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Updated: Nov 29 2021

Uterine Prolapse

  • 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
    • 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
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