What is Uterine Prolapse, and What is Genital Prolapse?
Uterine prolapse, or dropped womb, is a condition in which the uterus drops downward in the pelvis below its normal position. The uterus may drop slightly and remain above the introitus (vaginal opening, grade 1). Or, it may drop further so that the cervix or lower portion of the uterus reaches the region of the introitus (grade 2). In the most severe form, the cervix or even the entire uterus bulges out of the introitus (grade 3). Uterine prolapse is the indication for hysterectomy in 20% of all hysterectomies performed in the U.S.
Genital prolapse is a more general term that includes several conditions, which may occur separately or in combination. These include uterine prolapse (dropped womb), vaginal prolapse, cystocele (dropped bladder), rectocele (dropped rectum), and enterocele (herniation of the small bowel into the space between the rectum and vagina).
What are the Causes of Uterine and Genital Prolapse?
There are three layers that support the pelvic floor:
1. the endopelvic fascia, a layer consisting primarily of connective tissue which includes several thicker portions (ligaments);
2. the levator ani muscles, which close off the pelvic floor so that the pelvic organs rest upon them;
3. the perineal membrane, including the perineal body (located between the vaginal opening and anus), and the anal sphincter. This layer is less critical for the support of the pelvic floor.
Whenever there is a rise in abdominal pressure (e.g., coughing, sneezing, jumping, etc.) which pushes the abdominal contents downwards, there is an immediate reflex contraction of the levator ani muscles to prevent the fall of these abdominal organs. When the levator ani muscles are damaged (from such things as pudendal nerve injury from childbirth trauma, chronic coughing, aging, pelvic neuropathy, etc.,) the muscles fail to support the pelvic organs. The endopelvic fascia, with its ligaments, is exposed to increases in intra-abdominal pressure resulting in stretching of the ligaments. Consequently, these ligaments eventually tear resulting in pelvic organ prolapse. Because it is not possible to effectively restore the integrity and function of the levator ani muscles, the main mechanism for the treatment of pelvic organ prolapse is the repair or augmentation of the pelvic ligaments.
Uterine and genital prolapse may rarely be caused by congenital (inherited) weakness of the pelvic floor (muscles, ligaments, fascias that support the pelvic floor and prevent pelvic organs from dropping down). More commonly, genital prolapse is caused by damage to the pelvic floor during vaginal deliveries (especially those with protracted labor), instrumental deliveries (forceps, vacuum extraction), and vaginal delivery of large babies. Aging and menopause can weaken the pelvic floor in part because of diminished estrogen levels as well as by aging itself. The tissues comprising the pelvic floor are weakened in the absence of sufficient estrogen levels. Increased intra-abdominal pressure on a long-term basis can also contribute to genital prolapse. For example regular performance of heavy manual labor, heavy lifting, and use of a tight abdominal girdle. Chronic coughing and straining during bowel movements because of chronic constipation are also important contributing factors in genital prolapse.
A large recent Swedish population study shows that hysterectomy, regardless of surgical approach, increases the risk of subsequent genital prolapse: subtotal abdominal hysterectomy increased the risk twofold, vaginal hysterectomy increased it 3.8 fold, laparoscopic hysterectomy increased it 5.5 fold, and laparoscopic-assisted vaginal hysterectomy increased the risk of subsequent genital prolapse 7.5 fold. The first five years after hysterectomy was associated with the highest risk of prolapse. The study also found that subsequent surgery for stress urinary incontinence was increased 2.4 times, probably due to trauma to bladder support by the hysterectomy.
The abdominal organs such as the bowel, bladder, and uterus are prevented from falling down (prolapse) by the pelvic floor. The drive downwards of the genital organs is especially strong when a woman is standing and when abdominal pressure is suddenly increased such as when coughing, sneezing, running, bearing down during bowel movement. The pelvic floor is comprised of numerous muscles and connective tissue (endopelvic fascia). These pelvic supports are attached to the bony pelvis. Certain portions of the fascia are thickened and called ligaments. The most important ligaments are attached centrally to the uterine cervix.
Following hysterectomy, the strength of these ligaments may be reduced or their central attachment to the vaginal dome may be weakened and vaginal prolapse may result. These ligaments include two cardinal ligaments (lateral attachment systems to the cervix), two utero sacral ligaments (posterior attachment systems to the cervix), and pubo cervical fascia (anterior segment of the system which attaches the pubic bone to the cervix). The pubo cervical fascia extends laterally like a hammock that is attached to the pelvic sidewall along a horizontal line called the “white line”. This fascia supports the bladder base and urethra from prolapsing. Damage to the pub cervical fascia (such as tearing or stretching during a traumatic labor) can be centrally located and result in the bulging of the bladder and vagina into the anterior vagina, which is called central cystocele. Also, the hammock (pub cervical fascia) may be detached laterally from the white line, a condition called para vaginal defect, which also results in a dropped bladder (cystocele).
The physical and neurological integrity of the pelvic floor muscles and the integrity of the pelvic floor ligaments are vital for the prevention of genital prolapse. Damage to the nerves of the pelvic floor muscles will prevent them from effectively contracting to counteract downward push of the pelvic organs by a sudden increase in abdominal pressure (such as the pressure caused by coughing). The ligament system may be damaged by traumatic and instrumental delivery, or by the delivery of a big baby. Since the pelvic ligaments are also estrogen-dependent, the drop in estrogen levels during menopause, as well as the process of aging (independent of estrogen levels), may lead to weakness and stretching of these ligaments. This may lead to further weakening of the pelvic floor. This is why prolapse may develop or deteriorate after menopause (aging and estrogen deficiency).
Damage to the pelvic floor by a traumatic delivery may result in genital prolapse shortly thereafter. However, more frequently the damaged ligaments manage to hold the pelvic floor in place for several years. Later, with further weakening of the ligaments through aging and/or lack of estrogen, the patient may finally develop genital prolapse. Stretching or tearing of different portions of the pelvic floor may lead to prolapse of various organs. There may be uterine prolapse, cystocele (prolapse of the bladder and urethra into the anterior vagina), rectocele (prolapse of the rectum into the posterior vagina), and enterocele. The “cul de sac” is a blind pouch located between the back lower uterus and upper vagina and the front of the rectum. This pouch is usually shallow. However, if it extends downward as a hernia sac in the space between the vagina and rectum (frequently containing loops of small bowel), it is called enterocele. Enterocele is usually present in cases of uterine prolapse and must be specifically corrected at the same time as the prolapse. Enterocele causes low back pain, especially in the standing position.
What are the Symptoms of Uterine and Genital Prolapse?
Symptoms depend upon the genital organs involved in the prolapse, since uterine prolapse, cystocele, or rectocele many not cause any discomfort. A more significant uterine prolapse may cause pelvic pain or pressure, a feeling of something falling in the vagina, and low back pain. It may also interfere with sexual function. There may be pain or a feeling of something blocking penetration. Sex may also be less fulfilling because of loss of vaginal tone. Cystocele may cause pelvic discomfort and sexual dysfunction and may involve urinary stress incontinence (loss of urine with stress such as cough). There may be urinary frequency and urgency. In advanced cases there may be urinary retention. The patient may need to perform digital manipulation (splinting) in order to be able to urinate. Rectocele can cause rectal pressure and constipation. There may be incomplete bowel emptying. There may be need for digital splinting to defecate. Prolapse which results in a protrusion of the uterus and/or vagina out of the vaginal introitus may lead to irritation, ulceration, and infection. Enterocele may cause low back pain and painful defecation.
Normally, the bladder and upper urethra are “abdominal organs”. The bladder is kept in its intra-abdominal position by a hammock-like ligament, the pub-cervical ligament. This ligament is attached to the lateral pelvic floor. If this attachment is torn on one or both sides, the bladder loses its support and drops downwards, so the bladder neck is no longer an intra-abdominal organ. When the bladder and upper urethra are in an intra-abdominal position, any increase in abdominal pressure will lead to a similar increase in the pressure inside the bladder and the upper urethra. At rest, the urethra has a small closure pressure which prevents leakage of urine from the bladder. With normal anatomy, the increase in pressure in the bladder and the upper urethra while coughing will be identical, leaving still a somewhat higher pressure in the urethra thus preventing any leakage. Prolapse of the upper urethra so that it is no longer an “abdominal organ” leads to increased pressure during coughing in the bladder (but not in the urethra). This results in a higher pressure in the bladder relative to the pressure in the urethra and leads to the involuntary release of urine (urinary stress incontinence). Most women with uterine prolapse and bladder prolapse may not experience urinary stress incontinence because the prolapsing uterus prevents urine leakage during cough or laughter by kinking the urethra. However, after hysterectomy and lifting the vaginal dome to its normal position (sacral colpo pexy), 44% of women who did not experience urinary stress incontinence before surgery will now experience urinary stress incontinence for the first time. This was shown in a recent large study. This study has also shown that performing an additional procedure to lift the bladder neck (Burch colpo suspension) during prolapse surgery (hysterectomy plus sacral colpo pexy), will reduce post-operative urinary stress incontinence to 24%. In my own experience, when uterine prolapse is treated with uterine-sparing surgery, sacral utero colpo pexy (the uterus is preserved and repositioned to its normal place inside the pelvis) plus the bladder neck is lifted by the Burch procedure, post-operative urinary stress incontinence is rare indeed. I believe that this finding should be further studied. I believe that such study will show that the normally repositioned uterus adds to the normalcy of the pelvic floor and, along with Burch colpo suspension, reduces future urinary stress incontinence to almost zero. At any rate, it is now recommended that even those that treat uterine prolapse with hysterectomy plus sacral colpo pexy without existing urinary stress incontinence should also perform Burch colpo suspension in order to reduce the risk of future urinary stress incontinence by 50%.
What are the Non-Surgical Treatment Options for Genital Prolapse?
Mild degrees of cystocele, rectocele, or uterine prolapse may not require any intervention, especially if the patient has no discomfort. Special exercises to strengthen pelvic floor muscles (Kegel), especially when guided by biofeedback, can improve symptoms, urinary stress incontinence, sexual function, and pelvic discomfort. In fact, reduction of the size of a cystocele can be documented. Changes in lifestyle such as eliminating heavy lifting or avoiding use of a tight girdle, treatment and suppression of a chronic cough, and treatment of chronic constipation, can halt the progression of genital prolapse.
Estrogen replacement therapy (combined with progestin) can improve the strength of the pelvic floor ligaments and muscles, bringing an improvement in symptoms, and increasing the effectiveness of Kegel exercises.
Pessaries are special prostheses of different shapes and sizes that are fitted into the vagina and can effectively prevent prolapse. The pessary must be fitted according to the type and degree of prolapse. Specialized pessaries can also effectively prevent urinary stress incontinence. However, pessaries require some vaginal tone to stay in place and may be ineffective in the more advanced cases of genital prolapse.
What is the Role of Surgery in Genital Prolapse?
Surgery is designed to repair and reconstruct the weakened pelvic floor and restore normal function. It is indicated only when the prolapse is causing significant symptoms and when conservative non-surgical measures have failed. Surgery is also indicated when conservative measures are not desired by the patient and she is requesting relief by means of surgery. Surgery is rarely indicated for mild degrees of prolapse.
Surgery to correct prolapse requires great expertise and meticulous attention to detail. The weakened and stretched ligaments and muscles of the pelvic floor must frequently be reused in the repair process. These ligaments may fail again. It is, therefore, frequently necessary to use more sophisticated suspension techniques for a successful and long-lasting outcome. Pretreatment with estrogen, when deficient, may increase the success of surgery. For cystocele, rectocele, enterocele, and relaxed introitus (vaginal opening) specific procedures are available that can effectively correct the condition. In all these conditions, as well as in the treatment of urinary stress incontinence, the removal of the non-prolapsed, normal uterus is of no proven benefit.
Minimal uterine prolapse is usually not accompanied by any discomfort and can be monitored without any intervention. When the prolapse is more significant and symptomatic, treatment is necessary. If conservative treatment fails or is not desired, surgery is indicated.
There are several operations that can lift the dropped uterus to its original position without resorting to hysterectomy. These operations are customized according to the specific anatomical deviation leading to the prolapse, the general physical condition of the patient and the desire to have continued vaginal penetration with sex. The prevailing opinion among gynecologists is that the surgical correction of uterine prolapse is more effective and less likely to fail in the long run if it includes a hysterectomy. However, there are no large prospective studies to validate this opinion.
I have performed many operations for the total reconstruction of the pelvic floor with preservation of the uterus with long term success and great satisfaction of most patients. There are reports that the overwhelming majority of patients treated for uterine prolapse with hysterectomy had significant prolapse of all or parts of the vagina within less than five years. The prolapsing uterus is the result of damage to the pelvic floor supports. The uterus is the victim of the damaged pelvic floor and not the cause of the prolapse. Removing the uterus, per se, does nothing to address the true problem, that being the damage to the pelvic floor.
On the other hand, the normally positioned uterus is an important element in the pelvic floor’s absorption of abdominal pressure without suffering actual prolapse of the pelvic organs. Repositioning the prolapsed uterus back to its normal place in the pelvis and anchoring it snugly to the sacral bone adds to the strength of the pelvic floor rather than weakening it.
Commonly, genital prolapse includes several elements that are simultaneously prolapsing, such as uterine prolapse, enterocele, rectocele, and cystocele. All the prolapsing elements must be carefully defined before surgery. Examination of a patient for prolapse must include an evaluation while the patient is standing up and bearing down. Otherwise, the extent of the prolapse may be seriously underestimated. Failure to repair one of the abnormalities will lead inevitably to the fast progression of the untreated abnormality.
An excellent remedy for uterine prolapse is sacral utero colpo pexy. In this procedure, a strip of man-made non-absorbable mesh (i.e., prolin mesh) is used. Alternatively, a strip of fascia ( a strong parchment-like layer) is taken from the abdominal wall or from the fascia lata in the thigh. This strip serves to anchor the cervix and upper vagina to the sacral bone. Recent studies indicate that the synthetic graft in this particular procedure of sacral utero colpo pexy yields better outcomes and fewer graft-related complications compared to biologic or autologous grafts. Some women develop urge or stress urinary incontinence following abdominal sacro colpo pexy (the studies dealt with cases where hysterectomy was also performed at the same time).
Addition of Burch colpo suspension at the same time significantly reduced this complication. Other procedures such as repair of rectocele and the perineal body, repair of cystocele or para vaginal defect, lifting the bladder and upper urethra by Burch colpo suspension, or by sling procedure, are added as needed. The latter procedure lifts the bladder and upper urethra and restore the intra-abdominal position of the upper urethra. This restores bladder control (continence).
A newer treatment for stress urinary incontinence is the Tension-Free Vaginal Tape. This can replace the more traditional Burch Colposuspension. A synthetic sub-urethral sling is placed either vertically through the retropubic space or, more horizontally through the obturator foramina in the pelvic bones. The mesh sling is passed with the help of specially designed metal guides, the sling on both sides is held in place by friction between the tissue canals created by the metallic needle passers. Scar tissue formed later fixes the mesh, preventing migration. No suspension sutures are used. The sling is positioned under the mid urethra and supports it from moving downward and thus prevents stress urinary incontinence. The retro pubic sling creates sometimes post-operative voiding dysfunction, like the more traditional retropubic bladder neck suspension, such as Burch Colposuspension, especially if the sling or the sutures are pulling the urethra or the bladder neck too tightly upward. On the other hand, the more horizontally positioned trans-obturator sling, rarely creates post-operative voiding dysfunction.
The retropubic sub urethral tension-free vaginal tape had been associated with a number bowel, bladder, vascular and nerve injuries. Such complications appear to be related to the upward vaginal of the metallic guide through the retropubic space. The newer, Trans obturator vaginal tape avoids the upward retro pubic approach and involves a much lower risk of such complications. This approach reproduces the natural suspension of the urethra while preserving an intact retropubic space. For this reason, the customary cystoscopy performed at the end of a Burch colpo suspension or a retro pubic sling is not required after a trans obturator sling.
The synthetic mesh mid-urethral sling, particularly the trans obturator sling, is rapidly becoming the treatment of choice for stress urinary incontinence caused by urethral hypermobility. Postoperatively, patients urinate freely in the morning after the procedure when the bladder catheter is removed. This shorten hospital stay compared to Burch colpo suspension.
When the cause of Stress urinary incontinence is due, not to bladder neck hypermobility, but to urethral sphincter deficiency (weakness of the intrinsic urethral sphincter that allows urine to escape through the closed urethra when pushed with reduced pressure; closure pressure is less than 20 cm water). In such cases, retro pubic sling is a much more effective treatment than either Burch colpo suspension or Trans obturator sling. It appears that retro pubic sling provides more compressive force around the urethra. When the cause of the incontinence is bladder neck hypermobility, trans obturator sling is preferred because it provides the same cure rate with much less risk of surgical complications and postoperative urinary retention.
The complete reconstruction of the pelvic floor will resolve all the symptoms caused by prolapse, good bladder control, normal bowel movement, satisfying intercourse, no back pain, and no feeling of “something falling”. Women may conceive and carry a baby to term but delivery must be through a cesarean section. Alternatively, a woman may choose to complete her family and only then have pelvic floor reconstruction.
In the elderly woman who does not have vaginal intercourse the prolapse may be corrected by a subtotal closure of the vagina (partial colpocleisis). This procedure is better tolerated than hysterectomy. In conclusion, mild prolapse can usually be treated with conservative measures.
When surgical correction of prolapse is required, it is possible to perform corrective surgery without a hysterectomy. The informed patient who chooses to preserve her uterus should look for a surgeon who is experienced and willing to perform such procedures. Vaginal vault prolapse (prolapse of the dome of the vagina) can be repaired through an abdominal or vaginal approach. However, the abdominal approach produces better long-term results. In one study, after five years of follow-up, women who underwent repair through the vaginal approach had a six-fold increased incidence of recurrent vault prolapse, three-fold increase in recurrent cystocele, and double re-operation rate compared to repairs performed using the abdominal approach. The vaginal approach requires a shorter operative time and hospital stay, but in addition to the above-mentioned disadvantages is also associated with urinary tract infections and post-operative urinary incontinence.
The abdominal approach is more effective because it better restores the normal (horizontal) vaginal axis which is crucial for long-term success. Additionally, the utilization of synthetic material for the abdominal approach (the sacral utero colpo pexy) provides stronger, more durable support than the native tissues used in the vaginal approach. Even para-vaginal defect repair is stronger when done using the abdominal approach because the vaginal approach requires extensive peri-urethral dissection which can damage the fine branches of the pudendal nerve which controls the urethral sphincter. In a vaginal approach, it also can be difficult to gain access high in the retroperitoneum in order to attach the endopelvic fascia of the vaginal dome to the white line near its origin at the ischial spine.
There are numerous conditions that necessitate the abdominal approach for prolapse surgery. These include a desire for uterine preservation, re-operation for a failed vaginal approach when there is a definite requirement to access the ovaries when pelvic bone anatomy limits vaginal access, and also when there are additional elements that increase the risk of surgical failure. The latter include athletic activities, chronic cough, obesity, and congenital weakness of the connective tissue (the ligaments). It is also important to know that after a repair through using the vaginal approach, the vagina is significantly shorter which may affect the quality of sexual intercourse.
Recently several kits of synthetic grafts have been introduced for anterior and posterior vaginal repair. It is claimed that these synthetic grafts increase the success and longevity of such repairs. However, the Society of Gynecologic surgeons issued (in 2009) guidelines for use of such grafts in the anterior compartment. Whereas the synthetic mash may improve anatomic outcomes there are significant trade-offs, such as vaginal mesh exposure in the vagina in up to 25%, as well as infection, hemorrhage, dyspareunia (pain during intercourse) urinary incontinence, bladder injury, voiding dysfunction, ureteric obstruction. Regarding the use of synthetic mesh in posterior vaginal repair, the scant data available does not reveal any benefit when such mesh is used.
In conclusion, the approach to correcting genital prolapse should have as a goal a long-term solution to a difficult problem, without unnecessarily sacrificing the genital organs. This can be accomplished through a combined abdominal and vaginal approach, with the comprehensive reconstruction of all damaged ligaments and utilizing a man-made proline mesh for the critical step of anchoring the uterus and upper posterior vagina to the sacral bone. Such a procedure, in expert hands, can be accomplished safely and effectively, should last a lifetime and restore quality sexual intercourse, eliminate chronic low back pain and the feeling of “something falling in the vagina”, and provide excellent control of the urinary and rectal systems.