Uterine Prolapse (sagging)

Uterine (womb) sagging occurs when the pelvic floor muscles and ligaments do not provide sufficient support to the womb as a result of stretching and weakening of the ligaments. In this case, the uterus slides down or comes out of the vagina.

Uterine prolapse may occur in women of all ages, and it is often seen in the post-menopausal women who had one or more vaginal deliveries. The sagging of the uterus as a result of weakening of the pelvic floor muscles can be caused by:

  • Damage to the supporting connective tissue during pregnancy and childbirth
  • Gravity effect
  • Estrogen deficiency
  • Repetitive strains over the years
  • If there is a slight degree of uterine prolapse, treatment is generally not required. However, if the prolapse of the uterus bothers you and prevents your normal life, you can benefit from treatment.

Symptoms

The severity of the sagging of the uterus varies. You may have a slight uterus sagging and you may not have experienced any signs or symptoms. If you have moderate or severe sagging of the uterus, you may experience the following symptoms:

  • A feeling of heaviness around your lower tummy and genitals with a dragging discomfort inside your vagina.
  • A tissue bulging out of your vagina
  • Urinary problems, such as urinary incontinence or inability to urinate
  • Problem with bowel movements
  • Low back pain
  • Feeling as if you are sitting on a small ball or something will come out of the vagina
  • Symptoms that are less in the morning and worsen in the evening

When should we see a doctor?

Uterine prolapse does not require treatment unless it is severe. If your signs and symptoms are bothersome and interfere with your normal activities, you can talk to your doctor about treatment options.

Causes

Weakening of the pelvic muscles and supporting tissue contributes to uterine prolapse. These can be a result of:

  • Pregnancy
  • Trauma during childbirth
  • Giving birth to a large baby
  • Difficult childbirth
  • Loss of muscle tone
  • Decreased estrogen in the blood after menopause
  • Risk factors

Some factors that may be a risk for uterine prolapse:

  • One or more pregnancy and vaginal birth
  • Having a large baby
  • Advanced age
  • Frequent heavy lifting
  • Chronic cough
  • Previous pelvis surgery
  • Frequent straining for bowel movements
  • Having a genetically weak connective tissue
  • Being a white or latino
  • Certain conditions, such as obesity, chronic constipation, and chronic obstructive pulmonary disease, create tension in the muscles and connective tissues in your pelvis, thus may play a role in uterine prolapse.

Complications

Possible complications of uterine prolapse include:

Ulcers: In cases of severe uterine prolapse, the vaginal area may bulge out with the uterus and rub against the underwear. This can lead to ulcers (sores) in the vagina in some cases. In rare cases, ulcers can become infected.

Prolapse of other pelvic organs: If your uterus is prolapsed, other pelvic organs, namely the bladder and rectum may also prolapse. A prolapsed bladder (cystocele), which makes it difficult to urinate and increases the risk of urinary tract infection, creates a protrusion in the anterior wall of the vagina. Weakness of the connective tissue on the rectum can cause a prolapsed rectum (rectocele), which can complicate bowel movements.

Diagnostic Tests

Examinations or tests to diagnose uterine prolapse are as follows:

Pelvis Examination: During this examination, your doctor will ask you to strain as if you are passing a stool. This will help the doctor to assess how much your womb is sagging into the vagina. Your doctor may ask you to contract your pelvic muscles as if you were holding your urine to check their strength.  Your exam can be done while standing or lying down.

Imaging tests such as magnetic resonance imaging (MRI) or ultrasound are generally not needed in uterine prolapse. However, these tests can sometimes be helpful in grading the prolapsus.

Treatment

Whether you have symptoms or not, you probably don’t need treatment if you have mild uterine prolapse that doesn’t bother you. However, your pelvic floor may continue to lose its tone over time and the uterus prolapse can progress to an advanced level. You should go for a follow-up and assess the progression of your prolapse and review the symptoms with your doctor.

Measures that you can take on your own, such as Kegel exercises to tighten your pelvic muscles, can soothe the symptoms of the disease. Reaching a healthy body weight and avoiding heavy lifting helps reduce pressure on the structures that support the pelvis.

Treatment options in cases of advanced uterine prolapse are as follows:

Vaginal Pessary: This tool is placed inside the vagina and keeps the womb in place. The pessaries used for temporary or permanent treatment come in various shapes and sizes. Your doctor will make the necessary measurerements and choose the most suitable pessary for you. You will learn how to remove, clean and replace the pessary. You can remove some pessaries in the evening and replace them in the morning, however some pessaries can stay for a longer time. However, vaginal pessaries have a limited use in advanced uterine prolapse. Pessaries can injure the vaginal tissue and prevent sexual intercourse.

Surgery: Although abdominal intervention is sometimes required to repair the damaged and weakened pelvis floor tissue, your surgeon can operate you vaginally. Repairing your prolapse may include transferring your own tissues from one place to another, or placing synthetic materials into the weakened pelvic floor structures to support your pelvic organs.

Sacrocolpopexy, Hysteropexy, Sacrospinous fixation: Your surgeon may recommend hysterectomy, which means removing your uterus. In some cases, keyhole surgery (Robotic or laparoscopic surgery) may be possible. This type of surgery is done through small abdominal skin incisions, using special surgical instruments and a light camera (laparoscope) that guides the surgeon through the abdomen. Your doctor will recommend the appropriate surgery and surgical approach for you. Each operation has its advantages and disadvantages, and you will need to make a decision with your surgeon.

If you desire conception in the future, you may not be a suitable candidate for uterine prolapse surgery. Because pregnancy and childbirth will create tension on the tissues that support your uterus, reversing the benefits of repair surgery. In addition, the risks of surgery may overshadow the benefits of surgery in patients with major health problems. In such cases, using a pessary may be the best treatment option for you to overcome the unpleasant symptoms.

Lifestyle Changes and Home Remedies

Depending on the severity of your condition, the following measures which you can take on your own may benefit your uterine prolapse:

  • Performing Kegel exercises
  • Avoiding constipation by eating high-fiber foods and drinking plenty of fluid
  • Avoiding straining and heavy lifting
  • Controlling chronic cough
  • Losing weight if you are obese or overweight

Kegel Exercises

Kegel exercises tighten your pelvic floor muscles that support your womb, bladder and intestine. A strong pelvic floor reduces symptoms related to uterine prolapse and provides better support to your organs inside the pelvis.

To do Kegel exercise, follow the steps below:

Tighten your pelvic floor muscles (the muscles you use to hold your urine).

Continue tightening the muscles for 5 seconds and then relax for 5 seconds. If this is hard, hold for 2 seconds at the beginning and relax for 3 seconds.

Keep working until you can tighten the muscles for 10 seconds.

Do this exercise 10 times each time, 3 sets a day.

Kegel exercises are most successful when applied together with a therapist and biofeedback. Biofeedback involves the use of instruments that track if the right muscles are used with the ideal intensity for the appropriate duration.

Once you learn the right method, you can do Kegel exercises cautiously at any time, while sitting on a chair or resting on a sofa.

Prevention

Although uterine prolapse cannot always be prevented, you can reduce your risk if you:

  • Do Kegel exercises regularly: These exercises can strengthen your pelvic floor muscles, especially affected after childbirth.
  • Preventing and treating constipation: Consume plenty of fluids; Eat high-fiber foods, such as fruits, vegetables, beans, and whole-grain cereals.
  • Avoid heavy lifting and use the right method when lifting heavy objects: While lifting something, use your legs instead of your waist and back.
  • Control chronic cough: Do not smoke and seek treatment for chronic cough or bronchitis.
  • Avoid weight gain: Determine your ideal weight and your weight loss strategy if you need it.

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