Snapshot A 60-year-old, G6P6, Caucasion woman presents to her obstetrician after having a three day history of increased pelvic pressure and a "bulge" that is felt in her vagina when she coughs. Additionally, she has had a recent worsening of lower back pain. SUmmary Uterine prolapse occurs when pelvic floor musculature is unable to provide adequate support ligaments can stretch and weaken over time round ligament ovarian ligament broad ligament uterosacral ligament most important in preventing prolapse Epidemiology incidence approximately 50% of women who have had children will develop organ prolapse demographics can affect women of any age occurs most often in postmenopausal women risk factors trauma during child birth multiple vaginal births obesity chronic coughing or straining chronic constipation ETIOLOGY Pathogenesis incomplete prolapse uterus drops part way down into the vagina creates a bulge complete prolapse uterus slips down and protrudes out of the vagina Presentation Symptoms heaviness or pressure in pelvis pelvic pain abdominal or lower back pain dyspareunia recurrent UTIs urinary incontinence symptoms worsened by prolonged standing or walking added pressure on muscles by gravity Physical exam inspection protrusion of tissue at opening of vagina (complete prolapse) excessive vaginal discharge Differential Cystocele (bladder) distinguishing factor anterior vaginal prolapse may present with difficulty starting urine stream, feeling of incomplete emptying of bladder, and frequency or urgency of urination may also have leakage of urine (stress incontinence) Rectocele distinguishing factor posterior vaginal prolapse may present with posterior soft bulge, difficulty with bowel movements, senesation of rectal pressure, and not feeling that rectum has fully emptied after a bowel movement Diagnosis pelvic examination palpation of bulges caused by uterus protruding into the vaginal canal Treatment Prevention Weight maintain healthy body weight Exercise regular physical activity kegel exercises Smoking cessation prevents chronic cough Conservative Kegel exercises indications mild cases mechanism strengthen pelvic floor musculature vaginal pessary indications mild to moderate mechanism rubber device that fits around the cervix to help hold the uterus in place Operative hysterectomy indications moderate to severe mechanism removal of uterus sacrohysteropexy indications moderate to severe mechanism resuspension of the prolapsed uterus using a mesh sling