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Definition Uterine prolapse

Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken, providing inadequate support for the uterus. The uterus then descends into the vaginal canal. Uterine prolapse often affects postmenopausal women who've had one or more vaginal deliveries. Damage to supportive tissues during pregnancy and childbirth, effects of gravity, loss of estrogen, and repeated straining over the years all can weaken your pelvic floor and lead to uterine prolapse. If you have mild uterine prolapse, treatment usually isn't needed. But if uterine prolapse makes you uncomfortable or disrupts your normal life, you might benefit from treatment. Options include using a supportive device (pessary) inserted into your vagina or having surgery to repair the prolapse. Symptoms

Uterine prolapse varies in severity. You may have mild uterine prolapse and experience no signs or symptoms. Or you could have moderate to severe uterine prolapse. If that's the case, you may experience the following:

Sensation of heaviness or pulling in your pelvis Tissue protruding from your vagina Urinary difficulties, such as urine leakage or urine retention Trouble having a bowel movement Low back pain Feeling as if you're sitting on a small ball or as if something is falling out of your vagina Sexual concerns, such as sensing looseness in the tone of your vaginal tissue Symptoms that are less bothersome in the morning and worsen as the day goes on

When to see a doctor Uterine prolapse doesn't require treatment unless it's severe. If your signs and symptoms

become bothersome and disrupt your normal activities, make an appointment with your doctor to discuss your options. Causes Pregnancy and trauma incurred during childbirth, particularly with large babies or after a difficult labor and delivery, are the main causes of muscle weakness and stretching of supporting tissues leading to uterine prolapse. Loss of muscle tone associated with aging and reduced amounts of circulating estrogen after menopause also may contribute to uterine prolapse. In rare circumstances, uterine prolapse may be caused by a tumor in the pelvic cavity. Genetics also may play a role in strength of supporting tissues. Women of Northern European descent have a higher incidence of uterine prolapse than do women of Asian and African descent. Risk factors Certain factors may increase your risk of uterine prolapse:

One or more pregnancies and vaginal births Giving birth to a large baby Increasing age Frequent heavy lifting Chronic coughing Frequent straining during bowel movements Genetic predisposition to weakness in connective tissue

Some conditions, such as obesity, chronic constipation and chronic obstructive pulmonary disorder (COPD), can place a strain on the muscles and connective tissue in your pelvis and may play a role in the development of uterine prolapse. Complications Possible complications of uterine prolapse include:

Ulcers. In severe cases of uterine prolapse, part of the vaginal lining may be displaced by the fallen uterus and protrude outside your body, rubbing on underwear. The friction may lead to vaginal sores (ulcers). In rare cases, the sores could become infected. Prolapse of other pelvic organs. If you experience uterine prolapse, you might also have prolapse of other pelvic organs, including your bladder and rectum. A prolapsed bladder (cystocele) bulges into the front part of your vagina, which can lead to difficulty in urinating and increased risk of urinary tract infections. Weakness of connective tissue overlying the rectum may result in a prolapsed rectum (rectocele), which may lead to difficulty having bowel movements.

Preparing for your appointment To evaluate pelvic organ prolapse, your first appointment may be with your primary care provider. However, in some cases when you call to set up an appointment, you may be referred immediately to a doctor who specializes in conditions affecting the female reproductive tract (gynecologist). Here's some information to help you prepare for your appointment and what to expect from your doctor. What you can do

Write down any symptoms you've had, and for how long. Make a list of your key medical information, including any other conditions for which you're being treated and the names of any medications, vitamins or supplements you're taking. Take a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot. Write down questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.

For uterine prolapse, some basic questions to ask your doctor include:

What is the most likely cause of my symptoms? Are there any other possible causes? Do I need any tests to confirm the diagnosis? What are the goals of treatment in my case? What treatment approach do you recommend? Am I at risk of complications from this condition? What is the risk that this problem will recur in the future? Do I need to follow any restrictions? Are there any self-care steps I can take? Should I see a specialist?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment if you don't understand something. What to expect from your doctor Your doctor is likely to ask you a number of questions, such as:

What symptoms are you experiencing? When did you first notice these symptoms? Have your symptoms gotten worse over time?

Do your symptoms include pain? If yes, how severe is the pain? Does anything in particular trigger your symptoms, such as coughing or heavy lifting? Do your signs and symptoms include urine leakage (urinary incontinence)? Have you had a chronic or severe cough? Does your work or daily activities involve heavy lifting? Do you strain during bowel movements? Are you currently being treated or have you recently been treated for any other medical conditions? What medications are you taking, including over-the-counter and prescription drugs as well as vitamins and supplements? Do any of your first-degree relatives such as a parent or sibling have a history of uterine prolapse or any other pelvic problems? How many children have you delivered? Were your deliveries vaginal or cesarean? Do you plan to have children in the future? Do you have any other concerns?

Tests and diagnosis Tests or exams to diagnose uterine prolapse include:

Pelvic exam. Your doctor will perform a complete pelvic exam to check for signs of uterine prolapse. You may be examined while lying down and while standing up. Your doctor may ask you to bear down as if having a bowel movement to see how much that affects the degree of prolapse. To check the strength of your pelvic muscles, you may also be instructed to contract them, as if you are stopping the stream of urine. Questionnaire. You may fill out a form that helps your doctor assess your degree of prolapse and how much it affects your quality of life. Information gathered also helps guide treatment decisions. Imaging tests. Imaging tests aren't generally needed for uterine prolapse, but they're sometimes helpful in assessing the degree of prolapse. Your doctor may recommend an ultrasound or magnetic resonance imaging (MRI) to further evaluate your condition.

Treatments and drugs Losing weight, stopping smoking and getting proper treatment for contributing medical problems, such as lung disease with coughing, may slow the progression of uterine prolapse. If you have very mild uterine prolapse, either without symptoms or with symptoms that aren't terribly bothersome, no treatment is necessary. However, your pelvic floor may continue to lose tone, making the uterine prolapse more severe. Lifestyle changes Lifestyle changes may be the first step to ease symptoms of uterine prolapse:

Achieve and maintain a healthy weight, to minimize the effects of being overweight on supportive pelvic structures. Perform Kegel exercises, to strengthen pelvic floor muscles. Avoid heavy lifting and straining, to reduce abdominal pressure on supportive pelvic structures.

Vaginal pessary A vaginal pessary fits inside the vagina and is designed to hold the uterus in place. The pessary can be a temporary or permanent form of treatment. Vaginal pessaries come in many shapes and sizes, so your doctor will measure and fit you for a device. Once the pessary is in place, your doctor may have you walk, sit, squat and bear down to make sure that the pessary fits you correctly, doesn't become dislodged and feels reasonably comfortable. You may be asked to return a few days after insertion of the pessary to check that it's still in the correct position. You may be advised to remove the device and clean it with soap and water frequently. Your doctor will show you how to remove and reinsert the pessary. You may be able to leave the pessary out overnight and reinsert it each day to use only during waking hours. There are some drawbacks to these devices. A vaginal pessary may be of little use for a woman with severe uterine prolapse. Additionally, a vaginal pessary can irritate vaginal tissues, possibly to the point of causing sores or ulcerations. Women with vaginal pessaries that aren't removed frequently for cleaning may report a foul-smelling discharge. Pessaries may interfere with sexual intercourse. Surgery to repair uterine prolapse If lifestyle changes fail to provide relief from symptoms of uterine prolapse, or if you'd prefer not to use a pessary, surgical repair is an option. Surgical repair of uterine prolapse usually requires vaginal hysterectomy to remove your uterus and excess vaginal tissue. In some cases, surgical repair may be possible through a graft of your own tissue, donor tissue or some synthetic material onto weakened pelvic floor structures to support your pelvic organs. Doctors generally prefer to perform uterine prolapse repair vaginally because vaginal procedures are associated with less pain after surgery, faster healing and a better cosmetic result. However, vaginal surgery may not provide as lasting a fix as abdominal surgery. And if you don't have your uterus removed during surgery, prolapse can recur. Laparoscopic techniques using smaller abdominal incisions, a lighted camera-type device (laparoscope) to guide the surgeon and specialized surgical instruments offer a minimally invasive approach to abdominal surgery. You might not be a good candidate for surgery to repair uterine prolapse if you plan to have more children. Pregnancy and delivery of a baby put strain on the supportive tissues of the uterus and can undo the benefits of surgical repair. Also, for women with major medical problems, anesthesia for surgery might pose too great a risk. Pessary use may be your best treatment choice for bothersome symptoms in these instances.

Prevention Uterine prolapse may not be something you can prevent. However, you may be able to decrease your risk of uterine prolapse if you:

Maintain a healthy weight. By keeping or getting your weight under control, you may decrease your risk of uterine prolapse. Practice Kegel exercises. Because pregnancy and childbirth can weaken pelvic floor muscles and connective tissue, your doctor may recommend Kegel exercises special exercises in which you repeatedly squeeze and relax the muscles of your pelvic floor during pregnancy and afterward. To perform these exercises, tighten your pelvic muscles as if you're stopping your stream of urine. Hold for a count of five, relax and repeat. Do these exercises several times a day. Control coughing. Treat a chronic cough or bronchitis, and don't smoke.

References DS00700 April 9, 2010 1998-2012 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "EmbodyHealth," "Enhance your life," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. Uterine prolapse

Normally, supporting ligaments and other connective tissues hold your uterus in place inside your pelvic cavity. Weakening of these supportive structures allows the uterus to slip down into

the vagina. As a result, the vagina also is pulled down and may turn inside out. Doctors refer to this downward movement of the uterus as uterine prolapse. IM01785 1998-2012 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "EmbodyHealth," "Enhance your life," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research.