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Uterine prolapse
Sunday, February 21, 2010



Uterine prolapse occurs when the integrity of supporting structures is lost. This allows the uterus to descend into the vagina. In advanced cases, complete protrusion with inversion of the vagina occurs. Prior to menopause, the degree and severity of prolapse is usually related to the number of children and the difficulty of childbirth. After menopause, atrophy and loss of tissue integrity further leads to prolapse.

System(s) affected:
  1. Reproductive
  2. Renal/Urologic
  3. Renal/Urologic
  4. Gastrointestinal
Common among Caucasian races. Less common among Asians and African Americans and particularly uncommon in South African Bantus and West Africans. Approximately 1 in 10 women will experience some degree of prolapse.

SIGNS AND SYMPTOMS:
  • 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
CAUSES:
  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
RISK FACTORS:
  • 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
LABORATORY:
  • Evaluation of renal function to rule out ureteral obstruction
  • Urinalysis to rule out urinary tract infection
PATHOLOGICAL FINDINGS:
  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
IMAGING:
  • 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)

DIAGNOSTIC PROCEDURES:
If ulceration or bleeding is present, Pap smears and appropriate cervical and endometrial biopsies should be done to rule out concomitant malignancies

TREATMENT
  • 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.
SURGICAL MEASURES:
  • 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
ACTIVITY:
Heavy lifting or significant increases in intra-abdominal pressure will lead to worsening of prolapse or recurrence after surgical correction. Lifting should therefore be restricted.

DIET:
Unlimited. Avoid constipation.

PATIENT EDUCATION:
•Kegel exercises when applicable

MEDICATIONS
Estrogen replacement therapy (oral or vaginal cream) can increase the blood supply to the vaginal tissues and in mild cases increase supporting tissue strength to a point where surgery or pessary use may be avoided

Contraindications: Those associated with the use of estrogen. Refer to manufacturer's literature.
Precautions: If estrogen therapy is utilized and the uterus is present, progesterone should be utilized to offset the potential of endometrial carcinoma
Significant possible interactions: Refer to manufacturer's literature

PREVENTION/AVOIDANCE:
  • 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
POSSIBLE COMPLICATIONS
  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

EXPECTED COURSE AND PROGNOSIS:
  • It is expected that as patients age, the incidence and severity of prolapse will increase
  • Surgical correction usually successful
ASSOCIATED CONDITIONS:
Cystocele, rectocele, enterocele and vaginal vault prolapse are often associated with uterine prolapse


REFERENCES

•Nichols DH, Randall CL: Vaginal Surgery. 4th Ed. Baltimore, Williams & Wilkins, 1996
•Ryan KJ, Berkowitz R, Barbieri RL: Kistner's Gynecology: Principles and Practice. 6th Ed. Chicago, Year Book Medical Publishers, Inc., 1995
•American College of Obstetricians & Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188, (800)762-ACOG
•Nichols DH: Gynecologic and Obstetric Surgery. 1st ed. St Louis, MO, CV Mosby, 1993
•Thompson JD, Rock JA: Telinde's Operative Gynecology. 8th ed. Philadelphia, Lippincott-raven, 1997
•Mishell DR, Stenchever MA, et al: Comprehensive Gynecology. 3rd ed. St Louis, CV Mosby, 1997
•Mann WJ, Stovall TG: Gynecologic Surgery. 1st ed. New York, Churchill Livingstone, 1996

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posted by Rodolfo T. Rafael,M.D. @ 12:13 PM  
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Name: Rodolfo T. Rafael,M.D.
Home: San Fabian, Pangasinan, Philippines
About Me: Family Physician, and Associate Professor (Medical Biochemistry, Medical Physiology and Medical Informatics)
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