UTERINE PROLAPSE

Uterine prolapse means your uterus has dropped from its position within the pelvis into your vagina. Normally, your uterus is held in place by the muscles and ligaments that make up your pelvic floor. Uterine prolapse results when pelvic floor muscles and ligaments weaken, providing inadequate support for the uterus. The uterus then descends into the vaginal canal.

Uterine prolapse most often affects postmenopausal women who've had one or more vaginal deliveries. Damage to supportive tissues incurred during pregnancy and childbirth plus the effects of gravity, loss of estrogen and repeated straining over the years can weaken pelvic floor muscles and lead to prolapse.

If you experience only mild uterine prolapse, treatment usually isn't needed. But if you experience discomfort or interruption of your lifestyle as a result of uterine prolapse, you might benefit from surgery to repair the prolapse, or you may elect to use a special supportive device (pessary), which is inserted into your vagina.

What are the symptoms of uterine prolapse?

Women with mild cases of uterine prolapse may have no obvious symptoms. However, as the uterus slips further out of position, it can place pressure on other pelvic organs--such as the bladder or bowel--causing a variety of symptoms, including: 

• A feeling of heaviness or pressure in the pelvis
• Pain in the pelvis, abdomen or lower back
• Pain during intercourse
• A protrusion of tissue from the opening of the vagina
• Recurrent bladder infections
• Unusual or excessive discharge from the vagina
• Constipation
• Difficulty with urination, including involuntary loss of urine (incontinence), or urinary frequency or urgency

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

Causes of uterine and bladder prolapse

Risk factors

Normally, the pelvic organs are held in place by the pelvic floor muscles and supporting ligaments, but when the pelvic floor becomes stretched or weakened, they may become too slack to hold the organs in place. A number of different factors contribute to the weakening of pelvic muscles over time, but the two most significant factors are thought to be pregnancy and ageing.

Pregnancy and childbirth

Pregnancy is believed to be the main cause of pelvic organ prolapse — whether the prolapse occurs immediately after pregnancy or 30 years later. The weight of the baby, and the physical trauma of labour and birth, stresses and strains the pelvic muscles and ligaments. Some of the tissues that become damaged during pregnancy never fully regain their strength and elasticity.

Certain situations in pregnancy and birth further increase the likelihood and extent of damage, such as a large baby, a long labour and the use of forceps or extraction devices. There is conflicting information about the effect an episiotomy (a cut made in the base of the vagina during childbirth) may have on a woman's risk of prolapse, but the most recent research suggests it does not prevent pelvic floor damage.

Women who have more than one child, whether the delivery is vaginal or by caesarean section, have a higher risk of prolapse than women who have one child or no children at all. Some people believe a caesarean section may be less damaging than a vaginal birth, but the majority of studies suggest that it is only slightly, if at all, protective. Studies also suggest that women who have children in close succession are at an even greater risk of prolapse because the muscles and ligaments are under constant strain.

Ageing and the menopause

Our muscles weaken as we grow older and the pelvic muscles are no exception. Although tissue damage is likely to have been caused much earlier, the ageing process further weakens the pelvic muscles, and the natural reduction in oestrogen at the menopause also causes muscles to become less elastic.

Obesity, large fibroids or tumours

Women who are severely overweight, or have large fibroids or pelvic tumours, are at an increased risk of prolapse due to the extra pressure this creates in their abdominal area.

Chronic coughing or strain

Chronic (long-term) coughing, from smoking, asthma or bronchitis for example, or the straining associated with constipation, increases a woman's risk of prolapse. A few bouts of bronchitis or constipation are unlikely to have a serious effect on your pelvic muscles, but if the stress and strain is ongoing, it may eventually weaken the pelvic support structures.

Heavy lifting

Heavy lifting can also strain and damage pelvic muscles and women in careers that involve regular manual labour or lifting, such as nursing, have an increased risk of prolapse.

Genetic conditions

Women with a genetic collagen deficiency (Marfan or Ehlers-Danlos syndrome) have an increased risk of prolapse even if they don't have any of the other risk factors. Collagen is a natural protein that helps keep tissues plump and elastic. Without it, the pelvic floor muscles become weak.

UTERINE PROLAPSE TREATMENT

Exercise -- Special exercises, called Kegel exercises, can help strengthen the pelvic floor muscles. This may be the only treatment needed in mild cases of uterine prolapse. 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 then release. Repeat 10 times. You may do these exercises anywhere and at any time (up to four times a day).

Vaginal pessary -- A pessary is a rubber or plastic doughnut-shaped device that fits around or under the lower part of the uterus (cervix), helping to prop up the uterus and hold it in place. A health care provider will fit and insert the pessary, which must be cleaned frequently and removed before sex.

Estrogen replacement therapy (ERT) -- Taking estrogen may help to limit further weakness of the muscles and other connective tissues that support the uterus. However, there are some drawbacks to taking estrogen, such as an increased risk of blood clots, gallbladder disease and breast cancer. The decision to use ERT must be made with your doctor after carefully weighing all of the risks and benefits.

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