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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
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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
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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 ...