Health For Life

1. Reproductive
2. Renal/Urologic
3. Renal/Urologic
4. Gastrointestinal
   

• Pelvic pressure and low back pain
• As prolapse progresses, eventually a bulging is noticed as a result of protrusion
• Dyspareunia
• Difficulty with urination or defecation
  

1. Advancing age and vaginal childbirth are the most important factors
2. The incidence of prolapse increases with the frequency and difficulty of vaginal deliveries. Less than 2% of prolapse occurs in nulliparous women.
3. Other causes of prolapse include connective tissue disorders with lax tissue, i.e., Marfan's syndrome and neurogenic disorders, i.e., multiple sclerosis, cloacal agenesis, chronic constipation, pelvic tumors or ascites and chronic coughing from chronic lung disease
4. Patients who have undergone radical vulvectomy with loss of the external supporting structures have a higher rate of prolapse
   

• Childbirth, particularly multiple parity
• Advancing age
• Caucasian race
• Various connective tissue and neurogenic disorders
• Conditions resulting in increased intra-abdominal pressure, such as obesity, abdominal or pelvic tumors, pulmonary disease with chronic coughing, chronic constipation
• Occupations requiring heavy lifting
  

• Evaluation of renal function to rule out ureteral obstruction
• Urinalysis to rule out urinary tract infection
  

1. Hyperkeratosis of the cervical and vaginal tissues occur with prolapse beyond the introitus due to chronic irritation and drying. As the irritation becomes more pronounced, bleeding and ulceration occur.
2. Degrees of prolapse:
   
   • First degree prolapse - to the ischial spine
   • Second degree prolapse - to the introitus
   • Third degree prolapse - just beyond the introitus
   • Fourth degree prolapse - complete uterine and vaginal inversion involving bladder and bowel
     

• Intravenous pyelogram to rule out ureteral obstruction in complete uterine prolapse (optional)
• Pelvic ultrasound or CT scan to rule out other pelvic pathology, if suspected (optional)
  

• Treatment depends on multiple variables including the severity of prolapse, age, sexual activity, associated pelvic pathology and desire for future fertility
• Treatment of first and second degree prolapse is expectant unless patient is symptomatic
• Mildly symptomatic patients and poor surgical candidates - can be treated nonoperatively with perineal (Kegel) exercises, estrogen replacement and vaginal pessaries. Estrogen replacement restores healthy vaginal mucosa and promotes healing.
  

• Surgically able patients without additional pelvic pathology - vaginal hysterectomy with or without enterocele, cystocele, rectocele repair and vaginal vault suspension
• For patients who desire to maintain reproductive function - uterine suspension with vaginal repair is an option
• Elderly, non-sexually active women - can be treated with a colpocleisis or vaginal obliteration procedure
  

• Kegel exercises will increase the strength of the pelvic diaphragm muscles and may provide some pelvic support
• Weight loss and proper management of conditions that would increase abdominal pressure help to prevent prolapse
  

1. Ureteral obstruction and renal failure
   
2. Incarceration of bowel herniations
3. Pessary use - may not always be effective, and may cause discomfort, ulcers, infection
   

• It is expected that as patients age, the incidence and severity of prolapse will increase
• Surgical correction usually successful
  

Labels: Uterine prolapse