Uterovaginal Prolapse

Types

• Cystocele — bladder descends into the vagina
• Urethrocele — urethra bulges into the vagina
• Rectocele — rectum protrudes into the vagina
• Enterocele — a loop of small intestine bulges into the vagina
• Uterine prolapse — uterus/cervix descend toward the vaginal introitus:
  • 1st degree — cervix remains in the vagina
  • 2nd degree — cervix protrudes on coughing/straining
  • 3rd degree (procidentia) — uterus lies outside the vagina

Common in women over 50.

Risk factors

Increased parity, higher birth weight, increasing age, chronic cough, obesity.

Presentation

Pelvic/vaginal discomfort, a dragging or bearing-down sensation, a noticed vaginal bulge, low back pain. Ulceration of prolapsed epithelium can cause bleeding or discharge. Bladder/ bowel dysfunction (difficulty emptying, or incontinence — see incontinence-male-and-female.md/urinary-retention.md) and sexual dysfunction may occur.

Examination

Sims speculum, or the posterior blade of a Graves speculum, in a lateral or lithotomy position. Ask the patient to cough/bear down repeatedly; observe the anterior, posterior and lateral vaginal walls and cervical descent.

Investigations

None routinely required.

Management

Correct modifiable risk factors: obesity, constipation, oestrogen deficiency, chronic cough, smoking, asthma.

Pelvic floor exercises — referral to a specialist pelvic floor physiotherapist improves outcomes; needs lifelong continuation; won’t help higher-grade prolapse.

Topical oestrogen cream can help in postmenopausal women. Daily vaginal packing with gauze plus oestrogen cream helps women with ulceration/chafing from severe prolapse.

Vaginal pessaries — appropriately selected and fitted; ring pessaries need changing/ washing at least every 3–6 months.

Surgery — useful for associated sexual, urinary and bowel dysfunction.

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See also womens-health’s female-sexual-dysfunction.md for the associated sexual dysfunction angle.