Chapter 120

There is a progressive relaxation of pelvic support for the uterus and vagina with advancing age. This relaxation may in turn lead to symptomatically important uterine prolapse in susceptible women. The quality of life issues associated with prolapse of the uterus have become increasingly more relevant with women living a third of their lives in the susceptible period after menopause. Manual reduction of the prolapsed uterus and placement of a pessary represents a safe, temporizing measure that may be performed in the Emergency Department. Surgical correction may ultimately be necessary. This chapter will address the nonsurgical management of a prolapsed uterus.1,2

The structural support of the female pelvis is subject to a number of identifiable stresses that may predispose certain women to uterine prolapse later in life. Multiparity seems to be the most commonly shared trait, suggesting that birth trauma has a primary role to play. Alternative mechanisms include anything that may increase intraabdominal pressure, such as heavy lifting, ascites, obesity, large intraabdominal tumors, or pelvic tumors. Similarly, chronic respiratory disorders (e.g., asthma, bronchitis, or emphysema) may put undue tension on the pelvic floor musculature.3 Two cases of acute uterine prolapse after restrained motor vehicle collisions were recently described.4 It was hypothesized that the sudden increase in intraabdominal pressure from the lap belt was the cause of the prolapse. A congenital form of uterine prolapse may be seen in newborns due to vigorous crying.3 The integrity of the pelvic connective tissues may have a role to play as suggested by the increased incidence of uterine prolapse in women with Marfan syndrome and other connective tissue disorders.5

Uterine prolapse is defined as the descent of the uterus and cervix down the vaginal canal towards the vaginal introitus. All forms of genital prolapse are described with reference to the vagina.6 The degree of uterine prolapse parallels the extent of weakening of the supporting structures.3 A first-degree or mild prolapse is defined with the cervix palpable as a firm mass in the lower third of the vagina. The patient is usually asymptomatic. Second-degree or moderate prolapse is defined as the cervix being visible and projecting into or through the vaginal introitus. The patient may be experiencing a falling-out sensation or may report the feeling of sitting on a ball. Additional symptoms include heaviness in the pelvis, low backache, lower abdominal discomfort, and inguinal discomfort. Third-degree prolapse, also known as severe prolapse or procidentia, is defined as the cervix and entire uterus projecting through the introitus, completely inverting the vaginal vault (Figure 120-1). The uterine mass frequently has one or more areas of easily bleeding atrophic lesions secondary to exposure and local pressure effects. It may result in leukorrhea, abnormal uterine bleeding, or spontaneous abortions.3

###### Figure 120-1

Uterine procidentia. Photo courtesy of Steve Miller, MD.

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