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Uterine prolapse is when the
uterus The uterus (from Latin ''uterus'', plural ''uteri'') or womb () is the organ in the reproductive system of most female mammals, including humans that accommodates the embryonic and fetal development of one or more embryos until birth. The ...
descends towards or through the opening of the
vagina In mammals, the vagina is the elastic, muscular part of the female genital tract. In humans, it extends from the vestibule to the cervix. The outer vaginal opening is normally partly covered by a thin layer of mucosal tissue called the hymen ...
. Symptoms may include vaginal fullness, pain with sex, trouble urinating, urinary incontinence, and
constipation Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel moveme ...
. Often it gets worse over time. Low back pain and vaginal bleeding may also occur. Risk factors include
pregnancy Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy usually occurs by sexual intercourse, but ...
,
childbirth Childbirth, also known as labour and delivery, is the ending of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million births glob ...
,
obesity Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's ...
,
constipation Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel moveme ...
, and chronic coughing. Diagnosis is based on examination. It is a form of pelvic organ prolapse, together with bladder prolapse, large bowel prolapse, and small bowel prolapse. Preventive efforts include managing chronic breathing problems, not smoking, and maintaining a healthy weight. Mild cases may be treated with a
pessary A pessary is a prosthetic device inserted into the vagina for structural and pharmaceutical purposes. It is most commonly used to treat stress urinary incontinence to stop urinary leakage and to treat pelvic organ prolapse to maintain the locati ...
together with hormone replacement therapy. More severe cases may require surgery such as a
vaginal hysterectomy Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovaries ( oophorectomy), Fallopian tubes (salpingectomy), and other surrounding structures. Usually performed by a gynecologist, a hysterectomy may be ...
. About 14% of women are affected. It occurs most commonly after menopause.


Causes

The most common cause of uterine prolapse is trauma during childbirth, in particular multiple or difficult births. About 50% of women who have had children develop some form of pelvic organ prolapse in their lifetime. It is more common as women get older, particularly in those who have gone through menopause. This condition is surgically correctable.


Pathophysiology

The
uterus The uterus (from Latin ''uterus'', plural ''uteri'') or womb () is the organ in the reproductive system of most female mammals, including humans that accommodates the embryonic and fetal development of one or more embryos until birth. The ...
(womb) is normally held in place by a hammock of muscles and ligaments. Prolapse happens when the ligaments supporting the uterus become so weak that the uterus cannot stay in place and slips down from its normal position. These ligaments are the round ligament,
uterosacral ligaments The uterosacral ligaments (or rectouterine ligaments) belong to the major ligaments of uterus. Structure The rectouterine folds contain a considerable amount of fibrous tissue and non-striped muscular fibers which are attached to the front of th ...
, broad ligament and the
ovarian ligament The ovarian ligament (also called the utero-ovarian ligament or proper ovarian ligament) is a fibrous ligament that connects the ovary to the lateral surface of the uterus. Structure The ovarian ligament is composed of muscular and fibrous tissu ...
. The uterosacral ligaments are by far the most important ligaments in preventing uterine prolapse. In some cases of uterine prolapse, the uterus can be unsupported enough to extend past the vaginal wall for inches.


Treatment

Treatment is conservative, mechanical or surgical.


Conservative

Conservative options include behavioral modification and muscle strengthening exercises such as Kegel exercise. Pessaries are a mechanical treatment that supports the vagina and elevates the prolapsed uterus to its normal, correct position. Pessaries are frequently offered as a first-line treatment for uterine prolapse.


Surgery

Surgical options are many and may include a
hysterectomy Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovaries ( oophorectomy), Fallopian tubes ( salpingectomy), and other surrounding structures. Usually performed by a gynecologist, a hysterectomy may b ...
or a uterus-sparing technique such as laparoscopic hysteropexy, sacrohysteropexy or the Manchester operation.Surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication versus vaginal hysterectomy with high uterosacral ligament plication
By de Boer T, Milani F, Kluivers K, Withagen M, Vierhout M. Part o
ICS 2009 Scientific Programme, Thursday 1 October 2009
/ref> In the case of hysterectomy, the procedure can be accompanied by sacrocolpopexy. This is a mesh-augmented procedure in which the apex of the vagina is attached to the
sacrum The sacrum (plural: ''sacra'' or ''sacrums''), in human anatomy, is a large, triangular bone at the base of the spine that forms by the fusing of the sacral vertebrae (S1S5) between ages 18 and 30. The sacrum situates at the upper, back part o ...
by a piece of medical mesh material. A Cochrane review found that sacral colpopexy was associated with lower risk of complications than vaginal interventions, but it was unclear what route of sacral colpopexy should be preferred. No clear conclusion could be reached regarding uterine preserving surgery versus vaginal hysterectomy for uterine prolapse. The evidence does not support use of transvaginal mesh (TVM) compared to native tissue repair for apical vaginal prolapse. The use of a transvaginal mesh is associated with side effects including
pain Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, ...
,
infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable di ...
, and organ perforation. According to the FDA, serious complications are "not rare".


Society and culture

A number of
class action A class action, also known as a class-action lawsuit, class suit, or representative action, is a type of lawsuit where one of the parties is a group of people who are represented collectively by a member or members of that group. The class actio ...
lawsuit - A lawsuit is a proceeding by a party or parties against another in the civil court of law. The archaic term "suit in law" is found in only a small number of laws still in effect today. The term "lawsuit" is used in reference to a civil act ...
s have been filed and settled against several manufacturers of TVM devices.


References


External links


Illustrated description of Manchester Operation
at atlasofpelvicsurgery.com

treatment, from Merck Professional {{Authority control Noninflammatory disorders of female genital tract Wikipedia medicine articles ready to translate