Uterine prolapse is descent of the uterus toward or past the introitus. Apical prolapse is descent of the vaginal vault (vaginal cuff) after hysterectomy. Symptoms include vaginal pressure and fullness. Diagnosis is clinical. Treatment includes reduction, pessaries, and surgery.
In uterine prolapse, the cervix descends and can be visualized on pelvic examination or, with severe prolapse, it can be visualized beyond the introitus. In patients who have had a total hysterectomy (cervix and uterus removed), the vaginal vault may prolapse. With severe vaginal vault prolapse, the vagina can completely evert.
Symptoms and Signs of Uterine and Apical Prolapse
Symptoms tend to be minimal with mild uterine or apical prolapse. In more severe uterine or apical prolapse, vaginal or pelvic fullness, pressure, sexual dysfunction, and a sensation of organs falling out are common. The most common presenting symptom is a vaginal bulge, although this may be intermittent because spontaneous reduction can occur. Lower back pain may develop. Incomplete emptying of the bladder and constipation are possible.
If vaginal or cervical mucosa protrudes beyond the vagina, it may become dried, thickened, chronically inflamed, edematous, and ulcerated. Ulcers may be painful or bleed and need to be differentiated from vulvovaginal infection or dermatosis.
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Cystocele or rectocele is usually also present.
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Urinary incontinence is also commonly present. Alternatively, the descending pelvic organs may intermittently obstruct urine flow, causing urinary retention and overflow incontinence and masking stress incontinence. Urinary frequency and urge incontinence may accompany uterine or vaginal prolapse.
Diagnosis of Uterine and Apical Prolapse
Pelvic examination at rest and while a patient strains
Diagnosis of uterine or vaginal apical prolapse is made with pelvic examination speculum and bimanual pelvic examination with the patient at rest and then with the patient straining. The Pelvic Organ Prolapse-Quantification (POP-Q) system is usually used to document severity.
Concomitant urinary incontinence or urinary retention requires evaluation.
Treatment of Uterine and Apical Prolapse
For mild symptomatic prolapse, pessaries
Surgical repair of supporting structures if necessary, usually combined with hysterectomy
Uterine prolapse
Asymptomatic prolapse does not require treatment. Symptomatic uterine prolapse is not likely to respond to pelvic floor exercises, but a pessary is a good first-line treatment option. Surgery can be offered for patients who do not wish to or are unable to use a pessary (1).
To fit a pessary, a clinician should do a pelvic examination and insert the pessary. The patient should then stand and walk around to assess comfort. The clinician should provide instructions for removing, cleaning, and reinserting the pessary. In some countries, pessaries may be available over the counter. Proper size, fit, and position are important, because a pessary can cause vaginal ulceration, if it is does not fit correctly, and infection, if it is not cleaned regularly (at least monthly).
Surgery for uterovaginal prolapse can be done transvaginally or transabdominally using various techniques. Factors determining choice of technique include surgeon experience and patient preference. Techniques may include one or a combination of the following:
Hysterectomy
Surgical repair of the pelvic support structures (colporrhaphy)
Suspension of the top of the vagina (suturing of the upper vagina to a stable structure nearby)
Colpocleisis (closure of the vagina after removal of the uterus or with the uterus in place [Le Fort procedure])
Regardless of the surgical route, symptoms often recur, especially along the anterior vaginal wall.
Surgery is delayed until all ulcers, if present, have healed.
Vaginal apical prolapse
Vaginal apical prolapse is treated similarly to uterine prolapse.
If women are not good candidates for prolonged surgery (eg, if they have serious comorbidities) and are not planning future vaginal intercourse, they may be offered colpocleisis (suturing the vagina closed). Advantages of vaginal closure include short duration of surgery, low risk of perioperative morbidity, and very low risk of prolapse recurrence.
Urinary incontinence requires concurrent treatment.
Reference
1. Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214. Obstet Gynecol. 2019 (reaffirmed 2024);134(5):e126-e142. doi:10.1097/AOG.0000000000003519
Key Points
Uterine prolapse is descent of the uterus toward or past the introitus. Vaginal apical prolapse is descent of the vaginal vault (vaginal cuff) after hysterectomy.
Symptoms include pelvic or vaginal fullness, pressure, and a sensation of organs falling out. Organs may bulge into the vaginal canal or through the vaginal opening (introitus), particularly during straining or coughing.
The descending pelvic organs may intermittently obstruct urine flow, causing urinary retention and overflow incontinence and masking stress incontinence.
Diagnose uterine or vaginal apical prolapse with speculum and bimanual pelvic examination with the patient at rest and then with the patient straining.
First-line conservative treatment is with pessaries; treat surgically if women prefer surgery to a pessary.
