers, Kirsten B. (2022). "Risk factors for primary pelvic organ prolapse and prolapse recurrence: an updated systematic review and meta-analysis". American Journal of Obstetrics and Gynecology. 227 (2): 192–208. doi:10.1016/j.ajog.2022.04.046.
  20. ^ Shi, Wei; Guo, Lingling (2023-12-31). "Risk factors for the recurrence of pelvic organ prolapse: a meta-analysis". Journal of Obstetrics and Gynaecology. 43 (1): 2160929. doi:10.1080/01443615.2022.2160929. ISSN 0144-3615.
  21. ^ Maher, Christopher; Feiner, Benjamin; Baessler, Kaven; Christmann-Schmid, Corina; Haya, Nir; Brown, Julie (2016-10-01). Cochrane Gynaecology and Fertility Group (ed.). "Surgery for women with apical vaginal prolapse". Cochrane Database of Systematic Reviews. 2017 (11). doi:10.1002/14651858.CD012376. PMC 6457970. PMID 27696355.{{cite journal}}: CS1 maint: PMC format (link)
  22. ^ Culligan, Patrick J.; Goldberg, Roger P. (2007-03-06). Urogynecology in Primary Care. Springer Science & Business Media. ISBN 978-1-84628-167-9.
  23. ^ Culligan, Patrick J.; Goldberg, Roger P. (2007-03-06). Urogynecology in Primary Care. Springer Science & Business Media. ISBN 978-1-84628-167-9.
  24. ^ a b c d e f g h i j k l m n o p q r s Downing, Keith T. (2012). "Uterine Prolapse: From Antiquity to Today". Obstetrics and Gynecology International. 2012: 1–9. doi:10.1155/2012/649459. ISSN 1687-9589. PMC 3236436. PMID 22262975.{{cite journal}}: CS1 maint: PMC format (link) CS1 maint: unflagged free DOI (link)
  25. ^ a b Health, Center for Devices and Radiological (2021-08-16). "Urogynecologic Surgical Mesh Implants". FDA. Retrieved 2023-01-25.
  26. ^ Kaplan, Sheila; Goldstein, Matthew (2019-04-16). "F.D.A. Halts U.S. Sales of Pelvic Mesh, Citing Safety Concerns for Women". The New York Times. ISSN 0362-4331. Retrieved 2023-01-25.
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