Prolapsed Uterus

Prolapsed uterus is an incorrect position of the uterus, displacement of the fundus and cervix below the anatomical and physiological boundary due to weakening of the pelvic floor muscles and ligaments of the uterus. In most patients, the prolapse and prolapse of the uterus is usually accompanied by a downward displacement of the vagina. Prolapsed uterus is manifested by a feeling of pressure, discomfort, pulling pains in the lower abdomen and in the vagina, urination disorder (difficulty, increased urination, urinary incontinence), pathological discharge from the vagina. It may be complicated by partial or complete prolapse of the uterus. Prolapsed uterus is diagnosed during a gynecological examination. Depending on the degree of prolapsed uterus, therapeutic tactics can be conservative or surgical.

General information

Prolapsed uterus is an incorrect position of the uterus, displacement of the fundus and cervix below the anatomical and physiological boundary due to weakening of the pelvic floor muscles and ligaments of the uterus. It is manifested by a feeling of pressure, discomfort, pulling pains in the lower abdomen and in the vagina, urination disorder (difficulty, increased urination, urinary incontinence), pathological discharge from the vagina. It may be complicated by partial or complete prolapse of the uterus.

The most common variants of the incorrect location of the internal genitalia of a woman are the prolapse of the uterus and its prolapse (uterocele). When the uterus is lowered, its neck and bottom shift below the anatomical border, but the cervix does not show from the genital slit even when straining. The exit of the uterus beyond the genital slit is regarded as a prolapse. The displacement of the uterus downwards precedes its partial or complete prolapse. In most patients, the prolapse and prolapse of the uterus is usually accompanied by a downward displacement of the vagina.

Prolapsed uterus is a fairly common pathology found in women of all ages: it is diagnosed in 10% of women under the age of 30, at the age of 30-40 it is detected in 40% of women, and at the age of 50 it occurs in half. 15% of all operations on the genitals are performed for the omission or prolapse of the uterus.

Prolapsed uterus is most often associated with a weakening of the ligamentous apparatus of the uterus, as well as the muscles and fascia of the pelvic floor and often lead to displacement of the rectum (rectocele) and bladder (cystocele), accompanied by a disorder of the functions of these organs. Often, prolapsed uterus begins to develop even at childbearing age and always has a progressive course. As the uterus descends, concomitant functional disorders become more pronounced, which brings physical and moral suffering to a woman and often leads to partial or complete disability.

The normal position of the uterus is considered to be its location in the pelvis, at an equal distance from its walls, between the rectum and the bladder. The uterus has an inclination of the body anteriorly, forming an obtuse angle between the neck and the body. The cervix is deflected posteriorly, forms an angle equal to 70-100 ° with respect to the vagina, its external pharynx lies against the back wall of the vagina. The uterus has sufficient physiological mobility and can change its position depending on the filling of the rectum and bladder.

The typical, normal location of the uterus in the pelvic cavity is facilitated by its own tone, mutual disposition with adjacent organs, ligamentous and muscular apparatus of the uterus and pelvic floor. Any violation of the architectonics of the uterine apparatus contributes to the prolapse of the uterus or its prolapse.

Classification

There are the following stages of prolapse and prolapse of the uterus:

• prolapse of the body and cervix – the cervix is determined above the level of the entrance to the vagina, but does not protrude beyond the genital slit;
• partial prolapse of the uterus – the cervix is shown from the genital slit when straining, physical exertion, sneezing, coughing, lifting weights;
• incomplete prolapse of the body and the bottom of the uterus – the cervix and partially the body of the uterus protrude from the genital slit;
• complete prolapse of the body and the bottom of the uterus – the exit of the uterus beyond the genital slit.

Causes

Anatomical defects of the pelvic floor, developing as a result of: damage to the pelvic floor muscles, lead to the lowering of the uterus beyond its normal physiological boundaries:

• birth injuries – when applying obstetric forceps, fetal vacuum extraction or fetal extraction by the buttocks;
• surgical operations on the genitals (radical vulvectomy);
• deep ruptures of the perineum;
• disorders of innervation of the genitourinary diaphragm;
• congenital malformations of the pelvic region;
• estrogen deficiency developing during menopause;
• connective tissue dysplasia, etc.

Risk factors in the development of prolapsed uterus and its subsequent prolapse are numerous births in the anamnesis, heavy physical labor and weight lifting, elderly and senile age, heredity, increased intra-abdominal pressure caused by obesity, abdominal tumors, chronic constipation, cough.

Often, the interaction of a number of factors plays a role in the development of prolapsed uterus, under the influence of which there is a weakening of the ligamentous-muscular apparatus of internal organs and pelvic floor. With an increase in intra-abdominal pressure, the uterus is displaced beyond the pelvic floor. Prolapse of the uterus entails displacement of anatomically closely related organs – the vagina, rectum (rectocele) and bladder (cystocele). Rectocele and cystocele increase under the influence of internal pressure in the rectum and bladder, which causes even greater prolapse of the uterus.

Symptoms

In the absence of treatment, prolapsed uterus is characterized by a gradual progression of displacement of the pelvic organs. In the initial stages, prolapsed uterus is manifested by pulling pains and pressure in the lower abdomen, sacrum, lower back, sensation of a foreign body in the vagina, dyspareunia (painful sexual intercourse), the appearance of whites or bloody discharge from the vagina. A characteristic manifestation of prolapsed uterus is changes in menstrual function by the type of hyperpolymenorrhea and dysmenorrhea. Infertility is often noted when the uterus is lowered, although the onset of pregnancy is not excluded.

In the future, the symptoms of prolapsed uterus are joined by urological disorders, which are observed in 50% of patients: difficulty or rapid urination, the development of a symptom of residual urine, stagnation in the urinary organs and further infection of the lower and then upper urinary tract — cystitis, pyelonephritis, urolithiasis develop. A prolonged course of prolapse and prolapse of the uterus leads to overgrowth of the ureters and kidneys (hydronephrosis). Often, the displacement of the uterus downwards is accompanied by urinary incontinence.

Proctological complications with prolapse and prolapse of the uterus occur in every third case. These include constipation, colitis, fecal incontinence and gas. Often it is the painful urological and proctological manifestations of prolapsed uterus that make patients turn to related specialists – a urologist and a proctologist. With the progression of prolapsed uterus, the leading symptom becomes an independently detectable female formation protruding from the genital slit.

The protruding part of the uterus has the appearance of a shiny, matte, cracked, sore surface. In the future, as a result of constant traumatization when walking, the bulging surface often ulcerates with the formation of deep bedsores that can bleed and become infected. When the uterus is lowered, a violation of blood circulation in the pelvis develops, the occurrence of stagnation, cyanosis of the uterine mucosa and swelling of adjacent tissues.

Often, with the displacement of the uterus below the physiological boundaries, sexual life becomes impossible. Patients with prolapsed uterus often develop varicose veins, mainly of the lower extremities, due to a violation of venous outflow. Complications of prolapse and prolapse of the uterus can also be infringement of the fallen uterus, bedsores of the vaginal walls, infringement of intestinal loops.

Diagnosis

Prolapse and prolapse of the uterus can be diagnosed at the consultation of a gynecologist during a gynecological examination. To determine the degree of prolapsed uterus, the doctor asks the patient to push, after which, during vaginal and rectal examination, he determines the displacement of the walls of the vagina, bladder and rectum. Women with genital displacement are placed on dispensary registration. Colposcopy is mandatory for patients with this pathology of the uterus.

In cases of prolapse and prolapse of the uterus, requiring organ-preserving plastic surgery, and with concomitant diseases of the uterus, additional examination methods are included in the diagnostic complex:

• hysterosalpingoscopy and diagnostic curettage of the uterine cavity;
• ultrasound diagnostics of pelvic organs;
• taking smears for flora, the degree of purity of the vagina, bacposev, as well as for the determination of atypical cells;
• urine vacuuming to exclude urinary tract infections;
• excretory urography to exclude urinary tract obstruction;
• computed tomography to clarify the condition of the pelvic organs.

Patients with prolapsed uterus are examined by a proctologist and urologist to determine the presence of rectocele and cystocele. They assess the condition of the sphincters of the rectum and bladder to detect gas and urine incontinence under stress. The prolapse of the uterus should be distinguished from the eversion of the uterus, vaginal cyst, myomatous node born and differential diagnosis should be carried out.

Treatment

When choosing treatment tactics, the following factors are taken into account:

1. Degree of prolapsed uterus.
2. The presence and nature of concomitant prolapsed uterus gynecological diseases.
3. The necessity and possibility of restoring or preserving menstrual and reproductive functions.
4. Age of the patient.
5. The nature of disorders of the functions of the sphincters of the bladder and rectum, colon.
6. Degree of anesthetic and surgical risk in the presence of concomitant diseases.

Taking into account the totality of these factors, treatment tactics are determined, which can be both conservative and surgical.

Conservative treatment

When the uterus is lowered, when it does not reach the genital slit and the functions of adjacent organs are not impaired, conservative treatment is used, which may include:

• physical therapy aimed at strengthening the pelvic floor and abdominal muscles (Kegel gymnastics, Yunusov gymnastics);
• gynecological massage;
• estrogen replacement therapy that strengthens the ligamentous apparatus;
• local administration of ointments containing metabolites and estrogens into the vagina;
• transfer of a woman to easier physical work.

If it is impossible to carry out surgical treatment for prolapse or prolapse of the uterus in elderly patients, the use of vaginal tampons and pessaries representing thick rubber rings of various diameters is indicated. There is air inside the pessary, which gives it elasticity and elasticity. After insertion into the vagina, the ring creates a support for the displaced uterus. When inserted into the vagina, the ring rests against the arches of the vagina and fixes the cervix in a special hole. The pessary can not be left in the vagina for a long time because of the danger of developing bedsores. When using pessaries for the treatment of prolapsed uterus, it is necessary to carry out daily vaginal douching with chamomile decoction, solutions of furacilin or potassium permanganate, and twice a month to be shown to a gynecologist. Pessaries can be left in the vagina for 3-4 weeks, then taking a break for 2 weeks.

Surgical treatment

A more effective radical method of treating prolapse or prolapse of the uterus is surgery, the indications for which are the ineffectiveness of conservative therapy and a significant degree of displacement of the organ. Modern operative gynecology for prolapse and prolapse of the uterus offers many types of surgical operations that can be structured according to the leading feature – anatomical education, which is used to correct and strengthen the position of organs.

The first group of surgical interventions includes vaginoplasty – plastic surgery aimed at strengthening the muscles and fascia of the vagina, bladder and pelvic floor (for example, colpoperineolevatoroplasty, anterior colporaphy). Since the muscles and fascia of the pelvic floor are always involved in prolapsed uterus, colpoperineolevatoroplasty is performed in all types of operations as the main or additional stage.

The second large group of operations involves shortening and strengthening the round ligaments supporting the uterus and fixing them to the anterior or posterior wall of the uterus. This group of operations is not as effective and gives the greatest number of relapses. This is explained by the use of round ligaments of the uterus for fixation, which have the ability to stretch.

The third group of operations for prolapse and prolapse of the uterus is used to strengthen the fixation of the uterus by stitching ligaments together. Some operations of this group deprive patients of the ability to procreate in the future. The fourth group of surgical interventions consists of operations with fixation of displaced organs to the walls of the pelvic floor (sacral, pubic bone, pelvic ligaments, etc.).

The fifth group of operations includes interventions using alloplastic materials used to strengthen ligaments and fix the uterus. The disadvantages of this type of surgery include a significant number of recurrences of prolapsed uterus, rejection of alloplast, development of fistulas. The sixth group of operations for this pathology includes surgical interventions that lead to a partial narrowing of the vaginal lumen. The last group of operations includes radical removal of the uterus – hysterectomy, in cases where there is no need to preserve the reproductive function.

Preference at the present stage is given to combined surgical treatment, which includes both fixation of the uterus, and vaginal plastic surgery, and strengthening of the ligamentous-muscular apparatus of the pelvic floor in one of the ways. All types of operations used in the treatment of prolapse or prolapse of the uterus are performed by vaginal access or through the anterior abdominal wall (cavity or laparoscopic access). After the operation, a course of conservative measures is necessary: physical therapy, diet therapy to eliminate constipation, exclusion of physical exertion.

Prevention

The most important preventive measures of prolapse and prolapse of the uterus is the observance of a rational regime, starting from the girl’s childhood. In the future, it is necessary to strictly comply with legislation in the field of women’s labor protection, preventing heavy physical work, lifting and carrying weights over 10 kg.

During pregnancy and during childbirth, the risk of displacement of the genitals increases. In the development of prolapsed uterus, not only the number of births plays an important role, but also the proper management of pregnancy, childbirth and the postpartum period. Properly provided obstetric care, protection of the perineum, prevention of prolonged labor, the choice of the correct method of delivery – will help to avoid further troubles associated with prolapsed uterus.

Important preventive measures in the postpartum period are careful comparison and restoration of perineal tissues, prevention of septic complications. After childbirth, in order to prevent prolapsed uterus, it is necessary to perform gymnastics that strengthens the muscles of the pelvic floor, abdominal press, ligamentous apparatus, in cases of traumatic childbirth, laser therapy, electrical stimulation of the pelvic floor muscles should be prescribed. In the early postpartum period, heavy physical activity is contraindicated. With a tendency to constipation, women are recommended a diet aimed at their prevention, as well as special therapeutic gymnastics.

Special attention should be paid to the prevention of prolapse and prolapse of the uterus in the premenopausal period: limit excessive physical activity, engage in therapeutic and preventive gymnastics and sports. An effective way to prevent prolapsed uterus into menopause is the appointment of hormone replacement therapy, which improves blood supply and strengthens the ligamentous apparatus of the pelvic organs.