Brief overview
- Causes: Weakened ligaments and muscles in the pelvic area, incorrect strain due to heavy lifting, severe overweight, chronic constipation, weak connective tissue, childbirth.
- Therapy: Pelvic floor exercises, hormonal treatment during menopause, surgical corrections, pessary
- Symptoms: lower abdominal or back pain, feeling of pressure in the vagina, pain when urinating or defecating, stress incontinence, for example when coughing, urinary tract infections, urine backing up into the kidney (very rare)
- Diagnosis: Gynecological examination with vaginal mirror and palpation, cough stress test, possibly ultrasound examination and control of urine.
- Prognosis: With appropriate treatment and preventive measures, recurrence of prolapse can be prevented.
- Prevention: Prevent recurrence through preventive measures such as regular exercise and pelvic floor exercises, avoid heavy lifting, reduce excess weight.
What is uterine prolapse and vaginal prolapse?
When there is a general lowering of the pelvic floor, doctors refer to this as genital descent or descensus genitalis. In this case, the uterus, urinary bladder, rectum, rectum or vagina “hang” lower in the pelvis than usual.
Descensus uteri refers to a lowering of the uterus. In extreme cases, the uterus even protrudes partially or completely through the vagina to the outside. Doctors then speak of a prolapsed uterus (uterine prolapse). In mild cases, uterine prolapse is asymptomatic. In most cases, however, various complaints occur.
In addition to uterine prolapse, there is also vaginal prolapse (descensus vaginae). In this case, the vagina sags downward so that the vagina bulges through the vaginal opening. If parts of the vagina hang out, this is called vaginal prolapse (prolaps vaginae or vaginal prolapse).
Overall, between 30 and 50 percent of all women develop pelvic floor prolapse in the course of their lives. However, symptoms do not necessarily have to occur. Many women have no complaints with mild prolapse, so it is often not medically relevant at all. Treatment is only necessary in the case of more severe descent with noticeable symptoms or functional impairment and, of course, in the case of uterine or vaginal prolapse.
Descent in the pelvic floor area sometimes also affects younger women. This is especially the case if there is a chronic weakening of the connective tissue.
What are the causes and risk factors?
- Overload and misload of the pelvic floor due to heavy physical work
- Pressure increase in the abdominal cavity due to diseases such as chronic bronchitis or chronic constipation
- Obesity
- General weakness of the connective tissue
In addition, in some women, the uterus lies in a deviated position in the abdomen from birth. Such positional anomalies also increase the risk of uterine prolapse. In this case, the first symptoms often appear from the age of 30.
Weakened pelvic floor after childbirth
After births, the likelihood of a lowered pelvic floor is increased. If the fetuses have a high weight, there is more stress on the ligaments in the pelvic area. Vaginal injuries during childbirth are also a possible risk. Women who have had several children in their lives suffer comparatively more frequently and earlier from uterine prolapse.
How is pelvic floor descent treated?
Depending on the stage of uterine or vaginal prolapse and the age of the affected person, different methods of treatment can be considered. Basically, therapy is necessary when the sagging causes discomfort. The method then depends on whether the patient still wishes to have children.
In mild forms and as a preventive measure, for example during pregnancy, pelvic floor exercises help. These are special exercises that specifically strengthen the muscles of the pelvic floor. This helps to prevent a lowering of the pelvic organs. Mild forms of descent may regress on their own, i.e. without special medical intervention.
Surgery for uterine prolapse or vaginal prolapse
In more severe cases, surgery is inevitable. In principle, the following “access routes” can be considered:
In the most favorable case, the doctor performs the operation only through the vagina.
In laparoscopy, an endoscope and the surgical instrument are inserted through a small incision in the abdominal wall and the operation is performed in this way.
However, sometimes it is necessary to make an incision about five centimeters long on the lower abdomen through which the surgery is performed.
During the operation, the pelvic muscles are tightened and organs that have lowered are returned to their original position. The doctor inserts a so-called vaginoplasty to tighten the pelvic floor muscles and strengthen the perineum.
In posterior vaginoplasty, the surgeon detaches the vaginal skin from the rectum and removes the excess stretched vaginal skin. After suturing up the bladder or rectum, he sutures the vaginal skin again. Posterior vaginoplasty is considered in case of rectal prolapse.
In the so-called sacrocolpopexy, the operating physician attaches the vaginal end or the cervix to the sacrum by means of a plastic mesh. This procedure is also possible through laparoscopy with the help of an endoscope. Sacrospinal fixation means that the surgeon attaches the uterus or vaginal end to the body’s own retaining ligaments (ligaments) in the pelvis, thus lifting it.
Which surgical technique is used also depends on whether there is a healthy uterus and whether the patient wants uterus-preserving surgery. For example, sacrospinal fixation is one of these techniques.
If uterine prolapse or vaginal prolapse is accompanied by uncontrollable urinary leakage (incontinence), there are a number of other surgical procedures such as elevation of the vaginal wall and correction of the urethral bladder neck angle (colposuspension).
The transvaginal mesh (TVM) procedure is another option for treating uterine prolapse. In this procedure, the doctor inserts a mesh between the bladder and the pelvic floor during surgery through the vagina.
Aftercare following surgery
The surgery takes about 30 to 60 minutes and is usually done under general anesthesia. Some hospitals and medical care centers also offer treatment under local anesthesia. After the surgery, a hospital stay of about two days is required. Complications are very rare during surgery. Usually, operated women go back to their normal work after a few days.
Pessary
For older and physically very weak women, surgery is not an option. Here, treatment is usually carried out gently using so-called pessaries. A pessary is cup-, cube- or ring-shaped and is made of hard rubber or silicone. The pessary is inserted into the vagina by the doctor and supports the uterus. It does not correct an existing descent, but only counteracts further descent. It is important that the pessary is cleaned regularly by a doctor and that it is reinserted so that it does not cause inflammation. Basically, it can only be used to treat a uterine prolapse if the perineal muscles are still sufficiently strong.
What symptoms does a sagging pelvic floor cause?
For most women, uterine prolapse causes a chronic feeling of pressure or foreign bodies in the vagina, as well as a constant downward pull. This creates the fear that something could “fall out” of the vagina. Affected women therefore often cross their legs. In addition, there is increased inflammation and mucosal coating because the vaginal flora is altered. Pressure ulcers also occur.
Another symptom is bloody discharge from the vagina. If the prolapse is relatively severe, the vagina or uterus may bulge through the vaginal outlet and can be palpated.
Urinary tract infections may also occur more frequently. In extreme cases, the urinary bladder shifts or sinks as well. As a result, urine backs up into the kidney. However, this complication is rare.
Towards the back, close to the uterus, are the rectum and the anal canal. If the uterus slips down and back, it may put pressure on the rectum. Possible consequences include constipation and/or pain during bowel movements. Fecal incontinence also occurs in isolated cases.
If a uterine prolapse remains unnoticed for a long time, it increasingly presses on the pelvic floor. In extreme cases, the uterus protrudes completely or partially from the vagina. Doctors then speak of uterine prolapse or uterine prolapse. The symptoms are obvious here: the uterus can be seen visually from the outside.
How is pelvic floor prolapse examined and diagnosed?
The doctor then makes a clear diagnosis by means of a gynecological examination. He uses a vaginal mirror to examine the vagina and also palpates the abdominal organs from the outside and through the vagina. A rectal examination is also part of a suspected uterine prolapse. The doctor palpates directly into the rectum. For example, an invagination of the wall of the rectum (rectocele) towards the vagina can be detected. Such a bulge is a common cause of constipation.
The so-called cough stress test is used to check whether stress incontinence is present. This is the case when urine leaks during physical exertion such as vigorous coughing or lifting. This is more likely to occur with mild pelvic floor prolapse. Women with a more severe drop, on the other hand, tend to have more difficulty emptying the bladder because the urethra may be kinked.
Course of the disease and prognosis
There are four different gradations of descent of the pelvic floor (descensus genitalis):
- Grade 1: Subsidence within the vagina
- Grade 2: Descent reaches the vaginal outlet
- Grade 3: Descent extends beyond the vaginal outlet
- Grade 4: The uterus or vagina protrudes to a large extent from the vaginal outlet (prolapse)
Uterine prolapse and vaginal prolapse are not independent diseases, but symptoms of a weakening pelvic floor. For this reason, pelvic floor prolapse can only be treated symptomatically. A causal treatment is not possible. Due to the weakness of the pelvic floor, repeated prolapses are possible. Preventive measures help to reduce the risk of recurrence.
Prevention
Another measure is to avoid excessive physical stress such as lifting heavy loads. If lifting is unavoidable, care should be taken not to lift from a bent position, but to squat while doing so. Regular exercise also prevents uterine prolapse. Endurance sports such as swimming, cycling or running have proven to be particularly beneficial. For overweight women, it is also recommended to reduce body weight.
All these measures help both before and after surgery for uterine prolapse or vaginal prolapse. However, there is no one method guaranteed to prevent pelvic floor descent. All preventive measures only reduce the individual risk.
