Uterine or Vaginal Prolapse
Except for a rare congenital form of the condition, genital prolapse occurs most commonly after multiple vaginal births, and it is more common in women of higher parity. We have also seen genital prolapse in women who have undergone hemipelvectomy or partial sacrectomy.
As is the case with any other hernia, uterine prolapse is initiated by weakening of supporting fascial structures above the pelvic diaphragm, including the uterosacral and pubocervical ligaments. Uterine prolapse can be associated with prolapse of the anterior or posterior vaginal wall.
Vaginal prolapse, however, can occur in the absence of uterine prolapse.
Early symptoms of uterine or vaginal prolapse may include lowerback pain, frequent need to urinate, and, sometimes, constipation associated with a large rectocele. As with other hernias, uterine prolapse is aggravated by conditions that increase intra-abdominal pressure, such as chronic pulmonary disease (frequently seen in smokers or patients with a history of chronic obstructive airway disease) and obesity.
In most patients with uterine prolapse, the degree of prolapse is not severe enough to compromise bladder or bowel function. Even in more severe cases, the use of a pessary, a prosthesis inserted into the vagina to provide pelvic support, may be sufficient to deal with the problem while therapy for breast cancer is ongoing. Vaginal pessaries come in different shapes and sizes. The most common types include Hodge’s pessary, the ring pessary, and the cube pessary. In our experience, a cube pessary is efficient and relatively easy for patients to use with appropriate instruction. In women who also complain of leaking urine when coughing and sneezing, the ring pessary with the incontinence knob (a ridge on one side of the ring that sits behind the pubic symphysis) is often effective.
When prolapse contributes to difficulty emptying the bladder or rectum, a surgical approach may be needed. The goal of the surgical approach is to correct the fascial defect, restore anal sphincter function, and remove redundant vaginal mucosa. If an enterocele is detected at surgery, the peritoneal sac must be entered, and the defect must be closed. Patients in whom the uterus prolapses partially or completely outside of the introitus, either spontaneously or with minimal increases in intra-abdominal pressure, usually require a suspensory operation that attaches the vaginal vault to the sacrospinous ligaments after removal of the uterus. In frail or elderly patients who no longer wish to be sexually active, a colpocleisis can be performed. This is a short surgical procedure that essentially closes the vagina on the inside.
Most patients do not experience incapacitating symptoms from vaginal prolapse. Even patients who have the worst degree of prolapse may benefit from the use of a vaginal pessary until breast cancer treatment has been completed and an adequate follow-up period has elapsed. Nonsurgical or conservative measures should be utilized if the patient has other significant medical problems that would increase the risk of surgery or if the patient has progressive cancer or a significant risk of cancer progression. In some patients, the use of pessaries may have to be definitive.
Elizabeth R. Keeler, Pedro T. Ramirez, and Ralph S. Freedman
Committee on Gynecological Practice, the American College of Obstetricians and Gynecologists. Obstet Gynecol 2007