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Uterine prolapse is a form of pelvic organ prolapse in which the uterus and a portion of the upper vagina protrude into the vaginal canal and, in severe cases, through the opening of the vagina. It is most often caused by injury or damage to structures that hold the uterus in place within the pelvic cavity. Symptoms may include vaginal fullness, pain with sexual intercourse, difficulty urinating, and urinary incontinence. (2015). 9780323378222, Elsevier Health Sciences. ISBN 9780323378222 Risk factors include older age, pregnancy, Childbirth, obesity, chronic constipation, and chronic cough. Prevalence, based on physical exam alone, is estimated to be approximately 14%.
Diagnosis is based on a symptom history and physical examination, including pelvic examination. Preventive efforts include managing medical risk factors, such as chronic lung conditions, smoking cessation, and maintaining a healthy weight. Management of mild cases of uterine prolapse include pelvic floor therapy and pessaries. More severe cases may require surgical intervention - options include uterine suspension (hysteropexy); Hysterectomy (partial or supra-cervical hysterectomy) with surgical fixation of the vaginal vault to a nearby pelvic structure; or permanent surgical closure of the vagina (colpocleisis). Outcomes following management are generally positive with reported improvement in quality of life.
Most women who experience pelvic organ prolapse do not have symptoms. When symptoms are present, the most common and most specific symptoms for uterine prolapse—and organ prolapse in general—into the vagina are bulge symptoms, such as pelvic pressure, vaginal fullness, or a palpable vaginal bulge, and these symptoms are often more common and more severe if the prolapse reaches the vaginal hymen. Urinary symptoms, such as uncontrollable loss of urine or difficulty urinating, may also be present. Complete uterine prolapse in which the uterus protrudes through the vaginal hymen is known as procidentia. (2025). 9780323388528, Elsevier. ISBN 9780323388528 In the absence of treatment, symptoms of procidentia may include purulent vaginal discharge, ulceration, and bleeding. Complications of procidentia include urinary obstruction.
People may also report sexual dysfunction symptoms, such as pain with sexual intercourse and decreased libido. There is conflicting data concerning the effect of pelvic organ prolapse on sexual function. The severity of the symptoms associated with prolapse seems to have a negative effect on sexual activity and reported satisfaction. Mild or asymptomatic prolapse does not seem to be associated with sexual complaints while more symptomatic prolapse is associated with more negative sexual symptoms.
Additionally, the pelvic musculature and connective tissues are estrogen sensitive and respond to changes in estrogen level. Estrogen deficiency, which can occur during menopause, can affect the production of collagen that is needed to build connective tissue that makes up ligaments and fascia, which can contribute to uterine prolapse. This is also a reason that connective tissue disorders can predispose certain people to uterine prolapse.
If a hysterectomy is performed, a vaginal vault suspension (known as colpopexy), in which the upper portion of the vagina is surgically connected to another structure in the pelvis, is commonly performed to prevent vaginal vault prolapse in the future. Forms of colpopexy include sacrocolpopexy, in which the vaginal vault is attached to the sacrum using a surgical mesh; sacrospinous ligament fixation, in which the upper vagina is attached to the sacrospinous ligaments using sutures; and uterosacral ligament vaginal vault suspension, in which the upper vagina is attached to the uterosacral ligaments using sutures. Colpopexy can be performed with or without a hysterectomy. If performed without a hysterectomy, the procedure is known as a hysteropexy. Hysteropexy procedures include sacrohysteropexy and sacrospinous hysteropexy.
In severe cases of prolapse where the person no longer desires vaginal intercourse and has contraindications to more invasive surgery, vaginal closure procedures may be offered. These include LeFort partial colpocleisis and complete colpocleisis, in which the vagina is sutured closed.
Also taken into consideration prior to surgery is use of native, or one's own, tissue versus a synthetic mesh. Generally, mesh may be considered in instances where the connective tissue is weak or absent, if there is an empty space at the surgical site that needs to be bridged, or if there is a high risk of prolapse recurrence. Synthetic mesh is indicated and used for sacrocolpopexy and sacrohysteropexy procedures. However, the use of synthetic mesh transvaginally, or within the vaginal tissue itself, is not indicated and is not routinely used for apical vaginal or uterine prolapse due to a lack of safety and effectiveness data, higher rate of mesh exposure compared with native tissue repair, and lack of data regarding long-term outcomes and complication rates.
It can be difficult to determine success when discussing the outcomes of surgical intervention for pelvic organ prolapse due to multiple factors that can define success, such as anatomic success versus patient-reported outcome measures. Improvement of symptoms after surgery appears to be more of a measure of success for patients themselves, than does anatomic success alone.
The rate of pelvic organ prolapse recurrence following surgery depends on several factors, the most significant being patient age (patients younger than 60 years have higher likelihood of recurrence), POP-Q stage (POP-Q greater than 3 has higher likelihood of recurrence), surgeon's experience performing the procedure, and prior history of pelvic surgery. Additionally, the surgical approach, for instance vaginal versus abdominal, also affects recurrence rate. The rates of reoperation following pelvic organ prolapse surgery ranges from 3.4% to 9.7%. Reoperation rates appear to be higher with transvaginal mesh repair compared to other procedures, due in part to complications such as mesh exposure.
Throughout Western history, advancements in the management of uterine prolapse have been hampered by a poor understanding of female pelvic anatomy. During the Hippocratic era, approximately 460 B.C.E., it was thought that the uterus was akin to an animal. Therefore, common treatments included fumigation, placing a foul-smelling object near the uterus to convince it to move into the vagina; the use of topical astringents, such as vinegar; and succussion, in which a woman was tied upside-down and shaken until the prolapse reduced.
During the first century C.E., the Greek physician Soranus would disagree with many of these practices and recommended the use of wool, dipped in vinegar or wine and inserted into the vagina, to lift the uterus back into place. He would also go on to recommend surgical removal of gangrenous portions of a prolapsed uterus. However, these ideas did not become commonly accepted practices during that era, and the Middle Ages brought about a return to previous beliefs and practices for uterine prolapse. In 1603, for instance, it was recommended that burning the prolapsed uterus with a hot iron would frighten it back into the vagina. Towards the end of the 16th century, pessaries became more common in the management of uterine prolapse, due in part to advances in anatomic knowledge of the female genitourinary tract earlier in the century. Pessaries were usually made out of wax, metal, glass, or wood. Charles Goodyear's invention of Vulcanization in the mid-1800s made it possible to produce pessaries that would not decompose. However, even into the 1800s, alternative practices were still used, such as the use of sea-water douches, postural exercises, and leeching.
Although the use of surgery in the treatment of uterine prolapse had been described previously, the 19th century saw advances in surgical techniques. During the mid to late 1800s, surgical attempts to manage uterine prolapse included narrowing the vaginal vault, suturing the perineum, and amputating the cervix. In 1877, LeFort described the process of a partial colpocleisis. In 1861, Choppin in New Orleans reported the first instance in which vaginal hysterectomy was performed for uterine prolapse. Prior to that, vaginal hysterectomies were mainly performed for malignancies.
Following Alwin Mackenrodt's 1895 publication of a comprehensive description of the female pelvic floor connective tissue, Fothergill began working on the Manchester-Fothergill surgery with the belief that the cardinal and uterosacral ligaments were key support structures for the uterus. In 1907, Josef Haban and Julius Tandler theorized that the levator ani muscles were also very important for uterine support. Combined with a better understanding of female pelvic floor connective tissue, these ideas would go on to influence surgical approaches for the treatment of uterine prolapse.
By the early 20th century, different techniques for vaginal hysterectomies had been described and performed. As a result, post-hysterectomy vaginal vault prolapse became more common and a growing concern for some surgeons, and new techniques to correct this complication were attempted. In 1957, Arthure and Savage of London's Charing Cross Hospital, suspecting that uterine prolapse could not be cured with hysterectomy alone, published their surgical technique of sacral hysteropexy. Their technique is still used in modern practice with the addition of a graft.
Since 2008, a number of class action have been filed and settled against several manufacturers of transvaginal mesh after people reported complications following surgery.
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