Urinary Prolapse - Altius Hospital

What is a prolapse uterus?

The uterus, or womb, is a muscular structure that's held in place by pelvic muscles and ligaments. If these muscles or ligaments stretch or become weak, they're no longer able to support the uterus, causing prolapse. Uterine prolapse occurs when the uterus sags or slips from its normal position and into the vagina, or birth canal.

Uterine prolapse may be incomplete or complete. An incomplete prolapse occurs when the uterus is only partly sagging into the vagina. A complete prolapse describes a situation in which the uterus falls so far down that some tissue rests outside of the vagina.

WHAT ARE THE POSSIBLE Risk factors for uterine prolapse?

The risk of having a prolapsed uterus increases as a woman ages and her estrogen levels decrease. Estrogen is the hormone that helps keep the pelvic muscles strong. Damages to pelvic muscles and tissues during pregnancy and childbirth may also lead to prolapse. Women who've had more than one vaginal birth and postmenopausal women are at the highest risk.

Any activity that puts pressure on the pelvic muscles can increase your risk of a uterine prolapse. Other factors that can increase your risk for the condition include:

Confirmed risk factors

• Increasing age
• Vaginal delivery
• Increasing parity
• Obesity
• Previous hysterectomy

Possible risk factors :

• Obstetric factors:

1. Prolonged second stage of labour.
2. Increased birth weight.
3. Pregnancy itself (as opposed to delivery factors).
4. Use of forceps.
5. Age < 25 years at first delivery.
6. Shape of pelvis.

• Family history of prolapse.
• Constipation.
• Connective tissue disorders
• Occupations involving heavy lifting.

What are the Vaginal/general symptoms?

• Sensation of pressure, fullness or heaviness.
• Sensation of a bulge/protrusion or 'something coming down'.
• Seeing or feeling a bulge/protrusion.
• Difficulty retaining tampons.
• Spotting (in the presence of ulceration of the prolapse).

What are the Urinary symptoms?

• Incontinence.
• Frequency.
• Urgency.
• Feeling of incomplete bladder emptying.
• Weak or prolonged urinary stream.
• The need to reduce the prolapse manually before voiding.
• The need to change position to start or complete voiding.

Is there any Coital difficulty in prolapse?

• Dyspareunia.
• Loss of vaginal sensation.
• Vaginal flatus.
• Loss of arousal.
• Change in body image.

HOW IS IT GRADED?

Uterine prolapse is graded based on level of descent:

• 1st degree: To the upper vagina
• 2nd degree: To the introitus
• 3rd degree: Cervix is outside the introitus
• 4th degree (sometimes referred to as procidentia): Uterus and cervix entirely outside the introitus

Vaginal prolapse may be 2nd or 3rd degree.

What are the Types of prolapse?

Prolapse can occur in the anterior, middle, or posterior compartment of the pelvis.

What is Anterior compartment prolapsed?

• Urethrocele: prolapse of the urethra into the vagina. Frequently associated with urinary stress incontinence; other symptoms are infrequent.
• Cystocele: prolapse of the bladder into the vaginaa large cystocele may cause increased urinary frequency, frequent urinary infections and a pressure sensation or mass at the introitus.
• Cystourethrocele: prolapse of both urethra and bladder.

WHAT ARE THE BLADDER TRAINING EXERCISES?

Bladder training, to delay urination after you get the urge to go. You may start by trying to hold off for 10 minutes every time you feel an urge to urinate. The goal is to lengthen the time between trips to the toilet until you're urinating only every two to four hours.

Double voiding, to help you learn to empty your bladder more completely to avoid overflow incontinence. Double voiding means urinating, then waiting a few minutes and trying again.

Scheduled toilet trips, to urinate every two to four hours rather than waiting for the need to go.

Fluid and diet management, to regain control of your bladder. You may need to cut back on or avoid alcohol, caffeine or acidic foods. Reducing liquid consumption, losing weight or increasing physical activity also can ease the problem.

What is Middle compartment prolapse?

Uterine prolapse: descent of the uterus into the vagina.

• Vaginal vault prolapse: descent of the vaginal vault post-hysterectomy. Often associated with cystocele, rectocele and enterocele.
• Enterocele: herniation of the pouch of Douglas (including small intestine/omentum) into the vagina.

WHAT IS VAGINAL PROLAPSE?

Uterine prolapse is descent of the uterus toward or past the introitus. Vaginal prolapse is descent of the vagina or vaginal cuff after hysterectomy

How is uterine prolapse diagnosed?

Your doctor can diagnose uterine prolapse by evaluating your symptoms and performing a pelvic exam.

Any Conservative methods to treat prolapse?

These measures are particularly helpful for women who:

• Have mild prolapse.
• Want to have further pregnancies.
• Are frail or elderly.
• Have a high anaesthetic risk.
• Do not wish to have surgery.

What are the Conservative measures available?

Watchful waiting. If a women reports little in the way of symptoms this is probably appropriate. Treatment may be needed if symptoms become troublesome or if complications develop.

Lifestyle modification: including treatment of cough, smoking cessation, constipation and overweight and obesity. However, even though the association of prolapse with these lifestyle factors has been demonstrated, the role of lifestyle modification as a prevention or treatment of prolapse is not supported by evidence.

Pelvic floor muscle exercises.

Vaginal oestrogen creams.

Oestrogen creams before surgery may reduce the incidence of postoperative cystitis

When to consider Surgery?

• Failure of conservative treatment.
• Presence of voiding problems or obstructed defecation.
• Recurrence of prolapse after surgery.
• Ulceration.
• Irreducible prolapse.
• The woman prefers surgical treatment.

WHAT ARE THE SURGICAL OPTIONS?

1. Surgical treatments include uterine hysterectomy( hysterectomy with surgical repair of the pelvic support structures (colporrhaphy) OR
2. suspension ( (suturing of the upper vagina to a stable structure nearby).
3. Surgical options include a vaginal approach (for sacrospinous ligament suspension or sacrospinous colpopexy) and an abdominal/laparoscopic approach (sacrocolpopexy).

Laparoscopic repair of prolapse has less risk of perioperative morbidity than laparotomy.

Using mesh may lower the risk of prolapse recurrence after a vaginal repair, but complications may occur more frequently. Patients should be advised that all mesh may not be removed completely so that they can make an informed decision.

How can I prevent uterine prolapse?

1. Uterine prolapse may not be preventable in every situation. However, you can do to things to reduce your risk, including:
2. Good intrapartum care, including avoiding unnecessary instrumental trauma and prolonged labour.

• Hormone replacement therapy, although its role in preventing prolapse is uncertain.
• Pelvic floor exercises may prevent prolapse occurring secondary to pelvic floor laxity and are strongly advised before and after childbirth.
• Smoking cessation will reduce chronic cough (and therefore intra-abdominal pressure).
• Weight loss if overweight or obese.
• Treatment of constipation throughout life.
• getting regular physical exercise
• practicing Kegel exercises

What is kegels exercise?

Kegel exercises, also called pelvic floor exercises, help strengthen the muscles that support the bladder, uterus, and bowels. By strengthening these muscles, you can reduce or prevent leakage problems.

How is it done?

Tighten your pelvic floor muscles, hold the contraction for five seconds, and then relax for five seconds. Try it four or five times in a row. Work up to keeping the muscles contracted for 10 seconds at a time, relaxing for 10 seconds between contractions.Do it 3-4 times a day.

• Is laparoscopy better option?

Laparoscopic sacrocervicopexy is an effective option for women with pelvic organ prolapse who desire uterine preservation. Laparoscopic surgery gives the added benefit of shorter hospital stay,better cosmesis,lesser postoperative pain,short recovery period .

• Will the sexual functions be hampered after this surgery?

not necessarily.

• what will be the time period to go back to work ?

2-3 days.

• dietary restrictions if any?

to have a balanced diet

• any form of exercises to be followed post-op?

Any form of physical activity say yoga,meditation,walking ,sport to keep urself fit n fine.

Will there be weight gain later?

No surgery does not make you put on weight.might be the restriction of physical inactivity self imposed can lead to weight gain.

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