Uterine prolapse is the displacement of the internal genitalia with their partial or complete exit to the outside of the genital slit. When the uterus falls out, pressure is felt on the sacrum, a foreign body in the genital slit, violations of urination and defecation, pain during sexual intercourse, discomfort when walking. The prolapse of the vagina and uterus is recognized during a gynecological examination. Treatment of uterine prolapse is operative, taking into account the degree of prolapse and the age of the patient. If surgical treatment is not possible, the use of a pessary is indicated for women
Pterine prolapse and vagina is considered as a hernial protrusion, which is formed when the functions of the closing apparatus – the pelvic floor – fail. According to the results of various studies conducted by gynecology, genital prolapse accounts for about 30% of gynecological pathology. Uterine prolapse and vagina rarely develops in isolation: the anatomical proximity and community of the supporting apparatus of the pelvic organs causes displacement after the genitals of the bladder (cystocele) and rectum (rectocele).
There is a partial (incomplete) uterine prolapse, characterized by an outward displacement of only the cervix, and a complete prolapse, in which the uterus is completely outside the genital slit. When the uterus prolapses, cervical elongation (elongation) develops. Usually, prolapse is preceded by a state of uterine prolapse – some displacement below the normal anatomical level within the pelvic cavity. Vaginal prolapse is understood as a displacement in which its anterior, posterior and upper walls are shown from the genital slit.
The leading role in the development of uterine prolapse and vagina belongs to the weakening of the ligaments and muscles of the diaphragm, pelvic floor, anterior abdominal wall, which become unable to hold the pelvic organs in their anatomical position. In situations of increased intra-abdominal pressure, the muscles cannot provide adequate resistance, which leads to a gradual displacement of the genitals downwards under the pressure of the acting forces.
The weakening of the ligamentous and muscular apparatus develops as a result of birth injuries, perineal ruptures, multiple pregnancies, multiple births, the birth of large children, radical interventions on the pelvic organs, leading to the loss of mutual support of organs. Uterine prolapse is facilitated by an age-related decrease in the level of estrogens after menopause, weakening of the uterus’s own tone, exhaustion.
Additional load on the pelvic muscles develops with overweight, conditions accompanied by increased intra-abdominal pressure (cough, chronic bronchitis, bronchial asthma, ascites, constipation, pelvic tumors, etc.). A risk factor for uterine prolapse is heavy physical work, especially in puberty, after childbirth, in menopause. More often, uterine prolapse and vagina occurs in old age, but sometimes develops even in unborn young women with congenital disorders of pelvic floor innervation or muscle hypoplasia.
The position of the uterus plays a role in the development of genital prolapse. In a normal position (anteversion-anteflexia), the pelvic floor muscles, pubic bones, and bladder walls serve as support for the uterus. With retroversion and retroflexion of the uterus, prerequisites are created for the appearance of hernial gates, the lowering of the walls of the vagina, then the uterus with appendages. Due to stretching of the ligamentous apparatus, vascularization, trophism and lymph outflow are disrupted. The uterine prolapse and vagina more often affects representatives of the Caucasian race; in African-American women and women of Asian descent, pathology is less common.
According to the degree of displacement of the uterus, 4 degrees of prolapse are distinguished.
- At the first degree (lowering of the uterus), there is some displacement of the uterus body downwards, but the cervix is in the vagina.
- Grade II (incipient or partial uterine prolapse) is characterized by the location of the external throat of the cervix in the vestibule of the vagina, and the body of the uterus – in the vagina. When straining, the cervix is shown from the genital slit.
- With grade III (incomplete uterine prolapse), the cervix and part of the uterus body are given out of the vagina at rest.
- With grade IV (complete uterine prolapse – prolapsus uteri), all parts of the uterus and the vaginal wall are located outside the genital slit.
The clinic of uterine prolapse and vagina is manifested by discomfort when walking, a feeling of heaviness, pressure and pain in the sacrum, a feeling of a foreign body in the perineum, soreness during sexual intercourse. When the uterus falls out, the topography and functions of adjacent organs – the bladder and rectum – are disrupted.
The development of a cystocele is characterized by involuntary urination under tension (coughing, laughing, lifting weights). In more severe cases, urination becomes difficult and becomes possible only after preliminary reduction of the uterus. Sometimes acute urinary retention develops, caused by an inflection of the urethra. The constant presence of residual urine in the bladder creates favorable conditions for the development of cystitis, pyelonephritis, urolithiasis. Prolonged uncorrectable uterine prolapse can lead to hydronephrosis.
With rectocele, defecation occurs, which is expressed in incomplete or difficult emptying of the rectum. Over time, patients may develop colitis, hemorrhoids, anal sphincter insufficiency, gas and fecal incontinence.
Uterine prolapse and vagina leads to a gaping of the genital slit, creating conditions for the penetration of infection and the development of endocervicitis. The walls of the vagina become dry, their mucosa becomes thinner or, conversely, sharply hypertrophied. Constant traumatization of the fallen genitals leads to bedsores, trophic ulcers, pseudo-erosions, swelling of the cervix and vaginal walls, contact bleeding. With severe edema and inflammatory infiltration of the uterus, its infringement may occur.
When the uterus falls out in women of reproductive age, the nature of menstruation changes according to the type of menstrual cramps and menorrhagia, infertility may develop. Sexual life with uterine prolapse becomes possible only after the reduction of the genitals. Patients with uterine prolapse often develop varicose veins of the lower extremities and pelvis, which is associated with a violation of venous outflow.
Recognition of uterine prolapse is not difficult. Upon examination, an education bulging out of the genital slit (when straining or at rest) is found on the chair. After the reduction of the fallen organs, the gynecologist conducts a vaginal-abdominal examination, during which he palpatively assesses the condition of the pelvic floor, the appendages of the uterus, the tone and position of the levator muscles.
The presence of a cystocele is clarified by catheterization of the bladder, rectocele – by finger rectal examination. With pseudoerosions and ulceration of the cervix, the exclusion of malignant lesions is required. For this purpose, an extended colposcopy is performed, a cytological examination of scrapings and a biopsy of the cervix is performed. To clarify the nature of the vaginal flora in case of uterine prolapse, smears are examined for the degree of purity and bacteriological seeding. In preparation for organ-preserving plastic surgery, as well as for concomitant pathology of the uterus, pelvic ultrasound, ultrasound hysterosalpingoscopy, hysteroscopy with separate diagnostic curettage is indicated.
Diagnosis of uterine prolapse and vagina requires the involvement of related specialists – a urologist and a proctologist. Urological examination of patients with uterine prolapse may include a study of general urine analysis, bacteriological urine culture, excretory urography, kidney ultrasound, chromocystoscopy, urodynamic studies. During the proctological examination, the presence and severity of rectocele, sphincter insufficiency, hemorrhoids are clarified. Uterine prolapse is differentiated from vaginal cysts, uterine fibromyomas, and cervical changes are differentiated from cervical cancer.
The only radical method of eliminating uterine prolapse and vagina in gynecology is surgical intervention. In preparation for the operation, treatment of ulceration of the mucous membrane, thorough sanitation of the vagina is performed. The method of surgery for uterine prolapse depends on the degree of prolapse, the somatic status and age of the woman.
In case of incomplete uterine prolapse in young patients who gave birth, a “Manchester” operation may be performed, including anterior colporaphy with shortening of the cardinal ligaments and colpoperineolevatoroplasty, and with elongation and hypertrophy of the cervix, ruptures and erosions of the cervix – with its amputation. Another intervention option in women of childbearing age with uterine prolapse can be an operation involving anterior colporaphy, colpoperineoplasty, ventrosuspension and ventrofixation of the uterus – attachment of the uterus to the anterior abdominal wall. With pronounced atrophy of the ligaments, they are strengthened with alloplastic materials.
In elderly patients with complete uterine prolapse, it is advisable to perform hysterectomy (complete removal of the uterus) and pelvic floor plastic surgery using colpoperineoplasty and uterine ligaments. With a burdened somatic history (diabetes mellitus, goiter, atherosclerosis, propensity to thrombophlebitis, severe cardiovascular diseases, pathology of the lungs, kidneys) and old age, when volumetric operations are difficult, the method of surgical choice is median colporaphy. After surgical elimination of uterine prolapse, physical therapy is prescribed, aimed at strengthening muscles, prevention of constipation is carried out, heavy physical labor and loads are excluded.
Conservative therapy for uterine prolapse and vagina is symptomatic and includes the use of a uterine ring (pessary), a hysterophore (a supporting bandage attached to the belt), large vaginal tampons. Such methods entail additional overstretching of the rectified vaginal walls, which over time increases the risks of uterine prolapse. In addition, prolonged use of the pessary can lead to the formation of bedsores. The use of various supportive devices for uterine prolapse requires daily vaginal douching and regular, twice a month, examination of the patient by a gynecologist.
Timely surgical intervention for uterine prolapse is prognostically favorable. Most women are recovering their social activity and sexual life. Pregnancy is possible after organ-preserving interventions. Pregnancy management in patients who have undergone surgery for uterine prolapse is associated with additional risks and requires increased precautions. Sometimes, even after eliminating the uterine prolapse, repeated prolapse of the genitals develops. With palliative treatment of uterine prolapse (using a pessary), irritation and swelling of the vaginal mucosa, ulceration, bedsores, infections, infringement of the cervix in the lumen of the ring, the formation of rectal and vesicovaginal fistulas often develops.
Prevention of uterine prolapse and vagina includes proper obstetric care during childbirth, careful suturing of ruptures of the perineum and birth canal, careful performance of vaginal operations, timely surgical treatment of genital prolapse of a small degree. In the postpartum period, to prevent uterine prolapse, it is necessary to fully restore the condition of the pelvic floor muscles – the appointment of special gymnastics, laser therapy, electrical stimulation of the pelvic floor muscles. Of preventive importance are fitness classes, exercise therapy, rational nutrition, maintaining optimal weight, eliminating constipation, eliminating hard work.