A female with uterine prolapse will present with the following symptoms:

• Lower backache
• A feeling of heaviness or pressure in the lower pelvis
• Difficulty or pain in performing sexual intercourse
• Bulging out of a mass from the vagina during straining (extreme cases)
• Urinary incontinence
• Recurring lower urinary tract infections
• Vaginal bleeding
• Vaginal ulceration or sores
• Vaginal discharge

Performing any strenuous activity such as straining, squatting, exercising, lifting heavy weights, sitting for a long time or long-term constipation may worsen the symptoms.

Workup consists of a detailed history and physical examination. The physical examination should be thorough and should help in staging the condition.

Laboratory tests

In uncomplicated cases, laboratory tests are generally not required. In complicated cases, such as cases of uterine prolapse along with infection or ulceration, the following tests may be conducted:

• Complete blood count
• Cervical swab and culture
• Urinalysis
• Pregnancy testing
• Pap smear
• Biopsy

Imaging 

• Pelvic Ultrasound: It is the imaging study of choice.
• MRI: It may be conducted to stage the prolapse.

Test results

A physical examination and history are sufficient to form a diagnosis. In complicated cases, the results of laboratory tests and imaging studies may provide further insight in making a definitive diagnosis.

Vaginal hysterectomy

Often, a vaginal hysterectomy is used to correct uterine prolapse [7]. The procedure can be accompanied by a sacrocolpopexy, in which the apex of the vagina is attached to the sacrum [8].

Pessary insertion

A 2013 Cochrane review found some evidence that pessaries are effective in around 60% of women [9].

Post-surgery care

Generally, women should avoid heavy lifting after surgery and avoid sexual intercourse for 6-8 weeks [10]. If the prolapse remains corrected and the patient conceives, an elective cesarean section may be advisable [10]. 

It has been traditionally assumed that if left untreated, uterine prolapse will gradually worsen. There is some evidence, however, that this may not be the case, and that spontaneous remission may happen [6].

With treatment, prognosis is good, but since the defect is primarily due to physiological weakening of muscles and ligaments, relapse may occur. However, it is possible to preserve fertility in younger patients with adequate treatment.

Complications

Complications of uterine prolapse may include exposure or friction of the vaginal epithelial lining leading to vaginal sores and ulceration. Uterine prolapse and its accompanying symptoms such as urinary incontinence may lead to recurrent lower urinary tract infections. Hemorrhage may also occur in some cases. A uterine prolapse due to weakened muscles may become complicated by accompanying prolapse of other pelvic organs, such as the urinary bladder, resulting in a cystocele, or the rectum, resulting in a rectocele.

The primary cause of uterine prolapse is pregnancy. Multiple factors associated with pregnancy such as trauma or complications during labor, malnutrition of the mother or weight of the fetus may result in undue stress on and damage of the muscles and ligaments supporting the uterus. Some of the damaged muscles and ligaments will never fully regain their strength and elasticity [4].

Other causes [5] that may lead to a uterine prolapse include:
lack of estrogen after menopause, old age, conditions that put a strain on the pelvic muscles such as chronic cough and obesity, pelvic tumor and long term constipation.

Incidence

Pelvic organ prolapse affects millions of women; approximately 200,000 inpatient surgical procedures for prolapse are performed annually in the United States [1]. Approximately half of all women olde than 50 years complain of symptomatic prolapse [2].

Age

Chances of developing uterine prolapse is in direct proportion to increase in age. 11% to 19% of women will undergo surgery for pelvic organ prolapse (POP) or incontinence by age 80 to 85 years, and 30% of these women will require an additional pelvic organ prolapse or in continence surgery [3].

Race

Studies reveal that uterine prolapse is much more common in white and Hispanic women. 

Uterine prolapse is due to weakening of uterosacral and other supporting ligaments of the uterus and pelvic floor muscles. The condition can be staged according to severity of the symptoms.

Staging

According to the Pelvic Organ Prolapse Quantification, uterine prolapse can be staged as per the following criteria:

• Stage 0: No prolapse
• Stage 1: Most distal portion of the prolapsed organ is >1 cm above the plane of the hymen
• Stage 2: Most distal portion of the prolapsed organ is less than or equal to 1 cm above or below the plane of the hymen.
• Stage 3: Most distal portion of the prolapsed organ is >1 cm below the plane of the hymen.
• Stage 4: Total eversion of the prolapsed organ. 

Uterine prolapse, or prolapse of any other pelvic organ for that matter, may be prevented by performing regular Kegel exercises and maintaining a healthy life style. Hormone replacement therapy for post-menopausal women may be helpful. Weight should be controlled and a high fibre diet should be implemented. Stool softeners may be used for constipation, if present.

A uterine prolapse is descent or dropping of the uterus through the cervix into the vagina. It is due to weakening of the various muscles and ligaments supporting the uterus, most important of which are the uterosacral ligaments. Others include the round ligament, broad ligament and ovarian ligaments.

Definition

Uterine prolapse is descent of the uterus (womb) into the vagina.

Cause

It is primarily due to weakening of the supporting muscles of the uterus during pregnancy. It may also occur due to normal aging, long term constipation, occupational hazards particularly in old age like sitting or standing for a long time, etc.

Symptoms

Symptoms include backache accompanied with a feeling of pressure in the lower pelvis or vagina. There may be increased vaginal discharge or bleeding. Urinary tract infections may occur and there may be urinary leakage and a constant feeling of a full-bladder.

Treatment

Treatment can be conservative in terms of exercise and lifestyle modifications, or it can be surgical. Treatment is optional and spends upon the severity of the symptoms. Mild cases may not require treatment at all.

Prevention

By performing regular Kegel exercises and taking a high-fibre diet, a uterine prolapse may be prevented. Hormone replacement therapy (HRT) may help. Obese women should reduce weight and maintain a healthy life style. 

1. Jones KA, Shepherd JP, Oliphant SS, et al. Trends in inpatient prolapse procedures in the United States, 1979-2006. Am J Obstet Gynecol 2010;202:501.e1.
2.  Swift SE. The distribution of pelvic organ support in a population of subjects seen for routine gynecologic health care. Am J Obstet Gynecol. Aug 2000;183(2):277-85.
3. Olsen AL, Smith VJ, Bergstrom JO, et el. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501.
4. Tsikouras P, Dafopoulos A, Vrachnis N, Iliodromiti Z, Bouchlariotou S, Pinidis P, et al. Uterine prolapse in pregnancy: risk factors, complications and management. J Matern Fetal Neonatal Med. July 9 2013
5. Lentz GM. Anatomic defects of the abdominal wall and pelvic floor: abdominal and Inguinal hernias, cystocele, urethrocele, enterocele, rectocele, uterine and vaginal prolapse, and rectal incontinence: diagnosis and management. In: Lentz GM, Lobo RA, Gershenson DM, Katz VL, eds. Comprehensive Gynecology. 6th ed. Philadelphia, Pa: Moseby Elsevier, 2012:chap 20.
6. Handa VL, Garrett E, Hendrix S, et al. Progression and remission of pelvic organ prolapse: a longitudinal study of menopausal women. Am J Obstet Gynecol. 2004 Jan;190(1):27-32.
7. Winters JC, Togamai JM, Chermansky CJ. Vaginal and Abdominal Reconstructive Surgery for Pelvic Organ Prolapse. In: Wein AJ, ed. Campbell-Walsh Urology. 10th ed. Philadelphia, Pa: Saunders Elsevier, 2011:chap 72.
8. NICE Interventional Procedure Guidance IPG284: Sacrocolpopexy with hysterectomy using mesh for uterine prolapse repair by the National Institute for Health and Care Excellence. Issued: Jan 2009.
9. Bugge C, Adams EJ, Gopinath D, et al. Pessaries (mechanical devices) for pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013 Feb 28;2:CD004010. doi 10.1002/14651858. CD004010.pub3.
10. Thakar R, Santon S. Management of genital prolapse. BMJ. 2002 May 24;324(7348):1258-62.