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Uterine Prolapse

Introduction
Signs and symptoms
Causes
Risk Factors
Screening and diagnosis
Treatment
Prevention

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.

Uterine prolapse varies in severity. You may have mild uterine prolapse and experience no signs or symptoms. Or you could have moderate to severe uterine prolapse. If that's the case, you may experience the following:

• Sensation of heaviness or pulling in your pelvis
• Pain during intercourse
• Something protruding from your vagina
• Low back pain

Some women who have uterine prolapse describe feeling as if they're sitting on a small ball or as if something is falling out of their vagina. Symptoms tend to be less bothersome in the morning - after a long period of lying down - and worsen as the day goes on.

Pregnancy and trauma incurred during childbirth, particularly with large babies or after a difficult labor and delivery, are the main causes of muscle weakness leading to uterine prolapse. Loss of muscle tone associated with aging and reduced amounts of circulating estrogen after menopause also may contribute to uterine prolapse. In rare circumstances, uterine prolapse may be caused by a tumor in the pelvic cavity.

Genetics also may play a role. Women of Northern European descent have a higher incidence of uterine prolapse than do women of Asian and African descent.

Certain factors may increase your risk of uterine prolapse:

• One or more pregnancies and vaginal births
• Giving birth to a large baby
• Increasing age
• Frequent heavy lifting
• Chronic coughing
• Frequent straining during bowel movements

Some conditions, such as obesity, chronic constipation and chronic obstructive pulmonary disorder (COPD), can place a strain on the muscles and connective tissue in your pelvis and may play a role in the development of uterine prolapse.

Losing weight, stopping smoking and getting proper treatment for contributing medical problems, such as lung disease, may slow the progression of uterine prolapse.

If you have very mild uterine prolapse, either without symptoms or with symptoms that aren't terribly bothersome, no treatment is necessary. However, you may continue to lose uterine support, which could require future treatment.

Possible treatments for uterine prolapse include:

• Lifestyle changes. If you're overweight or obese, your doctor may suggest ways to achieve a healthy weight and maintain that weight. Exercises to strengthen your pelvic floor muscles (Kegel exercises) may help. Your doctor may advise you to avoid heavy lifting or straining.

• Vaginal pessary. A vaginal pessary fits inside the vagina and is designed to hold the uterus in place. The pessary can be a temporary or permanent form of treatment. The device comes in many shapes and sizes, so your doctor will measure and fit you for the device. Once the pessary is in place, your doctor may have you walk, sit, squat and bear down to make sure that the pessary fits you correctly, doesn't become dislodged and feels reasonably comfortable. You'll be asked to return a few days after insertion of the pessary to check that it's still in the correct position. You may be advised to remove the device and clean it with soap and water periodically. Your doctor will show you how to remove and reinsert the device.

  There are some drawbacks to these devices. A vaginal pessary will be of little use for a woman with severe uterine prolapse. Additionally, a vaginal pessary can irritate vaginal tissues, possibly to the point of causing small sores (ulcers). Some women with vaginal pessaries report a foul-smelling discharge, which requires removal and cleaning of the device by a physician. Pessaries may interfere with sexual intercourse.

• Surgery to repair uterine prolapse. If lifestyle changes fail to provide relief from symptoms of uterine prolapse or pessary use isn't desirable, surgical repair is an option. The surgery involves repairing your pelvic floor muscles by grafting your own tissue, donor tissue or some synthetic material in such a way that it provides support to your pelvic organs. Often, doctors recommend surgical removal of the uterus (hysterectomy) as well.

  Doctors generally prefer to perform the surgical repair vaginally because it's associated with less pain after surgery, faster healing and a better cosmetic result. However, vaginal surgery may not provide as lasting a fix as abdominal surgery. And if you didn't have your uterus removed during surgery, prolapse can recur. Laparoscopic techniques - using smaller abdominal incisions, a lighted camera-type device (laparoscope) to guide the surgeon and specialized surgical instruments - offer a minimally invasive approach to abdominal surgery.

  Not everyone is a good candidate for surgery to repair uterine prolapse. This includes women who plan to have more children. Pregnancy and delivery of a baby put strain on the supportive tissues of the uterus and can undo the benefits of surgical repair. Other women who aren't recommended for surgery include older women for whom the risks of surgery are too great. Pessary use may be the best treatment choice for these women.

Uterine prolapse may not be something you can prevent. However, you may be able to decrease your risk of uterine prolapse if you:

• Maintain a healthy weight. By keeping or getting your weight under control, you may decrease your risk of uterine prolapse.
• Practice Kegel exercises. Because pregnancy and childbirth can weaken pelvic floor muscles and connective tissue, your doctor may recommend Kegel exercises - special exercises in which you repeatedly squeeze and relax the muscles of your pelvic floor - during pregnancy and afterward. To perform these exercises, tighten your pelvic muscles as if you're stopping your stream of urine. Hold for a count of five, relax and repeat. Do these exercises several times a day.
• Control coughing. Treat a chronic cough or bronchitis, and don't smoke.

Taking estrogen after menopause seems to help older women maintain muscle tone, including muscles in the pelvic area. However, hormone replacement therapy (HRT) carries risks. Talk with your doctor and make sure the benefits derived from HRT outweigh the risks in your personal situation.