Uterine prolapse

Definition

• Descent of the uterus with the cervix towards or past the introitus; in women without a uterus the vaginal vault (cuff) can descend in the same way (apical prolapse).
• In complete uterine prolapse (procidentia), the anterior and posterior vaginal walls collapse together with the apex, and the uterus may protrude out of the introitus.

Classification

• In the POP-Q system, point C describes the cervix or vaginal cuff and point D the posterior fornix; without prolapse the cervix lies about 4.5 to 7.5 cm above the hymenal remnants.
• POP-Q stages range from 0 (no prolapse) to IV (complete eversion); the older Baden-Walker system is considered imprecise and is no longer commonly used.

Occurrence & epidemiology

Epidemiology

• Pelvic organ prolapse is a common gynaecological condition, although reported prevalence varies; in a study of 8000 women, 8.3% reported symptomatic prolapse.
• A cystocele or rectocele is usually also present in uterine prolapse.

Aetiopathogenesis

Aetiology and pathogenesis

• It results from hernia-like laxity of the ligaments, fascia and muscles that support the pelvic organs.
• Common risk factors are vaginal births, particularly with a prolonged second stage, instrumental vaginal birth or a large newborn, as well as obesity, increasing age and chronically raised intra-abdominal pressure; sacral nerve and connective tissue disorders are less common.

Clinical features

• Symptoms tend to be minimal in mild prolapse; the most common presenting symptom is a vaginal bulge, which may be intermittent because of spontaneous reduction.
• In more severe prolapse, fullness, pressure, sexual dysfunction, a sensation of organs falling out, lower back pain, incomplete bladder emptying and constipation occur.
• Urinary incontinence is common; the descending organs may intermittently obstruct urine flow, causing urinary retention and overflow incontinence and masking stress incontinence.
• Mucosa prolapsed beyond the introitus can dry, thicken, become chronically inflamed and oedematous, and ulcerate; the ulcers may be painful or bleed.

Diagnosis

• The diagnosis is made clinically by speculum and bimanual pelvic examination at rest and on straining, and severity is documented with the POP-Q system.
• Prolapse appears more severe in the standing than in the supine position, whereas cervical traction may overstate the degree of apical prolapse.

Keep learning in the app

Further reading (selection)

1. MSD Manual Professional: Uterine and Apical Prolapse
2. MSD Manual Professional: Overview of Pelvic Organ Prolapse (POP)
3. International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction (Int Urogynecol J 2023, PubMed Central)

Cross-references