Uterine prolapse

Female genital prolapse
Uterine prolapse in a 71-year-old woman, with the cervix visible in the vaginal orifice.
Classification and external resources
Specialty gynaecology
ICD-10 N81.4
ICD-9-CM 618.1
DiseasesDB 13651
MedlinePlus 001508
MeSH D014596

Uterine prolapse is a form of female genital prolapse. It is also called pelvic organ prolapse or prolapse of the uterus (womb).

Risk factors for uterine prolapse include pregnancy, childbirth, chronic increases in intra-abdominal pressure such as lifting, coughing or straining, connective tissue conditions,[1][2] and damage to or weakness of the muscles.[3]

Treatment may be conservative or surgical and should be based upon patient symptoms and preference.

Pathophysiology and causes

The uterus (womb) is normally held in place by a hammock of muscles and ligaments. Prolapse happens when the ligaments supporting the uterus become so weak that the uterus cannot stay in place and slips down from its normal position. These ligaments are the round ligament, uterosacral ligaments, broad ligament and the ovarian ligament. The uterosacral ligaments are by far the most important ligaments in preventing uterine prolapse.

In some cases of uterine prolapse, the uterus can be unsupported enough to extend past the vaginal wall for inches.[4]

The most common cause of uterine prolapse is trauma during childbirth, in particular multiple or difficult births. About 50% of women who have had children develop some form of pelvic organ prolapse in their lifetime.[5] It is more common as women get older, particularly in those who have gone through menopause. This condition is surgically correctable.

Treatment

Treatment is conservative, mechanical or surgical. Conservative options include behavioral modification and muscle strengthening exercises such as Kegel exercise.[6] Pessaries are a mechanical treatment as they elevate and support the uterus.[7][8] Surgical options are many[9] and may include a hysterectomy or a uterus-sparing technique such as laparoscopic hysteropexy,[10] sacrohysteropexy[11][12] or the Manchester operation.[13]

In the case of hysterectomy, the procedure can be accompanied by sacrocolpopexy.[14] This is a mesh-augmented procedure in which the apex of the vagina is attached to the sacrum by a piece of medical mesh material.[15]

A Cochrane Collaboration (2016) review found[9] that sacral colpopexy was associated with lower risk of complications than vaginal interventions, but it was unclear what route of sacral colpopexy should be preferred. No clear conclusion could be reached regarding uterine preserving surgery versus vaginal hysterectomy for uterine prolapse. The evidence does not support use of transvaginal mesh compared to native tissue repair for apical vaginal prolapse. The use of a transvaginal mesh is associated with side effects including pain, infection, and organ perforation. According to the FDA, serious complications are "not rare". A number of class action lawsuits have been filed and settled against several manufacturers of TVM devices.

References

  1. ↑ Carley ME, Schaffer J (May 2000). "Urinary incontinence and pelvic organ prolapse in women with Marfan or Ehlers Danlos syndrome". Am. J. Obstet. Gynecol. 182 (5): 1021–3. doi:10.1067/mob.2000.105410. PMID 10819815.
  2. ↑ Mastoroudes H, Giarenis I, Cardozo L, Srikrishna S, Vella M, Robinson D, Kazkaz H, Grahame R (January 2013). "Prolapse and sexual function in women with benign joint hypermobility syndrome". BJOG. 120 (2): 187–192. doi:10.1111/1471-0528.12082. PMID 23240798.
  3. ↑ DeLancey JO, Morgan DM, Fenner DE, Kearney R, Guire K, Miller JM, Hussain H, Umek W, Hsu Y, Ashton-Miller JA (February 2007). "Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse". Obstet Gynecol. 109 (2 Pt 1): 295–302. doi:10.1097/01.AOG.0000250901.57095.ba. PMID 17267827.
  4. ↑ D'Amico D, Barbarito C. Health & physical assessment in nursing (3rd ed.). Boston. p. 665. ISBN 9780133876406. OCLC 894626609.
  5. ↑ "Oxford Gynaecological and Pelvic Floor Centre, Gynaecology in Oxford". www.oxfordgynaecology.com. Retrieved 2017-04-25.
  6. ↑ Hagen, Suzanne (7 December 2011). "Conservative prevention and management of pelvic organ prolapse in women". The Cochrane Library (12): CD003882. doi:10.1002/14651858.CD003882.pub4. PMID 22161382.
  7. ↑ Bugge C, Adams EJ, Gopinath D, Reid F (February 2013). "Pessaries (mechanical devices) for pelvic organ prolapse in women". Cochrane Database Syst Rev (2): CD004010. doi:10.1002/14651858.CD004010.pub3. PMID 23450548.
  8. ↑ Cundiff GW, Amundsen CL, Bent AE, Coates KW, Schaffer JI, Strohbehn K, Handa VL (April 2007). "The PESSRI study: symptom relief outcomes of a randomized crossover trial of the ring and Gellhorn pessaries". Am. J. Obstet. Gynecol. 196 (4): 405.e1–8. doi:10.1016/j.ajog.2007.02.018. PMID 17403437.
  9. 1 2 Maher, Christopher; Feiner, Benjamin; Baessler, Kaven; Christmann-Schmid, Corina; Haya, Nir; Brown, Julie (2016-10-01). "Surgery for women with apical vaginal prolapse". The Cochrane Database of Systematic Reviews. 10: CD012376. doi:10.1002/14651858.CD012376. ISSN 1469-493X. PMID 27696355.
  10. ↑ Rahmanou P, White B, Price N, Jackson S (January 2014). "Laparoscopic hysteropexy: 1- to 4-year follow-up of women postoperatively". Int Urogynecol J. 25 (1): 131–8. doi:10.1007/s00192-013-2209-5. PMID 24193261.
  11. ↑ Price N, Slack A, Jackson SR (January 2010). "Laparoscopic hysteropexy: the initial results of a uterine suspension procedure for uterovaginal prolapse". BJOG. 117 (1): 62–8. doi:10.1111/j.1471-0528.2009.02396.x. PMID 20002370.
  12. ↑ Rosati M, Bramante S, Conti F (August 2014). "A review on the role of laparoscopic sacrocervicopexy". Curr. Opin. Obstet. Gynecol. 26 (4): 281–9. doi:10.1097/GCO.0000000000000079. PMID 24950123.
  13. ↑ Surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication versus vaginal hysterectomy with high uterosacral ligament plication By de Boer T, Milani F, Kluivers K, Withagen M, Vierhout M. Part of ICS 2009 Scientific Programme, Thursday 1 October 2009
  14. ↑ Nygaard I, Brubaker L, Zyczynski HM, Cundiff G, Richter H, Gantz M, Fine P, Menefee S, Ridgeway B, Visco A, Warren LK, Zhang M, Meikle S (May 2013). "Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse". JAMA. 309 (19): 2016–24. doi:10.1001/jama.2013.4919. PMC 3747840. PMID 23677313.
  15. ↑ "Sacrocolpopexy with hysterectomy using mesh to repair uterine prolapse". NICE. GOV.UK. Retrieved March 28, 2018.

Further reading

  • Abha, Sharma; Ping, Zhang Jing (March 2014). "Risk factors and symptoms of uterine prolapse: reality of Nepali women". Asian Women. Research Institute of Asian Women (RIAW). 30 (1): 81–95. doi:10.14431/aw.2014.03.30.1.81.
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