Uterine prolapse is a clinical condition characterized by protrusion of the uterus through the vagina. It can occur due a number of different causes, and treatment options are a fair few. In this article, we shall take a brief look at the treatment of prolapse of the uterus, discussing both the medical and surgical management of this rather distressing condition.
Uterine prolapse can be mild, moderate or severe, depending on the degree of protrusion and the symptoms that patients experience as a result. Medical treatment options also vary according to this. in most cases of mild uterine prolapse, patients do not experience any symptoms, and therefore are either unaware of the condition or do not require any specific treatment.
However, when patients do become symptomatic, treatment options are put forth. In early stages, patients are managed conservatively, which involves the use of pessaries and performing pelvic exercises.
Pelvic exercises are often discussed with the patient by a physical therapist or by the treating physician, and involve the use of Kegel exercises. Kegel exercises are a series of different exercises that help strengthen the pelvic floor muscles that are responsible for supporting the uterus. The videos below briefly describe the exercises that can be performed -
But conservative treatment just does not end with pelvic floor exercises. These days, pessaries are available that can be easily fitted inside the cervix, and this can help support the uterus. However, pessaries are not a cure in any way, and may not necessarily help the patient tremendously. There are different types of pessaries that are available on the market, and different types suit different patients.
Vaginal pessaries must be avoided in patients who are suffering from pelvic inflammatory conditions (infections) such as vaginitis. In some cases, patients will be offered pessaries along with application of estrogen cream, particularly due to the link between low estrogen levels and prolapse of the uterus.
Below is a video that explains how pessaries can help manage prolapse in general.
Surgical treatment of uterine prolapse
Surgery remains one of the best treatment options for management of prolapse of the uterus. It is offered to patients in who attempts at managing uterine prolapse with pelvic floor exercises and pessaries have failed.
There are different approaches to the treatment of uterine prolapse surgically. Some surgeons prefer to operate through the abdomen, while some prefer to use a pelvic approach i.e through the vagina.
The main benefits of a surgical approach include better repair and lesser recurrence rate. The surgery is fairly straightforward, and in the hands of an experienced surgeon can produce rather remarkable results.
In the abdominal approach, treatment is aimed at securing the position of the uterus within the pelvic cavity against a strong structure in the pelvis called the sacral promontory. The surgery is performed in a way that while the uterus is firmly fixed, the attachment is such that it moves naturally when there is a rise in intra-abdominal pressure.
The uterus is fixed using simple grafts that are harvested from tissues within the body (fascia), or using synthetic grafts, depending on the choice of the physician and the patient. Studies have shown that the use of the synthetic mesh is better than using the natural tissues within the body as a graft. Unfortunately, the procedure is characterized by the development of certain complications, but not all patients develop this.
Complications can include infection of the mesh graft and erosion of the mesh. Steps are taken to prevent this from happening, and for preventing bowels from tangling in between the mesh graft and the uterus. Other complications include bleeding from a nearby artery, which can be a serious problem as immediate steps need to be taken to control this.
Below is a short video that explains the procedure in a bit more detail.
The other approach that is used is called the vaginal approach. In this procedure, the prolapsed uterus is accessed through the vagina, and the ligaments that support the uterus are reinforced. The procedure bears the advantage of having a shorter time for recovery following surgery.
The procedure is fairly straightforward, and unlike the abdominal approach, no mesh grafts are required. The uterine supportive ligaments are accessed, and if they still possess their strength, are shortened so as to elevate the uterus to its normal position to maintain it there. Different ligaments may be accessed to help reinforce this support that the uterus requires to stay in position within the pelvic cavity.
On an average, the vaginal procedure has a lower complication rate when compared to the abdominal approach. Complications that patients may experience include bleeding (though not as serious as the abdominal approach), pelvic infection, injury to nearby structures such as the ureter and the bowels and infection of the bone.
The serious complication that can occur is injury to the nerve fibres that lie close to the site of the operation. This depends on which ligaments are tightened, and do not occur in all cases.
In some cases of uterine prolapse, especially severe ones where patients are experiencing extremely distressing symptoms, patients are advised to undergo a total hysterectomy as chances of recurrence with the above mentioned approaches can be high.
Long term management
The long term management of uterine prolapse is based around education and exercises. Conservative treatment in mild cases has good outcomes, and not many go on to require surgical treatment. However, in those that undergo surgery, it is essential that exercises are performed to keep the muscle strength of the pelvic floor intact.
Prolapse of the uterus can be a distressing and worrying condition that can have a significant impact on the quality of life of patients. Treatment options vary between patients, and are dependent on the degree of prolapse and the symptoms. Mild cases often settle well with conservative treatment, while more severe cases require surgical intervention. Recurrences can occur, and ensuring exercises are performed regularly is essential to maintain the strength of the pelvic floor.
Further Reading About Treatment of Uterine Prolapse