Uterine prolapse, or vaginal prolapse, occurs when the ligaments and muscles holding the uterus lose tone and can no longer hold it in its anatomically normal position. The uterus and vagina then shift downward according to gravity. Mild descent does not require therapy; severe cases require surgical intervention.
What is uterine prolapse?
Schematic diagram showing the anatomy and structure of the uterus in uterine prolapse…. Click to enlarge. The technical term for uterine prolapse is descensus uteri. Normally, the uterus lies in the small pelvis, held in place by a connective tissue support. From above it is suspended by various ligaments and from below it is additionally supported by the pelvic floor muscles. With increasing age, but also due to other causes, the musculature and ligaments can become loose, so that the uterus gradually slides downwards. Structures of the vagina then also move downward. There are four different degrees of uterine prolapse:
1st degree prolapse is very mild and is usually not even noticed, 2nd degree prolapse is when the uterus lowers to the vagina, and 3rd degree prolapse is when it becomes visible in the vagina. The 4th degree uterine prolapse is the so-called uterine prolapse or total prolapse, in which the uterus and parts of the vagina protrude from the body.
Causes
The cause of uterine prolapse is a decrease in the tone of the holding apparatus. Very often, the pelvic floor muscles are too weak and can no longer support the uterus. This pelvic floor weakness often develops with age. However, it can also be triggered in younger years by connective tissue weakness, many pregnancies, heavy exercise, chronic constipation or obesity. Connective tissue weakness is congenital, sometimes it is also triggered by a hormonal change and only appears after menopause. Heavy lifting and carrying in the presence of connective tissue weakness can lead to uterine prolapse. During pregnancies, the weight of the uterus increases, especially with multiples or very heavy children. As a result, the ligaments that hold the uterus can become overstressed and lose elasticity. They are then no longer able to tighten completely after pregnancy, the result is the sinking of the uterus. Excess weight leads to extreme stretching and weakening of the abdominal wall muscles. As a result, there is a lack of tension in the abdomen and the organs are no longer held properly, which can also cause uterine descent.
Symptoms, complaints and signs
Uterine prolapse occurs in many women and often causes no symptoms at all. This is especially the case with grade I uterine prolapse. At this stage, the uterus does not yet reach the vaginal entrance during the descent. This is not the case until stage II of a uterine prolapse. Beyond that, partial prolapse (grade III) or total prolapse (grade IV) of the uterus through the vaginal entrance may occur. From the second stage on, some women already complain of pulling abdominal pain, a feeling of pressure, a foreign body sensation in the vagina, bladder weakness and bladder emptying disorders. These complaints increase in parallel with the severity of the uterine prolapse. Bladder weakness manifests itself in involuntary leakage of urine when laughing, sneezing, coughing or having sexual intercourse. This is referred to as stress incontinence. In bladder emptying disorders, on the other hand, there is an increased urge to urinate, but only small amounts of urine are emptied (pollakiuria). This always leaves residual urine in the bladder, which greatly increases the risk of urinary tract infections. Bacteria already present in the residual urine multiply and can lead to frequent bladder and vaginal infections. In extreme cases, a severely recessed uterus can also cause urinary retention with the risk of total kidney failure. Furthermore, as a result of a lowered uterus, defecation disorders in the form of constipation and unpleasant feelings of fullness can also occur when an intestinal wall bulge filled with feces is pushed toward the vagina.
Diagnosis and course
Mild uterine prolapse usually causes no symptoms. However, if it progresses further, various symptoms become noticeable. Initially, a certain feeling of pressure or pulling downwards is felt in the lower abdomen.This may be accompanied by abdominal and lower back pain, especially after physical exertion. If the uterus has descended so far that it presses on the bladder, this can lead to frequent urination or bladder weakness. When sneezing, coughing or laughing, urine leaks uncontrollably in droplets. Bladder emptying disorders can also be caused by a lowered uterus. A little urine always remains in the bladder, which can trigger urinary tract infections. In 4th degree uterine prolapse, there is often inflammation in the vagina. In addition, affected women have limited mobility and a normal sex life is no longer possible. The gynecologist can make the diagnosis through a gynecological examination. By internal palpation of the abdomen, but also with an ultrasound examination, a uterine prolapse can be easily detected even at an early stage.
Complications
As a rule, the discomfort or complication always depends on the extent of the uterine prolapse. In the case of only minor subsidence, in most cases there is no particular discomfort or pain, and no direct treatment is performed. In this case, no further complications occur. In severe cases, however, there is pain in the lower abdomen and lower back. It is not uncommon for this pain to spread to other regions of the body and may also affect these areas. It is not uncommon for incontinence and bladder weakness to occur as well. As a result, sufferers often develop psychological discomfort and depression. Urination also has to occur more frequently, and it is not uncommon for patients to intentionally take a smaller amount of water. This can lead to dehydration, which is a very unhealthy condition for the sufferer. As the uterine prolapse progresses, urinary tract infections may also occur if the uterine prolapse is not treated. During the treatment, there are also no further complications. This is done with the help of therapies or surgeries. As a rule, there is no reduction in life expectancy.
When should you go to the doctor?
Women should see a doctor as soon as they experience pain in the abdomen that is not tied to the onset of menstruation or ovulation. If the pain increases or spreads, a doctor should be consulted. If additional back pain occurs or there is impairment in the pelvic area as well as in locomotion, a doctor should be consulted. Before taking any pain medication, it is always necessary to consult a medical professional in order to avoid complications or further disturbances. If the woman suffers from bladder weakness, frequent urination or if there is involuntary enuresis, she should consult a doctor. If urine cannot be held when sneezing or coughing, a visit to the doctor is necessary. If there is discomfort during the sexual act, a feeling of pressure or tightness in the abdomen, or the perception of a foreign body in the vagina, it is advisable to consult a doctor. Feelings of tension in the abdomen or lower abdomen are considered unusual and should be medically clarified. If there are disturbances of the female cycle, an inner restlessness as well as a diffuse feeling of illness, a visit to the doctor is necessary as soon as the complaints persist over a longer period of time. In case of discomfort or problems with the use of tampons, a doctor should be consulted.
Treatment and therapy
Uterine prolapse can be treated conservatively and surgically. In affected women beyond menopause, the administration of estrogens often helps. Furthermore, one can strengthen the holding apparatus of the uterus by exercising the pelvic floor muscles. It is recommended that the pelvic floor be exercised before the onset of the first symptoms, so that uterine prolapse does not occur in the first place. There are also special pessaries that are inserted into the vagina to support the uterus from below. If the uterine prolapse is already more advanced, it is usually treated surgically. In this case, the slipped organs are brought back to their original place and fixed there. The ligaments are shortened so that they can resume their support function. If the vagina is also lowered, a so-called vaginal lift is performed. Depending on the circumstances, the operation is performed through the vagina or with an abdominal incision.In some cases, when women no longer want children, the uterus is also removed.
Outlook and prognosis
Uterine prolapse, a sign of a weakening pelvic floor, may continue to intensify. First-degree vaginal prolapse is expected in women during menopause. On the other hand, vaginal prolapse that occurs earlier or is more severe can be more pronounced. This depends on the stress on the vagina, such as that caused by heavy lifting. The prognosis after symptomatically treated vaginal prolapse can only lead to the conclusion that vaginal prolapse may occur again. Whether this happens, and how likely it is, depends on the preventive measures taken by the affected woman. Lifting correctly (from the knees rather than the back) and practicing pelvic floor exercises reduce the likelihood of another uterine prolapse. Being overweight also increases the risk of further vaginal prolapse, while exercising lowers it. Safety from further vaginal prolapse can only be provided by a surgical procedure. This can sometimes mean removal of the uterus. Overall, all surgical procedures in this context are such that they can have an impact on the functionality of the uterus. Accordingly, family planning can be influenced by surgical procedures in this context.
Prevention
One can prevent uterine prolapse by eating a healthy diet and getting enough exercise. This counteracts obesity, which is a major risk factor for uterine prolapse. Furthermore, sports activities and regular training of the pelvic floor muscles help already at a young age.
Aftercare
If the patient suffered from uterine or vaginal prolapse, then there should be some follow-up care. The patient should have regular follow-up visits with a specialist, in this case a gynecologist. The uterine prolapse should always be monitored. If surgery was necessary or if the patient continues to have severe pain, follow-up visits to the specialist are inevitable. Also, the ointments that are usually prescribed should always be continued. It is often the case that the affected person is given suppositories to alleviate the symptoms. These, too, must by no means be discontinued without medical consultation. Following surgery, it is advisable for the person to take it easy. Carrying heavy objects is also taboo. It is important that no complications arise during the aftercare of a uterine prolapse. After surgery, it is quite possible that postoperative bleeding may occur. This post-operative bleeding may be prevented by rest or may only occur in a reduced manner. It is important to always follow these points of aftercare in order to let the recovery of the prolapse arrive as soon as possible. The support and aid of family members are also essential factors that contribute to recovery and rapid healing.
This is what you can do yourself
Depending on the severity of symptoms, women can do a lot to improve. The first thing to do is targeted pelvic floor exercises. Brochures on gymnastics and strengthening the pelvic floor muscles are available at every gynecologist’s office, but doctors, midwives, trainers and nurses will also be happy to provide information about this. Strengthening sports are unsuitable as they strain the pelvic floor muscles and increase symptoms such as urine leakage. In contrast, yoga, Pilates, Nordic walking and hiking as well as light running on soft ground are particularly suitable. Horseback riding is considered the most effective sport against uterine prolapse, as the entire pelvic floor is stimulated by the rocking motion of the horse. When running, the pelvic floor can be additionally trained with so-called vaginal weights, which are inserted into the vagina. Women should accustom their bodies to these only slowly, i.e. they should start training with the lightest weight and increase it slowly. Contraction of the pelvic floor muscles has proven to be very effective in all life situations: whether in the office, cooking, gardening, walking, it can become a very useful and effective habit and even during sexual activity can lead to increased awareness.
