Women Talk: Uterine prolapse: When the pelvic organs ‘fall down’

Lola Marcia, a 75-year-old former piano teacher, came to see me because she was bothered by “something coming out of her vagina.” The problem started about 5 years ago when she noted vague, lower abdominal fullness and discomfort every time she urinated or moved her bowels. Over time a small mass in her introitus (the entrance to the vagina) appeared, especially when she deferred urinating during long trips. The mass did not bother her too much as it was not painful and she could still push it back. Over the years though, the mass slowly grew; still she did not seek any medical consultation, hoping it would resolve itself. A week before her consultation, after lifting some wet clothes from the washing machine, she felt something “give”, and saw that an orange-sized mass was protruding out of her vagina, and she could no longer push it back. Alarmed, she asked one of her daughters, the youngest of eight children, to accompany her to see me.

Upon examination, a 6 cm. mass was protruding out of the introitus. On further pelvic examination the pelvic outlet was very loose and the entire uterus, covered by vaginal skin, had fallen out of the vagina, bringing with it parts of the bladder (a condition called cystocoele) and the rectum (rectocoele).

Why prolapse occurs

How do women develop uterine prolapse? Medical literature mentions a few women with congenital laxity of the ligaments that hold the uterus in place, hence the propensity for developing this condition. Increased intra-abdominal pressure, like the presence of a huge abdominal mass, or frequently lifting heavy objects could contribute to its formation. Age, especially menopause, also brings about loss of estrogen, the hormone that keeps the vaginal skin supple. With lack of elasticity come dryness and atrophy, and some support is lost.

However, the most common cause is multiple vaginal deliveries. During delivery, the pelvic organs have to stretch to accommodate the baby’s passage through the vaginal canal. Here, the advantage of having a clean, aseptic cut (called an episiotomy) in the fourchette (middle of the lower portion of the vulva, or vaginal outlet) is obvious. With additional room for the baby’s head to pass through, the lower vaginal areas need not be stretched to the utmost. Unwanted tears in the vaginal walls are minimized. Some obstetricians cut through the central part of the levator ani muscles (circular muscles of the rectum) as part of the episiotomy to help the baby’s birth. After delivery, a thorough repair with careful approximation of the tissues (muscle, fascia, subcutaneous fat, skin) is done. Here, the muscles, the most important support of the pelvic floor, are given more attention.

Also, multiple deliveries cause relaxation of the structures that keep the uterus in its place, like the cardinal and utero-sacral ligaments. These could stretch to more than twice their lengths every time a woman reaches a full term pregnancy. These ligaments naturally shorten after the baby is born but because of the stretching, they could no longer return to their original lengths. Each pregnancy then stretches these ligaments more, and the frequent stretching of the pelvic floor add to the set-up for a uterine prolapse. For Lola Marcia, the eight pregnancies have taken their toll, especially because the first four babies were delivered at home in the province, assisted by a traditional birth attendant. However, not all women who have multiple vaginal deliveries will develop uterine prolapse, especially if there were good, anatomical repairs after every delivery.

What can be done

Theoretically, anything that can “prop up” a descending uterus and prevent it from coming out could be used to prevent “descensus” or total prolapse. Pessaries and rings had been used to buttress the pelvic organs against the symphysis pubis (the bone found at the middle of the pubis). However, these are temporary answers to an anatomical defect.

The definitive treatment of a uterine prolapse is surgery. A removal of the uterus through the vagina (vaginal hysterectomy) is done, together with repair of the loose bladder and rectum (anterior and posterior repair). This is not an easy procedure, because the surgeon works in such a small space. Moreover, these women are elderly, and usually have concomitant medical problems like hypertension and diabetes. Her tissues are thin and fragile. There are many variations to the surgical intervention, and the doctor would want to know if the particular woman is still sexually active. If so, leaving enough length in the vaginal canal is important. If sex is not an issue, closing of the vaginal canal, which is a simpler procedure (especially for those medically-compromised patients) is an option.

Some gynecologists also advise obese women to lose some weight first, before doing the surgery. With weight loss, there will be less intra-abdominal pressure bearing down on the newly-operated area on the pelvic floor, with less probability of a vaginal stump prolapse. In these cases, the pelvic floor is so weak, that parts of the intestines also descend and form a mass (enterocoele).

A few gynecologists will give hormonal treatment (mainly estrogen) to women who have vaginal skin dryness and atrophy, but this is a case to case basis. Taking a good family history (especially that of breast cancer), and a thorough work-up for any medical condition are imperative before starting any estrogen replacement therapy.

After a medical screening, especially a clearance from a cardiologist, Lola Marcia underwent a vaginal hysterectomy with anterior and posterior repair. Intra-operatively, her ovaries were palpated, and were found to be small and atrophic. Fascial and muscle supports were insured in the repairs of the bladder and the rectum, and blood loss was kept to the minimum.

One month after the surgery she came back to the clinic and reported that she almost could not believe she had surgery, as there were no visible stitches. I assured her there were a lot inside the vagina, so she needed to take care and rest, for them to heal. — BM, GMA News

Dr. Alice Sun-Cua is a practicing obstetrician-gynecologist at the San Juan de Dios Hospital in Pasay City.