Uterine prolapse
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Uterine prolapse (Latin: descensus uteri) is a disorder of pelvic organ support involving displacement of the uterus toward the vaginal canal due to weakening of supporting structures such as the pelvic floor muscles, fascia, and uterine ligaments. This condition belongs to the group of so‑called pelvic organ support disorders (POP – pelvic organ prolapse) and may coexist with prolapse of the vaginal walls, urinary bladder, or rectum. Uterine prolapse develops gradually, and its severity depends on the degree of damage to the supporting apparatus and on loading factors such as childbirth, age, or chronic increases in intra‑abdominal pressure.
Uterine prolapse – causes
The etiopathogenesis of uterine prolapse is multifactorial and includes both mechanical, hormonal and genetic factors. A key role is played by damage to the pelvic floor structures, which leads to loss of proper support of the organs.
The most important causes include:
- Vaginal deliveries, particularly:
- multiple deliveries,
- instrumental deliveries (forceps, vacuum extractor),
- delivery of large babies,
- Involutional changes related to aging, leading to weakening of connective tissue,
- Estrogen deficiency, especially during menopause, resulting in decreased tissue elasticity and trophic changes,
- Chronic increase in intra-abdominal pressure, e.g. in the course of:
- obesity,
- chronic cough (e.g., COPD),
- constipation,
- physical work requiring lifting,
- Congenital weakness of connective tissue (e.g., collagen disorders),
- Surgical procedures within the pelvis, leading to damage of the ligamentous apparatus.
Contemporary studies also indicate an important role of abnormalities in the structure of type I and III collagen, which lead to decreased mechanical strength of the fascia and ligaments.
Uterine prolapse – stages
The degree of uterine prolapse is most often assessed according to the POP-Q (Pelvic Organ Prolapse Quantification) system, which allows precise anatomical assessment. In clinical practice, a simplified classification into four stages is used:
- Stage I
The uterus descends but remains above the vaginal introitus.
- Stage II
The cervix is at the level of the vaginal vestibule.
- Stage III
The cervix protrudes beyond the vaginal introitus.
- Stage IV (uterine prolapse)
Complete prolapse of the uterus beyond the vulvar cleft.
The clinical significance of the degree of prolapse is important for choosing a treatment strategy – from conservative management to surgical treatment.
Uterine prolapse – symptoms
The clinical presentation of uterine prolapse is varied and depends on the degree of advancement and coexisting disorders of the support of other organs.
The most commonly observed symptoms include:
- A feeling of heaviness or "dragging" in the lower abdomen, worsening when standing,
- A sensation of a foreign body in the vagina,
- Visible bulging in the vagina or vaginal vestibule,
- Pain in the lumbosacral region,
- Urinary disorders, such as:
- difficulty emptying the bladder,
- frequent urination,
- urinary incontinence,
- Defecation disorders, including constipation or a sensation of incomplete evacuation,
- Discomfort or pain during intercourse (dyspareunia).
In the early stages the condition may be minimally symptomatic, which delays diagnosis. In advanced cases the symptoms significantly reduce the patient's quality of life.
Uterine prolapse – when does it require intervention
The decision to initiate treatment depends on the severity of symptoms, the stage of advancement, and the impact of the condition on the patient's daily functioning.
Medical intervention is required in situations in which the following occur:
- Symptoms that significantly reduce quality of life, including pain, discomfort, or limitation of activity,
- Disorders of urinary or bowel function, e.g. urinary retention, recurrent urinary tract infections,
- Advanced stages of prolapse (III–IV),
- Complications, such as:
- mucosal ulcerations,
- infections,
- mechanical tissue damage.
Therapeutic management includes:
- Conservative treatment:
- urogynecological physiotherapy (pelvic floor muscle training),
- use of vaginal pessaries,
- topical estrogen therapy,
- Interventional and surgical treatment:
- pelvic floor reconstruction,
- procedures using meshes (in selected cases),
- hysterectomy in advanced cases.
In clinical practice, supportive methods are also becoming increasingly important, such as procedures from aesthetic and regenerative medicine (e.g., gynecological laser therapy, radiofrequency), which can improve tissue tone and the quality of life of patients in milder stages of the condition.