Uterine Prolapse

The gradual increase in life expectancy in developed countries over the past century has produced an increased demand on the health care system for practitioners conversant with disorders of the elderly population. Pelvic organ prolapse (POP) and urinary incontinence (UI) are common conditions affecting many adult women today. POP is the abnormal descent or herniation of the pelvic organs from their normal attachment sites or their normal position in the pelvis. In this article, the authors discuss the clinical presentation, pathophysiology, evaluation, and management of uterine prolapse (UP).

UP was first recorded on the Kahun papyri in about 2000 BCE. Hippocrates described numerous nonsurgical treatments for this condition. In 98 CE, Soranus of Rome first described the removal of the prolapsed uterus when it became black. The first successful vaginal hysterectomy for the cure of UP was self-performed by a peasant woman named Faith Raworth, as described by Willouby in 1670. She was so debilitated by UP that she pulled down on the cervix and slashed off the prolapse with a sharp knife. She survived the hemorrhage and continued to live the rest of her life debilitated by UI. From the early 1800s through the turn of the century, other successful surgical approaches were used to treat this condition.

UP is a defect of the apical segment of the vagina and is characterized by eversion of the vagina with attendant descent of the uterus. Because the vagina is typically involved, many term the condition "uterovaginal prolapse." Patients may present with varying degrees of descent. In the most severe cases, procidentia, the uterus protrudes through the genital hiatus. UP is the most troubling type of pelvic relaxation because it is often associated with concomitant defects of the vagina in the anterior, posterior, and lateral compartments.

Frequency

The exact prevalence of POP is difficult to determine. However, it is estimated that the lifetime risk of requiring at least 1 operation to correct incontinence or prolapse is approximately 11%. ^[1]  Swift et al found that over 50% of asymptomatic women presenting for annual gynecologic examination have at least stage 2 prolapse on examination. Swift et al found that over 50% of asymptomatic women presenting for annual gynecologic examination have at least stage 2 prolapse on examination. ^[2]  

Pelvic floor defects are created as a result of childbirth and are caused by the stretching and tearing of the endopelvic fascia and the levator muscles and perineal body. Partial pudendal and perineal neuropathies are also associated with labor. ^[3] Impaired nerve transmission to the muscles of the pelvic floor may predispose them to decreased tone, leading to further sagging and stretching. Therefore, multiparous women are at particular risk for UP. Genital atrophy and hypoestrogenism also play important contributory roles in the pathogenesis of prolapse. However, the exact mechanisms are not completely understood. Prolapse may also result from pelvic tumors, sacral nerve disorders, and diabetic neuropathy.

Other medical conditions that may result in prolapse are those associated with increases in intra-abdominal pressure (eg, obesity, chronic pulmonary disease, smoking, constipation). Certain rare abnormalities in connective tissue (collagen), such as Marfan disease, have also been linked to genitourinary prolapse. ^[4] A review of the detailed mechanisms that can lead to UP is beyond the scope of this article. However, thorough evaluation and definition of all support defects is of critical importance because most women with UP have multiple defects. ^[5]

In a 1999 study of Swedish women aged 20-59 years, Samuelsson and colleagues found that, although signs of POP frequently are observed, the condition seldom causes symptoms. ^[6] Minimal UP generally does not require therapy because the patient is usually asymptomatic. However, uterine descent of the cervix at or through the introitus can become symptomatic. Symptoms of UP may include a sensation of vaginal fullness or pressure, sacral back pain, vaginal spotting from ulceration of the protruding cervix or vagina, coital difficulty, lower abdominal discomfort, and voiding and defecatory difficulties. Typically, the patient feels a bulge in the lower vagina or the cervix protruding through the vaginal introitus.

Evaluation

Identification of concomitant pelvic defects before surgery facilitates simultaneous repair of other defects and minimizes the chance for recurrence. Optimally, surgeons should plan the most appropriate procedures necessary to correct all defects at the same surgical setting. When a patient presents with complaints of UP, a detailed history and a site-specific assessment of all pelvic floor defects are critical to the evaluation. Patients are often referred for asymptomatic prolapse. Shull's axiom that "the asymptomatic patient cannot be made to feel better by medical or surgical therapy" provides good advice (1993). The gynecologist's responsibility is to address the individual needs and wishes of patients.

Assessment of quality of life is also helpful in determining appropriate treatment. A detailed sexual history is crucial, and focused questions or questionnaires should include quality-of-life measures. Voiding difficulties and urinary frequency, urgency, or incontinence are common symptoms associated with POP. If present, these symptoms should be investigated because advanced prolapse may contribute to lower urinary tract dysfunction, including hydronephrosis and obstructive nephropathy. Surgery for the correction of incontinence is less successful in patients with POP. ^[7]

Incontinence is discussed elsewhere (see Incontinence, Urinary: Comprehensive Review of Medical and Surgical Aspects, Incontinence, Urinary: Surgical Therapies, and Incontinence, Urinary: Nonsurgical Therapies). Urinary retention is also common for patients with UP because they often have concomitant descent of the anterior vaginal wall. An anatomic kinking of the urethra may cause obstructive voiding and urinary retention. Always determine the postvoid residual urine volume to exclude obstruction as a consequence of urethral kinking or incomplete emptying secondary to poor bladder contractility.

Complete preoperative assessment can prevent many postoperative complications. The authors recently reported a series of patients with significant anterior vaginal wall prolapse who exhibited urinary retention. Each patient underwent preoperative prolapse reduction testing using a pessary. This test was found to have high sensitivity, specificity, and positive predictive value for the postoperative cure of urinary retention. In this series, reconstructive pelvic surgery cured most patients with urinary retention problems. ^[8]

Note significant medical history (eg, obesity, asthma, long-term steroid use) that may have contributed to prolapse or UI. It may be wise to attempt to correct some of these problems, if possible, before any surgical treatment. Recurrences may be more likely if such conditions are not addressed.

A site-specific physical evaluation is essential. Methods for noting pelvic floor relaxation include (1) the Baden halfway system; (2) the International Continence Society (ICS) classification, using the Pelvic Organ Prolapse Quantification (POPQ) system; and (3) the revised New York Classification (NYC) system. ^{[9, 10, 11]}

In all these systems, stage I is defined as descent of the uterus to any point in the vagina up to 1 cm proximal to the hymen; stage II, as descent from 1 cm proximal to the hymen, to the hymen, or up to 1 cm distal to the hymen; stage III, as descent beyond 1 cm distal to the hymen; and stage IV, as total uterine prolapse or uterine procidentia.

Evaluate the patient in both the lithotomy and standing positions, during relaxation and maximal straining. To perform the evaluation, place a standard double-bladed speculum in the vaginal vault to visually examine the vagina and cervix. The speculum is removed and taken apart, leaving only the posterior blade, which is then replaced into the posterior vagina, allowing visualization of the anterior wall. The mono valve speculum is then everted to view the posterior wall. Note the point of maximal descent of the anterior, lateral, and apical walls in relation to the ischial spines and hymen. Next, place 2 fingers into the vagina such that each finger opposes the ipsilateral vaginal wall, and ask the patient to bear down. After evaluating the lateral vaginal support system, assess the apex (cervix and apical vagina). Repeat the examination with the patient standing and bearing down in order to note the maximum descent of the UP.

Next, grade the strength and quality of pelvic floor contraction, asking the patient to tighten the levators around the examining finger. Assess the external genitalia, noting estrogen status, diameter of the introitus, and length of perineal body. Perform a careful bimanual examination and note uterine size, mobility, and adnexa. Lastly, perform a rectal examination, assessing the external sphincter tone and checking for the presence of rectocele or enterocele.

When the patient has significant anterior vaginal wall prolapse (cystocele), it is important to exclude the development of postoperative potential incontinence (PI) prior to management of uterine prolapse. By definition, PI is the development of incontinence only when the prolapse is reduced. This unmasking of urinary incontinence is a result of a possible unkinking of the urethra with the prolapsed reduced. If potential incontinence is not addressed before reconstructive surgery, up to 30% of patients may become incontinent after surgical repair. ^[12]

To test for potential incontinence, a cystometrogram is performed and the bladder is retrograde filled to maximum capacity (or at least 300 mL) with sterile water or saline. If the patient leaks urine during Valsalva or with cough, (with or without reduction of the prolapse) the patient may benefit from an anti-incontinence procedure performed concomitantly with the uterine prolapse surgery.

This approach of performing adequate testing (urodynamics) prior to management of uterine prolapse (especially during sacrocolpopexy surgery) is supported by several studies. ^[13] In this study, for women with uterine or apical vaginal prolapse undergoing abdominal sacrocolpopexy and who were continent before surgery, Burch decreased the rate of postoperative stress UI (32% for Burch versus 45% for no Burch).

However, other authors have challenged the accuracy and predictability of urodynamics prior to open sacrocolpopexy (Colpopexy and Urinary Reduction Efforts [CARE] trial) and advocated a prophylactic Burch colposuspension be performed concomitantly with sacrocolpopexy to reduce postoperative development of stress urinary incontinence. ^[14] In a study of practice questionnaire of American Urogynecological Society (AUGS) members, most clinicians (57%) do not perform a prophylactic anti-incontinence procedure (Burch colposuspension) at the time of sacrocolpopexy, illustrating the ongoing debate on the issue of preoperative testing and management of PI. ^[15]

The primary management of severe UP is surgical. For patients in whom conservative management has failed, a variety of surgical approaches to correct POP are available.

When planning the appropriate approach, the surgeon must consider operative risk, coital activity, and vaginal canal anatomy. The following list illustrates variables that must be considered.

Important considerations for nonsurgical or surgical decision making

See the list below:

• Medical condition and age

• Severity of symptoms

• Patient's choice (ie, surgery or no surgery)

• Patient's suitability for surgery

• Presence of other pelvic conditions requiring simultaneous treatment, including urinary or fecal incontinence

• Presence or absence of urethral hypermobility

• Presence or absence of pelvic floor neuropathy

• History of previous pelvic surgery

Knowledge of the anatomy of the pelvis is essential to understanding prolapse. Teleologic reasoning aids in the understanding of POP. The pelvic floor evolved in primates, particularly humans, who as bipeds, spend most of their waking hours in the upright position. As the name suggests, the floor of the pelvis is the lowest boundary on which all the pelvic and abdominal contents rest. The pelvic floor is composed of a sling of several muscle groups (levators) and ligaments (endopelvic fascia) connected at the perimeter to the 360° ovoid bony pelvis.

Furthermore, knowledge of the biaxial orientation of the vagina and uterus is critical to understanding the anatomic and functional relationships and to proper surgical restoration of the pelvic supports.

In the supine position, the upper vagina is almost horizontal and superior to the levator plate. ^[12] The uterus and apical vagina have 2 principal support systems. Active support is provided by the levator ani; passive support is provided by the condensations of the endopelvic fascia (ie, the uterosacral-cardinal ligament complex, the pubocervical fascia, the rectovaginal septum) and their attachments to the pelvis and pelvic sidewalls through the arcus tendineus fascia pelvis. The levator ani muscles are fused posteriorly to the rectum and attach to the coccyx. The genital hiatus is the perforation on the pelvic floor through which passes the urethra, vagina, and rectum.

Contraindications to surgical correction of uterine prolapse are based on the patient's comorbidities and her ability to tolerate surgery. Patients with mild (Stage I) UP do not require surgery because they are usually asymptomatic. Patients contemplating future pregnancy, may delay surgery for UP as pregnancy and vaginal delivery after prolapse surgery may require additional surgical repair for recurrent POP. ^[16]

Thus, for premenopausal women contemplating future pregnancy, adequate preoperative counseling needs to be performed with regards to the timing of surgery for UP, prior to or after completing childbirth. Contraindications to uterine preservation surgery include any uterine abnormalities, uterine fibroids, history of current or recurrent cervical dysplasia, postmenopausal vaginal bleeding, abnormal menstrual bleeding, hereditary nonpolyposis colonic cancer, familial cancer (BRCA), current or past history of selective estrogen receptor modulators (ie, tamoxifen), or any patient who cannot comply with routine gynecologic surveillance.