Uterine Prolapse

Uterine Prolapse: Intro & Risks - Slippery Slope Starters

• Uterine prolapse: Downward displacement of the uterus into or beyond the vaginal canal.
• Key Risk Factors:
  • Parity: Multiparity significantly ↑ risk.
  • Advancing age: Weakening of pelvic support structures.
  • Obesity: BMI > 30 kg/m² ↑ intra-abdominal pressure.
  • Chronic straining: Constipation, chronic cough.
  • Vaginal delivery: Especially instrumental or traumatic.
  • Family history & genetics.
  • Connective tissue disorders.
  • Previous pelvic surgery.

⭐ Vaginal childbirth is the most significant predisposing factor for uterine prolapse development later in life.

Pelvic Supports & Failure: Anatomy's Anchor Adrift

• DeLancey's Levels of Vaginal Support: Crucial for understanding prolapse.
  • Level I (Apical Suspension): Cardinal & Uterosacral ligaments; suspend cervix/upper vagina.
  • Level II (Lateral Attachment): Paravaginal attachments to Arcus Tendineus Fascia Pelvis (ATFP); support mid-vagina.
  • Level III (Distal Fusion): Perineal body, perineal membrane & muscles; support distal vagina/urethra.
• Primary Anatomical Supports:
  • Ligaments: Uterosacral, Cardinal (Mackenrodt's), Pubocervical.
  • Muscles: Levator ani (puborectalis, pubococcygeus, iliococcygeus) - forms pelvic diaphragm.
  • Fascia: Endopelvic fascia (pubocervical & rectovaginal components).
• Pathophysiology of Failure:
  • Direct trauma (childbirth), chronic ↑Intra-Abdominal Pressure (IAP), nerve damage (pudendal), estrogen deficiency, iatrogenic.

⭐ The Uterosacral ligaments (Level I support) are paramount; their laxity is the most common reason for uterine/apical prolapse.

Symptoms & Staging (POP-Q): Grading the Sag

Symptoms:

• Pelvic heaviness, "lump/dragging" sensation
• Urinary: Stress Urinary Incontinence (SUI), urgency, retention
• Bowel: Constipation, splinting
• Sexual: Dyspareunia
• Low backache

POP-Q Staging (Pelvic Organ Prolapse Quantification):

• Objective system; measurements (cm) to hymen (0 point).
• Stage 0: No prolapse (key points typically at -3 cm).
• Stage I: Leading edge > 1 cm above hymen (value < -1 cm).
• Stage II: Leading edge between -1 cm and +1 cm relative to hymen.
• Stage III: Leading edge > 1 cm below hymen, but < (tvl-2) cm.
• Stage IV: Complete eversion (leading edge ≥ (tvl-2) cm).

⭐ The hymen serves as the fixed anatomical reference point (0 cm) for all POP-Q measurements.

Diagnosis & Treatment: Prolapse Repair Plan

• Diagnosis:

  • History: Symptoms (bulge, pressure, voiding/defecatory dysfunction).
  • Examination: Pelvic exam (Sims' speculum, bimanual), assess with Valsalva. POP-Q staging for severity.
  • Investigations: Urine routine/microscopy, Ultrasound (if mass suspected). Urodynamics if significant urinary symptoms.

• Treatment Goals: Alleviate symptoms, restore anatomy & function, improve quality of life.

• Management Options:

  • Conservative (First-line/Mild/Unfit for surgery):
    • Lifestyle: Weight loss, manage constipation/chronic cough.
    • Pelvic Floor Muscle Training (PFMT/Kegel's).
    • Pessaries: Ring, Gellhorn. Regular follow-up for hygiene & erosions.
  • Surgical (Symptomatic/Failed Conservative/Patient Choice):
    • Reconstructive (Preserves vaginal function):
      • Uterus Preserving: Manchester repair, Sacrohysteropexy.
      • With Hysterectomy: Vaginal hysterectomy + pelvic floor repair (e.g., McCall culdoplasty, Sacrospinous Fixation (SSF), Uterosacral Ligament Suspension (USLS)). Abdominal Sacrocolpopexy (gold standard for apical/vault prolapse).
    • Obliterative (Closes vagina; for frail, not sexually active):
      • Colpocleisis (LeFort partial or complete).

⭐ McCall culdoplasty, performed during vaginal hysterectomy, helps prevent post-operative vault prolapse by suspending vaginal apex to uterosacral ligaments.

High‑Yield Points - ⚡ Biggest Takeaways

• Uterine prolapse: Apical compartment descent of uterus/cervix into or beyond the vagina.
• Major risks: Multiparity, advancing age, obesity, chronic ↑intra-abdominal pressure.
• POP-Q system is the standardized method for staging prolapse.
• Common symptoms: Pelvic heaviness, sensation of a vaginal bulge, urinary/bowel dysfunction.
• Conservative management: Pelvic floor muscle exercises (Kegels), vaginal pessaries.
• Surgical options: Vaginal hysterectomy with apical support procedures (e.g., sacrospinous fixation).
• Weakness of Level I support (uterosacral-cardinal ligament complex) is primary defect.