Uterine prolapse

A prolapse in women may be classified as:

• Prolapse affecting the anterior (front) part of the pelvic region: Can include prolapse of the urethra (the tube through which urine is removed from the body) known as a urethrocele. The urinary bladder might also prolapse—this is known as a cystocele. When both the structures prolapse, it is called a cystourethrocele.
• Prolapse that affects the middle part and the posterior (rear) part of the pelvis: Sometimes, the uterus can prolapse into the vagina. This is called uterine prolapse. It is the second most common type of genitourinary prolapse (after cystourethrocele prolapse). Another kind of prolapse that may be observed in combination with this is a rectal or back passage prolapse into the vagina that is termed as a rectocele.
• In certain situations, the space between the uterus and the rectum may prolapse into the vagina. This space is called the pouch of Douglas. This type of prolapse is called an enterocele and usually consists of bowel loops.

Sometimes, uterine prolapse is asymptomatic. Your doctor might observe it while examining you for any other reason like a cervical smear test/pap smear test. Where symptoms of uterine prolapse occur, they may include:

• Most females with a uterine prolapse might experience a dragging or coming down sensation.
• Some patients might get the feeling that there is a lump in their vagina. This protrusion or lump may actually be felt. 
• Pain: Patients could experience abdomen (tummy) pain, back pain or pain in the vagina. 
• Discharge: A uterine prolapse may be associated with vaginal discharge. This discharge may contain blood or may be foul-smelling.
• Pain during sex or uncomfortable intercourse
• It is important to remember that the symptoms of uterine prolapse increase on standing for long durations and improve on resting or lying down.  
• If a uterine prolapse occurs in combination with a urethra or bladder prolapse, the patient may experience excessive urination (daytime and nighttime), urinary leakage with certain activities like coughing, sneezing or lifting something heavy, excessive urge to pass urine, poor urinary flow and having a feeling of incomplete evacuation of the bladder. Sometimes, the patient might have to change her position or push the prolapse back with her finger to pass urine. Certain complications might also occur in these patients that may include urinary tract infections, urinary incontinence (loss of control of urination) or urinary retention (not able to pass any urine).
• If a uterine prolapse occurs in combination with rectal prolapse, then the patient might experience difficulty in passing stools, straining during bowel movements, experiencing a sudden urge to defecate, stool incontinence (loss of control over bowel movements), the excessive passage of flatus or wind and a feeling of incomplete evacuation of faeces (tenesmus). Sometimes, the patient might have to push the prolapse back up to allow stools to pass during defecation. 
• Sexual issues: In some females, there might not be any sexual difficulties whereas in others there may be some problems. Patients might find having sex difficult or uncomfortable. The uterine prolapse might also interfere with arousal. Some females might also experience pain during intercourse (dyspareunia). 
• In some patients, if the prolapse extends outside the vagina, it can lead to the formation of ulcers in the cervix (neck of the womb) or the skin. This can result in infections, pain and bleeding.

There are numerous factors that may result in uterine prolapse. These may include the following:

• Childbirth: Uterine prolapse will not be seen in every woman who gives birth. Instrumental delivery (forceps delivery), giving birth to a large baby (macrosomic baby) or a complicated and prolonged labour can increase the risk of a female having a uterine prolapse during childbirth. Uterine prolapse is more commonly observed in females who give vaginal birth as compared to those who undergo a C-section.
• Advancing age: As females become older, their chances of developing a uterine prolapse increase drastically. After menopause, there is a deficiency of the estrogen hormone in the body. This lack of estrogen results in weakening of the pelvic floor muscles and supportive structures around the vagina. One consequence of these weakened support structures can be a uterine prolapse. (Read more: Kegel exercise benefits and how to do them)
• Increased intraabdominal pressure (pressure inside the stomach): Any factor that causes an increase in the intraabdominal pressure can result in a prolapse. This increase in pressure can occur due to excessive strain on the pelvic floor muscles and ligaments. The most common cause of increased intraabdominal pressure in females is pregnancy and giving birth. Other causes of high intraabdominal pressure may include being overweight, chronic (persistent) lung diseases such as chronic obstructive pulmonary disease (COPD) (associated with a chronic cough), straining during bowel movements due to constipation and females whose jobs require lifting any sort of heavy weights. 
• Surgery: Females who undergo any kind of gynaecological surgery are more likely to develop a prolapse. This is due to the weakened pelvic floor structures that support the uterus and other organs. With the development of laparoscopic or keyhole surgery, this has become relatively rare nowadays.
• Congenital diseases: A congenital issue (a problem that somebody is born with) that results in a deficiency of collagen can make one more prone to uterine prolapse. Collagen is a substance that is necessary for the development of ligaments that are an integral part of the supporting structure in the pelvic area. 
• Family history: Females whose mothers or sisters have a history of uterine prolapse are more likely to develop one themselves.

There are a few preventive steps that all women should take, irrespective of their age and family history of prolapse. These include:  

• Pelvic floor exercises should be performed regularly by females who are planning to get pregnant or have recently given birth. 
• Weight loss, if you are overweight
• Eat a high fibre diet and drink adequate fluids to prevent constipation
• Stop smoking
• Avoid work that requires you to lift heavy weights. If you need to lift weights, pay attention to the proper form and technique for doing so and be vigilant—see a doctor if you experience discomfort in the pelvic region or if you see any of the above-mentioned symptoms of uterine prolapse.

A doctor can diagnose a uterine prolapse clinically. A thorough vaginal examination should be performed. The doctor will need you to lie down on your left side and bend your knees towards the chest. The second part of the examination will be performed while standing. During the examination, an instrument called a speculum is inserted into the vagina. This speculum is used to move to the front and back walls of the vagina and observe the prolapse. You may be asked to cough or strain during this examination. This examination is not painful, but some women may feel slight discomfort.

Usually, a proper clinical examination is sufficient to make a diagnosis. In the case of urinary issues, though, a urine sample may be collected and sent for:

• Urine routine and microscopy (analysis)
• Urine culture and sensitivity microbiological examination

Your doctor may even ask for certain blood tests like a kidney function test. Some patients may also be referred to specialists for urodynamic studies to test bladder functions and urinary flow. 

Radiological investigations such as an ultrasound may also be performed.

The ultimate aim of treatment of uterine prolapse is to make sure that the patient lives comfortably, is pain-free, is able to urinate and defecate properly without any issues, does not have any sexual issues and does not experience any complications like ulcerations or urinary tract infections. The following treatment strategies may be used: 

• Watchful waiting: If you are asymptomatic, you may wish to wait and see if any symptoms start. Usually, the minimal symptoms that may be present do not worsen with time or may even improve. In case you develop new symptoms, visit your doctor. 
• Lifestyle changes: If you are overweight, aim for a reduction in weight. Patients should ask for proper treatment in case they are constipated as it can result in an increase in intraabdominal pressure. Patients should also stop smoking, as excessive coughing can worsen or aggravate the prolapse.  If you have a uterine prolapse, avoid lifting heavy weights.
• Pelvic floor exercises: All patients with a uterine prolapse should perform pelvic floor exercises. These exercises prevent the worsening of a prolapse and help in the reduction of abdominal discomfort and back pain. Your doctor might ask you to visit a physiotherapist to learn these exercises. 
• Vaginal pessary: It is preferred by women suffering from uterine prolapse who do not want surgery, who wish to maintain their fertility and those who have comorbidities that make them unfit for surgeries. Pessaries are usually ring-shaped and are made of plastic or silicone. This ring is inserted into the vagina and left in place. It aids by lifting the walls of the vagina along with the uterus that has prolapsed. The rings should be changed annually. Patients can be reassured that these pessaries do not interfere with sexual intercourse and can be left in place while having sex. 
• Vaginal estrogen creams: In case of a mild prolapse, your doctor might ask you to apply an estrogen cream for six weeks to reduce the discomfort that you might be experiencing due to vaginal dryness. Vaginal estrogen creams are a type of hormone replacement therapy (HRT). 

1. Surgery for uterine prolapse

If uterine prolapse is left untreated, it can become worse with time. Sometimes, it may improve with no treatment. Females who are young, have a normal weight and no comorbidities usually have a good disease outcome. Studies suggest that 29 out of 100 females require a second surgery at some point in their lives.