The uterus is held in place by ligaments attached to the cervix and by the pelvic floor muscles. When this support weakens, the uterus drops into the vagina; in advanced cases it can come out of the vaginal opening. Many women have prolapse in more than one area at the same time. In women who have had their uterus removed, the top of the vagina can drop in the same way; this is called vaginal vault prolapse.
Causes and symptoms
The main cause is pregnancy and vaginal birth. Menopause, aging, excess weight, long-term constipation, a persistent cough and frequent heavy lifting also contribute to prolapse. Mild prolapse often causes no complaints. When there are symptoms, they may include:
- A feeling of heaviness, fullness or dragging in the vagina, and lower back pain
- A bulge that can be felt in the vagina or that comes out of the vaginal opening
- Difficulty emptying the bladder or bowel, frequent urination and leakage of urine
- Discomfort during intercourse
Tissue that comes out of the vagina can develop a sore (ulcer) and bleed.
Assessment
Complaints related to urinary, bowel and sexual function, the wish for pregnancy and general health are asked about. During the examination, the degree of prolapse is assessed while straining and, if needed, standing; the front, middle and back compartments of the vagina are examined separately and can be recorded with the POP-Q system. Care is taken to rule out a pelvic mass or another condition. When discussing whether to preserve the uterus, situations such as abnormal uterine bleeding or a family history of uterine or cervical cancer are taken into account. If surgery for incontinence is also planned, urodynamic testing is performed before the operation.
Non-surgical options
Prolapse that causes no complaints may not need treatment. If there are complaints, losing weight if needed, reducing heavy lifting and preventing constipation are recommended; pelvic floor muscle exercises (Kegel exercises) supervised by a specialist and, if there is vaginal dryness related to menopause, vaginal estrogen are considered.
A pessary is a device, usually made of silicone, that is placed in the vagina to support the uterus and the vaginal walls. There are different types and sizes, such as ring, cube and Gellhorn pessaries; more than one fitting may be needed to find a suitable pessary. It is an option for people who want to delay or avoid surgery, those who have not completed their family and those at high risk from surgery. Some women can remove, clean and reinsert a ring pessary themselves; a cube pessary is removed and cleaned every day. The pessary is removed and cleaned and the vagina checked at regular intervals; removing it at least once every six months is recommended to prevent serious complications. Discharge, sores and bleeding in the vaginal wall, the pessary falling out and difficulty removing it are possible problems. After menopause, vaginal estrogen may be recommended to reduce the risk of sores in the vaginal wall.
Surgical options
Surgery is discussed for people whose complaints have not improved with non-surgical treatment or who do not want it. The choice depends on the wish to preserve the uterus, pregnancy plans, sexual life, any accompanying prolapse, previous surgery and general health. Evidence on the long-term results of these operations is limited, and it has not been clearly shown that any one of the operations recommended for uterine prolapse is better than the others.
- Vaginal hysterectomy: the uterus is removed through the vagina; if needed, the top of the vagina is supported by attaching it with stitches to a ligament at the back of the pelvis (the sacrospinous ligament). The methods and risks of hysterectomy are described on the Laparoscopic (Keyhole) and Open Surgery page.
- Sacrospinous hysteropexy: the uterus is preserved; through an incision in the vagina, the cervix is attached with stitches to the sacrospinous ligament.
- Manchester repair: the uterus is preserved; the cervix is shortened and the uterus is supported in place with stitches. It is not recommended for people who may want a pregnancy in the future.
- Sacrohysteropexy: the uterus is preserved; through the abdomen, by open or laparoscopic surgery, synthetic mesh attached to the uterus is fixed to the bone at the base of the spine (sacrum). The mesh is permanent.
- For vaginal vault prolapse: the top of the vagina can be attached with stitches to the sacrospinous ligament through the vagina (sacrospinous fixation) or fixed to the sacrum with synthetic mesh through the abdomen (sacrocolpopexy).
- Colpocleisis: the vagina is closed by stitching the vaginal walls together. The operation is short; it is considered for people who do not intend to have vaginal intercourse and who are at high risk from surgery. Vaginal intercourse is not possible after this operation.
Mesh placed through the abdomen is a separate group from the mesh used through the vagina for prolapse repair and is not among the products whose sale was stopped in the US in 2019. Regulations on transvaginal mesh are described on the Cystocele (Bladder Prolapse) page. If mesh is to be used, its type, whether it is permanent and its possible risks are explained beforehand, and it is recommended that details such as the name and manufacturer of the product be given in writing.
After surgery
A hospital stay of one or two days is usual after vaginal and laparoscopic operations; after open abdominal surgery the stay may be longer. There may be a urinary catheter and a vaginal pack for a short time. Heavy lifting, heavy housework and strenuous exercise are avoided for about four to six weeks. After vaginal surgery, intercourse, swimming and the use of hot tubs are postponed for a time. The return to work depends on the type of job and the operation performed. A check-up that includes a vaginal examination is recommended six months after surgery; if mesh was used, the vagina is checked for mesh exposure.
Possible risks
Bleeding, infection, urinary tract infection, blood clots in the legs or lungs and problems related to anesthesia can occur with any operation. Difficulty passing urine, new or worsening urgency or stress incontinence and pain during intercourse may develop. After operations that attach the vagina or cervix to the sacrospinous ligament, there may be buttock pain that often settles on its own. Operations through the abdomen carry a risk of injury to the bladder, bowel or ureter and of adhesions. After operations that use mesh, the mesh can work its way into the vagina, bladder or bowel, and further surgery may be needed. The prolapse may come back over time in the same or another compartment.