Uterine prolapse

Reviewed by Dr Philip Owen, consultant gynaecologist and obstetrician

What is uterine prolapse?

A combination of muscles and ligaments in the pelvis called the pelvic floor support the uterus and vagina, to keep them in their correct position inside the pelvis.

Giving birth as well as the normal ageing process can weaken the pelvic floor and this can result in a prolapse.

Prolapse of the uterus and vagina becomes more common as women get older and is not often seen before the menopause.

A woman's prolapse is described according to the part or parts of the uterus and vagina that are involved. If the front wall of the vagina (below the bladder) is prolapsing it is called a cystocoele (pronounced sisto-seal).

If the back wall of the vagina is involved (in front of the bowel) it is called a rectocoele (pronounced recto-seal).

If the cervix is prolapsing all the way out beyond the entrance of the vagina (introitus) it is called a proccidentia (pronounced pro-sid-enshier).

Sometimes a woman will only have one part of the vagina involved in her prolapse or it may be a combination of the vagina and the uterus.

What kind of problems can a uterine prolapse cause?

Many women with a prolapse do not suffer any symptoms and only discover they have a prolapse when they are examined internally for some reason.

However, most women do have symptoms, the most common being a sensation of 'something coming down below'.

Occasionally, a rectocoele is associated with difficulty opening the bowels. A cystocoele may be associated with leaking of urine when coughing or laughing (stress urinary incontinence).

A prolapse may also cause difficulties with sexual intercourse.

What is the treatment for a uterine prolapse?

The best option is to prevent the prolapse in the first place. Performing pelvic floor exercises on a daily basis to strengthen the muscles of the pelvic floor is recommended. These can be done anywhere and at any time by simply tightening the pelvic floor muscles, as if trying to stop the urine flow.

A smoker's cough is prone to make a woman more likely to develop a prolapse, as is being overweight.

Once the prolapse is established, it is much more difficult to control symptoms with exercises. A physiotherapist will have the specialist knowledge and equipment to perform techniques aimed at stimulating and strengthening the pelvic floor muscles, but often a ring pessary or surgery will become necessary.

Elderly women or those who don't want to or are unfit to undergo surgical repair may be content to have a ring pessary - a ring of celluloid or vinyl - inserted. It will keep the uterus and the bladder in place without them being able to feel it. The ring is usually changed or removed and washed and replaced every four to six months.

How is surgical repair carried out?

Surgical repair is most commonly performed through the vagina. The type of repair is determined by the type of prolapse present, but the idea is that the weakened muscles of the pelvic floor are pulled together with stitches to make the pelvic floor stronger. A hysterectomy is sometimes necessary, although removing only the cervix is often an option.

Before the repair a woman should aim to lose weight if she is overweight, and stop smoking if she smokes.

After the repair, a woman will usually remain in hospital for three to five days. Recovery is fairly rapid afterwards.

Repair operations are usually very successful in getting rid of the sensation of 'something coming down below', but other symptoms that might have been blamed on the prolapse, such as tiredness or backache, are less likely to improve. If there was incontinence of urine then around two thirds of women will have complete control or be much improved after a prolapse repair involving the front wall of the vagina near the neck of the bladder.

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