Chapter 141. Prolapsed Uterus Reduction

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 uterine prolapse have become increasingly more relevant with women living a third of their lives in the susceptible period after menopause. Population-based studies note that up to 10% of women report symptoms of pelvic organ prolapse. The Women's Health Initiative study found evidence of uterine prolapse on physical examination in 14% of study participants. Manual reduction of the prolapsed uterus and placement of a pessary represents 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.1–4

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.5 Two cases of acute uterine prolapse after restrained motor vehicle collisions were recently described.6 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.7 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.8

Uterine prolapse is defined as the descent of the uterus and cervix down the vaginal canal toward the vaginal introitus. All forms of genital 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 proplapse.3 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 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. Grade 4, also known as severe prolapse or procidentia, involves the cervix and entire uterus projecting through the introitus, completely inverting the vaginal vault (Figure 141-1).9 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.5

The pelvic diaphragm, the endopelvic fascia, and the vagina provide the primary support for the pelvic organs. The superficial muscles of the perineum lie below the pelvic diaphragm and indirectly support the pelvic organs by inserting centrally into the perineal body. The perineal body serves to fix the distal vagina and anus. The bony pelvis is the ultimate support for all the soft tissues of the pelvis.8

The pelvic diaphragm is made up of a bilaterally paired group of three striated muscles: the pubococcygeus (including the puborectalis), the iliococcygeus, and the coccygeus. The pelvic diaphragm is innervated by fibers originating from sacral segments four and five. The pelvic diaphragm is normally in a state of tonic contraction. It increases its tone reflexively in response to increases in intraabdominal pressure.8

The endopelvic fascia is the layer of fibrous connective tissue that envelops all pelvic organs. The endopelvic fascia develops supportive thickenings along lines of tension that are referred to as ligaments (e.g., uterosacral and cardinal ligament complex). These ligaments provide further support for the pelvic structures. The uterosacral and cardinal ligaments suspend the uterus and are in fact simple extensions of the endopelvic fascia.8

The vagina has supportive functions as well. The uterosacral and cardinal ligaments shift the upper one-third of the vagina posteriorly and laterally. This provides support for the cervix. The middle third of the vagina is attached bilaterally to the fascia overlying the pelvic sidewall musculature and supports the bladder. The lower third of the vagina is fused to the tissues about the vaginal outlet.

There are numerous causes that lead to the development of a prolapsed uterus. Prolonged labor can lead to significant pelvic floor damage, suggesting that women who delivered vaginally or who later required cesarean section because of failure to progress are more at risk.8 As yet, no factor has been identified that allows the identification of apparently normal individuals in which pelvic floor dysfunction is destined to develop after vaginal delivery.8 The quantity and quality of collagen appears to deteriorate in women after menopause, likely attributable to the resultant estrogen deficiency.11,12 It is thought that defective connective tissue contributes significantly to uterine prolapse in the absence of other risk factors. One study of premenopausal women with uterine prolapse found a 25% reduction in the collagen content of tissues.12 Conditions that affect spinal cord pathways and pelvic nerve roots (e.g., muscular dystrophy, trauma, myelodysplasia, meningomyelocele) can result in paralysis of the pelvic floor with the subsequent prolapse of pelvic structures. Spina bifida has been associated with the majority of cases of uterine prolapse in newborn girls and nulliparous women.8

Increased intraabdominal pressure is a major factor in the development of pelvic organ prolapse. Obesity contributes to pelvic prolapse by increasing intraabdominal pressure that is, in turn, transmitted to the pelvic organs. Chronic respiratory conditions that are associated with forceful coughing are also thought to predispose to uterine prolapse. Occupational and recreational activities, such as heavy lifting or repeated jumping, result in repeated and prolonged increases in intraabdominal pressure. A review of 1.6 million women found an increase risk of uterine prolapse in a group of nurses whose jobs required heavy lifting.8 The deterioration in muscle function and connective tissue associated with aging together with gravity, childbirth, neurological deterioration, and hormonal status all combine to lead to a progressive decline in pelvic floor function in older women. This may be compounded by factors that increase intraabdominal pressure leading to the development of symptomatic pelvic floor prolapse.11

All aspects of the vaginal support should be carefully surveyed when examining a patient with a uterine prolapse. Look for the presence of a cystocele or rectocele. Examine the patient in the standing position, as well as in the standard dorsal lithotomy position, since the prolapse is almost invariably worse when the patient is upright.11 It may be necessary to have the patient strain to assess the full extent of the prolapse.15 The examination may be facilitated by having the patient stand with one foot on a well-supported footstool. Some degree of a cystocele, urethrocele, enterocele, or rectocele may develop or may be associated with a uterine prolapse as the uterus progressively descends. Some authors recommend expanding the traditional speculum examination by using a single blade speculum (e.g., Sims speculum) to selectively visualize each portion of the vaginal vault for defects in pelvic support. Perform a rectovaginal examination with the patient in the standing position to detect an occult enterocele, suggested by the presence of small bowel easily palpable in the cul-de-sac using the thumb and forefinger.13,14

Asymptomatic uterine prolapse requires no treatment in the Emergency Department. The patient with only intermittent symptoms can prevent against prolapse by simply inserting a tampon or a diaphragm. This additional support may be used in anticipation of increased activity or prolonged periods of standing. The patient, however, should be informed that she is losing some aspects of pelvic support and should be referred to a Gynecologist for evaluation of future treatment options.7 Lifestyle changes can prevent the progression or recurrence of prolapse, precluding the need for future surgical evaluation and complications. Most of these changes focus on decreasing unnecessary increases in intraabdominal pressure like losing weight, removing girdles, avoiding heavy lifting, stopping smoking, and treating allergies or pulmonary disease accordingly.1 Kegel proposed a series of pelvic muscle exercises for the treatment of urinary incontinence, which can accompany uterine prolapse. These exercises strengthen the pelvic muscles and may be helpful early. They are of limited value in patients with significant prolapse since fascial attachments have already been disrupted.7,16

Symptomatic women can be treated conservatively or surgically. Pelvic organ prolapse is frequently not recognized until advanced disease is present because prolapse does not become symptomatic until the descending segment is at or through the introitus.10 Therapeutic options are variable and relate to the age and health of the patient, the severity of the symptoms, and the degree of prolapse. The options for uterine prolapse include observation, reduction with or without supportive pessary therapy, vaginal hysterectomy with corrective therapy for pelvic relaxation (hysteropexy), and some form of colpocleisis (surgical obliteration of the vagina).17

Conservative management of symptomatic uterine prolapse in the Emergency Department involves reduction and subsequent fitting of the patient with a pessary. The pessary is largely used as an alternative to surgery or as a temporizing measure in patients awaiting surgery.18 Preoperative use of a pessary in advanced degrees of prolapse may aid in decongesting the mucosa, improving circulation, and reestablishing vaginal tonicity. Patients desiring surgical management may be treated conservatively in the Emergency Department and referred to a Gynecologist. Symptomatic women who wish to complete childbearing before having a surgical repair may also be candidates for a vaginal pessary.1 The gynecologic and obstetric indications for pessary support after reduction of the prolapsed uterus are listed in Table 141-1.5

There are no absolute contraindications to the manual reduction of a prolapsed uterus. Pessaries are contraindicated in patients with acute genital tract infections and in those with adherent retroposition of the uterus.5 Any vaginal inflammation, ulceration, infection, or atrophy should be treated before pessary fitting to decrease the likelihood of vaginal erosions and granulation tissue formation. These latter conditions can be mitigated by oral or topical estrogen supplementation. The use of large amounts of lubricants, such as K-Y Jelly, should be encouraged with the pessary in the event that estrogen is contraindicated.18 Other contraindications include patients with impaired mental capacity, lack of patient dexterity, a history of noncompliance, or severe atrophic mucosal changes.

• Pessaries
• Standard pelvic bed
• Vaginal speculum
• Water-soluble lubricant
• Culture swabs
• Biopsy and Pap smear brush, optional
• Uterine forceps
• Sterile gloves
• Sedation, as needed

The vaginal pessary is of ancient lineage. They are now made of plastic, rubber, or silicone that functions to support the uterus, cervical stump, or hernias of the pelvic floor.5 They are available in numerous sizes and shapes (Figure 141-2). Silicone pessaries have the advantage of being flexible and pliable while causing less vaginal discharge and odor than the rubber pessaries.17 Pessaries elevate the vagina and maintain normal anatomic relations by supporting prolapsing structures against the perineal body and pubic bone. They thereby reduce vaginal relaxation and increase the tautness of the pelvic floor structures. Usually all that is needed is adequate support anteriorly and a reasonably good perineal body. Otherwise, the pessary may slip from behind the pubic symphysis and extrude from the vagina.5 Unfortunately, the education of Emergency Physicians is somewhat compromised in the use of pessaries. Placement of a pessary is often a trial and error experience. Review the accompanying brochures to obtain the most satisfactory results from the pessary.17

Explain the procedure, its risks, and complications to the patient and/or their representative. Obtain an informed consent prior to performing the procedure. Place the patient in the lithotomy position with both feet comfortably resting in standard stirrups. An assistant should be available to assist with positioning.

The management of complete uterine prolapse in the Emergency Department depends upon successful replacement of the uterine fundus into the pelvis and subsequent fitting of the appropriate pessary. Refer the patient for surgical management upon discharge from the Emergency Department. An incarcerated uterus in the pregnant patient is an obstetrical emergency requiring immediate surgical elevation. Other indications include any pregnant patient who develops acute urinary retention or is at risk of aborting.5

Uterine Reduction

Insert one gloved and lubricated hand into the vagina with the fingers extended to identify the margins of the cervix. Allow the uterine corpus to rest in the palm of the hand. Apply firm and gentle pressure to elevate the uterine fundus with the gloved hand by pressing against the cervix. Use the fingers on the edges of the uterus closest to the cervix to gently manipulate the uterus in the direction of the umbilicus. Gradually replace the uterus into the pelvis.

If this maneuver is not successful, insert a pessary into the posterior vaginal fornix while the patient is in the lithotomy position. Instruct the patient to sit up and assume the knee-chest position after insertion of the pessary. Instruct the patient to slip slowly into the prone position and then into the lithotomy position. The pessary will maintain the uterus in anteposition. It may be necessary to pack the vagina following manual reduction of a procidentia to maintain the uterine position as a preoperative management decision of an ulcerated or infected prolapse.5,19 This should be performed in consultation with a Gynecologist.

Fitting of the Pessary

Measure the distance from the introitus to the posterior vaginal vault using uterine forceps after reduction of the uterus. This measurement minus 1 cm is the approximate length of the pessary. To find the width (assuming an ovoid rather than a round pessary is required), place the forceps into the introitus to about the level of the cervix. Separate the handles until the blades touch the walls of the vagina. This represents the greatest diameter of the pessary.5

Liberally lubricate the pessary. Insert it with its widest dimension in the oblique diameter of the vagina to avoid painful distension of the introitus. Use the fingers of the nondominant hand to support the perineum. Slip the posterior bar behind the cervix using a finger on the dominant hand. The forefinger should pass easily between the sides of the frame and the vaginal wall at any point to ensure adequate fitting. If this is not possible, the pessary is too large.5

Ask the patient initially to walk around the examination room to confirm comfort and exclude partial or complete expulsion of the pessary or recurrence of the prolapse. Replace the pessary with one of a different size or style to prevent any further prolapse.

Instruct the patient to remove the pessary each night and clean it with warm soapy water during the first few weeks of use. The soap should not contain any deodorants, detergents, or perfumes. These agents can irritate the vaginal mucosa and result in a chemical vaginitis. Weekly cleanings and overnight removal are adequate after the patient has become comfortable with its use. Apply vaginal cream once a week if the patient is not receiving systemic supplemental estrogen replacement. Warm, low-pressure acetic acid douches or acidic vaginal creams (such as ACI-JEL) may relieve irritation and prevent any discharge caused by the vaginal pessary.5

Refer the patient to a Gynecologist. Routine follow-up at 6 to 12 month intervals is recommended after several weeks of a well-managed and appropriately sized pessary. Additional care of these devices includes biannual pelvic examinations and replacement of pessaries every 12 to 18 months.2 Patients should be counseled on the hazards of leaving the pessary in for prolonged periods of time and the importance of complying with recommended follow-up. It is not uncommon to have to change the pessary size and/or type. Patients are sometimes unable to manage the responsibilities of a pessary. A family member or a nurse trained in the insertion, removal, and care of the pessary is an appropriate alternative.

Advise all patients to return to the Emergency Department for difficulty urinating, defecating, signs of infection, or any problems with insertion and removal of the pessary.

Attempts at reducing the symptomatic uterine prolapse may be unsuccessful. Review the surgical and medical options with the patient and arrange the appropriate follow-up. Consult a Gynecologist before the patient is discharged from the Emergency Department.

A loose pessary is ineffective and usually will be expelled. The patient may experience pelvic pain, vaginal bleeding, vaginal ulcers, urinary retention, urinary fistulas, bowel fistulas, vaginal discharge, and/or dyspareunia if the pessary is too large or not removed and cleaned periodically. Therefore, proper fitting is important initially with appropriate follow-up to address these issues.17

Minor complications include ulceration and abrasions of the vaginal mucosa secondary to local pressure effects. Pessaries act as foreign bodies and can become colonized by bacteria and lead to a vaginitis. Many patients experience a physiologic watery discharge with pessary use. This should not be confused with an infectious process that usually is accompanied by itching, burning, or odor. Severe vaginitis is more common in the elderly and debilitated patients because of the inability to remove and cleanse the pessary.20,21 These conditions should be treated accordingly with discontinuation of the pessary until the infection has cleared and local care with estrogen or antibiotic creams.18

Serious complications are a result of prolonged, often decades long, uninterrupted use caused by neglect rather than the pessary itself.18 Case reports described in the literature include vesicovaginal fistulas, rectovaginal fistulas, urosepsis, and malignancy.22 Cervical and vaginal cancer associated with pessary use is a rare complication and is perhaps related to prolonged irritation or the chemical constituents of some of the older models of pessaries.22 Pessary-related infections can occasionally develop local complications (e.g., abscess, sinus tract, pelvic cellulitis) or spread to other systems to cause systemic manifestations (e.g., pyelonephritis, peritonitis). Patient counseling and adequate follow-up is important.18 All of the complications are preventable and point to the need for periodic gynecologic examinations in pessary users.20

Reduction of the prolapsed uterus with subsequent pessary placement is a safe and acceptable mechanism for management of women who present to the Emergency Department with symptomatic prolapse. It is important that Emergency Physicians be familiar with this technique and recognize those women most at risk in order to avoid related complications.