A prolapsed uterus can cause uncomfortable symptoms but is not a dangerous condition. Fortunately, there are options for improving the symptoms and complications of pelvic organ prolapse. Appropriate treatment can improve a woman's quality of life and sense of well-being.
Symptoms of Uterine Prolapse
The uterus prolapses when the ligaments and pelvic floor muscles that support it weaken, stretch, and sag. This causes the uterus to slide down into the vagina. Symptoms depend on the degree of prolapse and other complications, such as bladder and rectal prolapse. They are mild in the early stages of uterine descent.
Pelvic Pressure and Vaginal Lump
Women complain of a feeling of pressure or heaviness low in the pelvis when the uterus prolapses. This is partly because of the uterus sitting partially or fully in the vagina and the stretched out ligaments. Back pain can also occur with this symptom.
In addition, with the cervix sitting lower in the vagina or protruding from it, women can have an uncomfortable feeling of a vaginal lump or ball. This discomfort is greater with sitting, walking, or exercising.
Urinary stress incontinence is a common problem with relaxation of pelvic supports and uterine prolapse. When the bladder descends, the urethra and its sphincter sags into the vagina. This new position of the sphincter allows urine to leak with coughing, sneezing, lifting, or bearing down. Other urinary problems include:
- Urinary urgency and frequency - running to the bathroom because of a sensation the bladder is full when it's not
- Urine retention because of difficulty emptying the bladder
- Increased risk of bladder infections because of poor bladder function
The effects of uterine prolapse and its complications can cause the following:
- Fecal incontinence - decreased ability to control the recto-anal sphincter leading to leaking of stool
- Rectal pressure and urgency to move bowels
- Difficulty moving and emptying bowels
The cervix can develop sores when it sits at the entrance to the vagina or sits outside the vagina. This happens from friction on underwear and sitting on the cervix and can cause bleeding or foul smelling discharge. The prolapsed cervical and vaginal tissues can also become swollen when they are outside the vagina.
Uterine prolapse causes the following problems with intercourse because of the position of the uterus in the vagina and stretched vaginal canal:
- Painful intercourse
- Difficult or awkward intercourse
- Diminished pleasure or orgasms
This can cause psychological distress for a woman and difficulties between a couple.
Complications of Uterine Prolapse
Uterine prolapse is often accompanied by prolapse of other organs into the vagina because they are also affected by weakening of the pelvic floor muscles.
A bladder prolapse or cystocoele can occur by itself or accompany a uterine prolapse. The bladder sits in front of the uterus, separated by only a thin layer of fatty tissue. It prolapses into the front wall of the vagina when the supporting tissues and pelvic floor muscles weaken or when the uterus descends into the vagina and takes the bladder with it.
Rectal and Bowel Prolapse
When the front wall of the rectum bulges into the back wall of the vagina it is called a rectocoele. It occurs when the layer of tissue between the rectum and vagina - the rectovaginal septum - gets thin. This causes the symptoms of rectal pressure and leaking of stool.
Small Bowel Prolapse
The peritoneum lining the bottom of the pelvic cavity can sag between the vagina and rectum to form a hernia sac. Small bowel can drop into the sac and form an enterocoele which bulges into the back wall of the vagina above the rectocoele.
The vagina will prolapse and gradually roll inside as its supporting tissues weaken and the uterus descends. A prolapsed vagina makes intercourse difficult or impossible and is also prone to sores on the surface lining and a smelly discharge.
Causes and Risk Factors
The following are the common causes of uterine prolapse:
- Gravity: Over time, the force of gravity causes the uterine ligaments and pelvic floor muscles to weaken and sag.
- Pregnancy: Ligaments and pelvic muscles stretch during pregnancy, and this can worsen with multiple pregnancies.
- Difficult labor and delivery: Prolonged pushing during the second stage of labor as well as giving birth to a big baby also weakens the pelvic floor.
- Trauma during delivery: Tearing or weakening of pelvic nerves and the muscles of the pelvic floor can occur during normal delivery or from forceps or vacuum extraction of the baby.
- Previous pelvic surgery: Surgery damages nerve supply, ligaments, and muscles.
- Chronic coughing: This increases abdominal pressure, and the force transmits to and weakens the pelvic floor muscles. Smoking and lung diseases, such as chronic obstructive pulmonary disease (COPD), bronchitis, and asthma, are a few of the causes of chronic coughing.
- Chronic constipation: Frequent straining and having to bear down while using the toilet puts stress on the pelvic floor.
- Frequent heavy lifting: Holding your breath during lifting of heavy weights can also put stress on the pelvic floor muscles. Jumping exercises and jogging can also do the same.
These are known risk factors for uterine prolapse:
- Normal aging weakens the muscles of the pelvic floor.
- Multiple pregnancies progressively weakens ligaments and muscles.
- Lack of estrogen after menopause decreases muscle tone.
- Obesity puts pressure on pelvic muscles.
- Damage to the lower spinal cord resulting in paraplegia and affects the pelvic nerves to the structures that support the uterus and surrounding organs.
Caucasians and Asians at greater risk for uterine prolapse although the reason is unknown.
Degree of Descent
Doctors refer to the degree of uterine descent into the vagina to describe the stages of uterine prolapse:
- First degree: The cervix reaches part way down the vaginal canal.
- Second degree: The cervix is at the entrance to the vagina.
- Third degree: The cervix is visible outside the entrance to the vagina.
- Fourth degree: The entire cervix and uterus have prolapsed outside the vagina - known as procidentia; the vagina is turned inside out as well.
You get to decide with your doctor when treatment is appropriate or unavoidable. First degree prolapse might not require treatment unless you are uncomfortable. Most women don't seek treatment until second degree prolapse when symptoms and intercourse are more affected.
Treatment can make a big difference to your comfort and quality of life. The type of treatment depends on the level of your symptoms and the degree of your uterine prolapse.
Kegel exercises strengthen the pelvic muscles and counteract the force of gravity. They work best if you practice them before you have a problem or in the early stages of prolapse. To be effective, do these exercises daily at least three times a day. Better yet, do them at every opportunity you get - sitting at your desk, waiting at a red light, taking a bath, making dinner. Don't do them while driving or when your bladder is full.
A pessary is a padded donut or other type of vaginal ring. It is used for mild to moderate prolapse when the cervix is not quite at the vaginal entrance. The device props up your uterus, vagina, bladder and urethra and relieves symptoms. A doctor has to fit you for the right size.
A pessary can be used for years but needs to be removed and cleaned every three months to prevent vaginal infection and foul-smelling discharge. Your doctor can teach you to remove your pessary, clean, and reinsert it. Some women are unable to do this and have to visit their doctor for cleaning and reinsertion.
Use of an estrogen cream will improve the tone and strength of the vaginal lining and tissues. Your doctor might prescribe this alone for treatment of first degree uterine prolapse. Unless there are contraindications, an estrogen cream is almost always placed in the vagina at the insertion of a pessary. You also insert the cream at home once a week using an applicator to prevent pressure sores from the pessary.
If you haven't completed your child-bearing, uterine suspension is a viable option for first to third degree prolapse. The ligaments that suspend the uterus are shortened with sutures and hitched to the walls of the pelvic cavity to hold it in place. A doctor might also use slings to suspend the uterus in place in the pelvis.
Doctors will advise a hysterectomy for any degree of prolapse if your symptoms are uncomfortable and a pessary or uterine suspension do not help. It is also necessary if you have complete uterine prolapse. Facts about this option include:
- The surgery can be either an abdominal or a vaginal hysterectomy depending on your exam findings, your doctor's recommendations, and the pros and cons for you.
- Abdominal surgery can be either open or through the laparoscope.
- With a hysterectomy, you can also have a repair of your vaginal wall, and correction of a cystocoele and sagged urethra, as well as a rectocoele and enterocoele if present.
In addition, your doctor will tighten the muscles of the pelvic floor to add support.
Prevention of Uterine Prolapse
Do the following to prevent weakening of your pelvic floor muscles and tissues:
- Treat causes of chronic coughing including quit smoking.
- Lose weight through a healthy diet and exercise if you are overweight.
- Avoid chronic constipation and straining while moving your bowels; include adequate fiber in your diet.
- Don't hold your breath and bear down while lifting heavy weights.
- Make a lifetime habit of doing Kegel exercises to keep your pelvic muscles strong. Do and hold a Kegel when you are lifting anything heavy.
Early Diagnosis and Treatment
If you have any of the symptoms of uterine prolapse, see your doctor for an evaluation. A complete pelvic exam will diagnose the extent of your problem and guide the options for treatment. The treatment will be less invasive if the diagnosis is made early. Seek care as soon as possible if it appears your uterus is completely out of your vagina.