Uterine prolapse is when the uterus drops down into the vagina, and in severe cases, outside the vagina. It is one of the more distressing gynecologic conditions and spares no age group. The experience of your uterus hanging outside your vagina is a somewhat bizarre one, to say the least. As one of my patient’s said to the male medical student, “You just have no idea what it’s like having something hanging down between your legs all the time!”
Women who have uterine prolapse frequently have other organs that are displaced. A cystocele results when a prolapsed bladder bulges through the vaginal roof; a rectocele occurs when the rectum bulges through the vaginal floor. Vaginal deliveries, smoking and family history are the greatest risk factors. Take a genetic predisposition, add a 9-pound baby and 3 hours of pushing … something is going to give. Once the tissue is damaged, it never completely regains its strength; gravity, age and menopause then compound the problem.
The most common symptom is the feeling that “something is falling down,” which is not surprising since that is exactly what has happened. Many women actually feel or see a bulge at the vaginal opening. If the uterus is only slightly dropped, most women are totally unaware that something has shifted unless their gynecologist points it out. By the time the uterus drops low enough for the vagina to be completely filled and the cervix reaches the opening of the vagina, most women are definitely aware there is a problem. And yes, in severe cases the uterus can drop outside the vagina. One of my patients called from her bathtub, appropriately upset, crying, “Something is floating out of my vagina … and I think it’s my uterus!”
In 1870, the recommended treatment for prolapse was application of leeches to the vulva or cervix. It is unclear if the uterus was “scared” back where it belonged, or if the woman just told her doctor things had improved to avoid further “treatment.” Fortunately, today there are other options.
Estrogen - Vaginal tissue depends on estrogen for strength and elasticity. Vaginal estrogen rings, tablets or creams will often improve a mild prolapse.
Exercise - Women are used to the idea of physical therapy for an injured arm or leg. The same concept applies to pelvic floor muscles. Kegels and pelvic physical therapy help in mild cases of prolapse, but are not going to fix a severe case.
Pessaries - A pessary is a device that comes in multiple shapes that is placed in the vagina to hold the uterus up. In the past, pessaries were recommended for women who were felt to be a surgical risk. Pessary use is less frequent now since improved surgical techniques have made surgery a safer, more reasonable option for older and sicker patients. Some women with slight prolapse are only symptomatic when they are playing golf, or tennis, and find a pessary useful on an as-needed basis.
Surgery - Ultimately, most women with severe symptomatic uterine prolapse will require a vaginal or laparoscopic hysterectomy to remove the uterus and correct other associated problems such as a cystocele or rectocele. Most women are not happy about having to have surgery, but are thrilled with the result.