Symptomatically important uterine prolapse can result from relaxation of pelvic support with age in susceptible women. Uterine prolapse can significantly impact a woman’s daily activities, sexual function, ability to exercise, and body image. Population-based studies note that approximately 10% of women report symptoms of pelvic organ prolapse.1 Approximately 14% of 16,616 participants possessing a uterus were found to have uterine prolapse in the Women’s Health Initiative Hormone Replacement Therapy Clinical Trial.2 Pelvic organ prolapse was the etiology for 15% to 18% of hysterectomies.3 The most common etiology in postmenopausal women for a hysterectomy is uterovaginal prolapse.3 Manual reduction of the prolapsed uterus and placement of a pessary represent a safe and temporizing measure that may be performed in the Emergency Department. Surgical correction may ultimately be necessary. It is estimated that pelvic organ prolapse is responsible for more than 200,000 surgical repair procedures each year (22.7 per 10,000 women). This chapter will address the nonsurgical management of a prolapsed uterus.2,4-7
ANATOMY AND PATHOPHYSIOLOGY
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 is the most commonly shared trait, suggesting that birth trauma has a primary role to play. Alternative mechanisms relate to increased intraabdominal pressure (e.g., heavy lifting, ascites, obesity, large intraabdominal tumors, chronic constipation, or pelvic tumors). A congenital form of uterine prolapse seen in newborns has been attributed to vigorous crying.8 Two cases of acute uterine prolapse after restrained motor vehicle collisions were described in 1997.9 It was hypothesized that the sudden increase in intraabdominal pressure from the lap belt was the cause of the prolapse.9 Chronic respiratory disorders (e.g., asthma, bronchitis, or emphysema) may put undue tension on the pelvic floor musculature and contribute to the increased risk of prolapse.10 The integrity of the pelvic connective tissues may have a role as suggested by the increased incidence of uterine prolapse in women with Marfan syndrome and other connective tissue disorders.11
Uterine prolapse is defined as the descent of the uterus and cervix down the vaginal canal toward the vaginal introitus. All forms of uterine prolapse are described in reference to the hymen. The uterine displacement is typically graded on a scale of 0 to 4, with 0 referring to no prolapse, 1 halfway to the hymen, 2 at the hymen, 3 halfway out of the hymen, and 4 referring to total prolapse (Figure 172-1).2,12 A first-degree or mild prolapse is defined with the cervix palpable as a firm mass in the lower third of the vagina. Patients with grades 0 or 1 prolapse are usually asymptomatic. Grade 3, or moderate prolapse, is characterized by the cervix being visible and projecting into or through the vaginal introitus. The patient may experience a falling-out ...