The Rubino OB/GYN Group Expands

Uterine Prolapse or "dropped uterus" is a condition where the uterus (womb) sags or slips out of its normal position. In the U.S. pelvic support defects are relatively common and increase with age. One study of 16,000 patients found the rate of uterine prolapse to be 14.2%. The average age of women who choose to undergo surgery for prolapse is 54.6 years.

Causes of Uterine Prolapse are varied and may include:

Vaginal delivery with a large baby
Difficult labor and delivery
Reduced muscle tone from aging
Lower circulating estrogen after menopause
Family history of prolapse
Any activity that increases intra-abdominal pressure (frequent heavy lifting, chronic cough, straining to have bowel movements)

Four Stages of prolapse are usually defined:

Stage I: Descent of the uterus to any point ABOVE the hymen
Stage II: Descent of the uterus to the hymen
Stage III:Descent of the uterus beyond the hymen BUT not completely out of the vagina
Stage IV:"Procidentia" Descent of the uterus completely out of the vagina

Symptoms

Women with mild uterine prolapse have no obvious symptoms and generally do not seek treatment. However, as the uterus drops further it may cause a variety of symptoms which may include:

Pelvic pressure (described as heaviness or pressure in the pelvis)
Pelvic pain discomfort in the pelvis/abdomen/lower back
Pain with sexual relations
Protrusion of tissue from the opening of the vagina
Constipation
Difficulty with urination

Symptoms may be worsened by prolonged standing or walking due to the pressure placed on the pelvic muscles by gravity.

In general women with any degree of prolapse or symptoms may seek care with a board certified Urogynecologist. A Urogynecologist is an Obstetrician/Gynecologist who has had three additional years of specialized training in the management and treatment of women with prolapse and/or urinary incontinence. The Urogynecologist will ask a detailed history and perform a complete pelvic exam to stage the prolapse, which may include examination while lying down and standing. Occasionally additional testing with ultrasounds may be performed to further evaluate uterine prolapse.

Once the examination is completed the urogynecologist will be able to provide you with a detailed discussion of your options for management and/or treatment of uterine prolapse.

Treatment

Currently there are no proven ways to reverse uterine prolapse asthere is muscular damage/trauma and neurologic (nerve trauma). The condition is managed either non-surgically, surgically or a combination of the two. Surgery will give symptomatic relief and kegels will maintain pelvic floor strength which may help to prevent recurrence of the prolapse

NON-SURGICAL OPTIONS

Kegel exercises: Kegel's strengthen the pelvic floor muscles, which support the uterus, bladder and bowel. The exercises can be performed discreetly just about any time. Women may elect to do these exercises on their own. Other women find the use of "vaginal weights" helpful in identifying the correct muscles. In addition, there are specialized physical therapists that have been trained specifically in pelvic floor issues. The physical therapist may use bio-feedback and imaging to instruct and guide women as they work to strengthen their pelvic floor muscles.

HOW DO I DO KEGEL EXERCISES?

To do kegel exercises, tighten your pelvic muscles as if you are trying to hold back urine. Hold the muscles tight for a few seconds and release, this should be repeated 10 times. Over time you will be able to hold the muscles tight for longer periods of time. You may do these exercises anywhere and anytime. In order to see any results it is recommended that you repeat the exercises four times daily.

Vaginal Pessary: A pessary is a device made of silicone that fits around or under the lower part of the uterus (cervix) helping to prop up the uterus and hold it in place. A woman must be fit with the appropriate size pessary and the pessary needs to be cleaned frequently and removed prior to any sexual relations.

Estrogen Therapy: Although estrogen receptors are plentiful in the pelvis, their role in pelvic support is not completely understood. There is NO scientific evidence to support the use of estrogen to prevent or treat prolapse. Topical estrogen to the vagina to treat vaginal dryness associated with menopause provides many women localized relief.

Many women elect surgical management of uterine prolapse however, they must realize that the kegel exercises remain the mainstay of a healthy pelvic floor. In addition, modification of lifestyle needs to be undertaken in order to prevent any further strain on the pelvic floor, this may include eliminating heavy lifting, chronic straining or coughing.

SURGICAL OPTIONS

Many women elect to have a surgical repair for uterine prolapse, either they felt the non-surgical approach did not provide them with adequate relief of their symptoms OR they simply chose not to try non-surgical management options.

Hysterectomy: Uterine prolapse may be managed by removing the uterus (hysterectomy). This can be accomplished through an incision made in the vagina (vaginal hysterectomy) or through the abdomen (abdominal hysterectomy). Regardless of which route is chosen it is important to restore the support to the "apex" or top of the vagina in order to prevent future prolapse of the vaginal wall. Abdominally this can be accomplished by attaching the top of the vagina to a piece of permanent mesh which is then fixated to the sacrum (back bone). Vaginally pelvic ligaments are used to assure adequate support of the vagina.

In general the vaginal route is preferred because it is associated with less pain after surgery, faster healing and no abdominal scar. However the vaginal surgery may not provide as lasting a "fix" as the abdominal surgery.

In women who desire to preserve the uterus a Uterine Suspensionmay be performed which simply involves putting the uterus back into its normal position. This may be accomplished vaginally (reattaching the pelvic ligaments to the lower part of the uterus to hold it in place or abdominally (using a piece of mesh to support the uterus and attaching to the sacrum (back bone).

More recently Laparoscopic or robotic (da Vinci Surgery) operating techniques have come into favor. These are described as minimally invasive procedures because they involve placement of a lighted camera and several other surgical instruments into the abdomen. These methods allow essentially the same procedures described above to be done via smaller abdominal incisions. The procedures have come into favor because they provide the patient:

Significantly less pain
Minimal blood loss
Fewer complications
Shorter hospital stay
Quicker recovery
Small incisions for minimal scarring

Laparoscopic or Robotic procedures are not appropriate for every individual. In addition there is some concern that the long term success (no recurrence of prolapse) is not as good with the minimally invasive procedures as with either the abdominal or vaginal approaches.

A detailed discussion with your Urogynecologist will allow you to work together to determine what is going to be in your best interest regarding management and/or treatment of uterine prolapse.