Uterine prolapse

visible in the vaginal orifice. While uterine prolapse is rarely life-threatening, the symptoms associated with uterine prolapse can have a significant impact on quality of life. The severity of prolapse symptoms does not necessarily correlate with the degree of prolapse, and one may experience little to no bothersome symptoms with even advanced prolapse. Additionally, different forms of pelvic organ prolapse often present with similar symptoms. In the absence of treatment, symptoms of procidentia may include purulent vaginal discharge, ulceration, and bleeding. Complications of procidentia include urinary obstruction. People may also report sexual dysfunction symptoms, such as pain with sexual intercourse and decreased libido. There is conflicting data concerning the effect of pelvic organ prolapse on sexual function. The severity of the symptoms associated with prolapse seems to have a negative effect on sexual activity and reported satisfaction. Mild or asymptomatic prolapse does not seem to be associated with sexual complaints while more symptomatic prolapse is associated with more negative sexual symptoms. ==Causes==

Conditions that chronically increase the pressure within the abdomen can predispose people to uterine prolapse. This includes chronic obstructive pulmonary disease (COPD), obesity, chronic cough, straining due to chronic constipation, and repetitive heavy lifting. Tobacco smoking has been found to be correlated to pelvic organ prolapse both due to the risk of developing lung conditions that lead to chronic cough or COPD as well as the negative effects of tobacco chemicals on connective tissue. ==Pathophysiology==

The uterus is normally held in place by the combined effort of pelvic floor muscles, various ligaments, pelvic fascia, and the vaginal wall. The levator ani muscle plays the most significant role in pelvic organ support by acting as a basket that keeps the pelvic organs suspended. The uterosacral ligaments are especially important in providing support to the uterus by attaching and holding the uterus, cervix, and upper vagina to the sacrum. Uterine prolapse occurs when there is a disruption to any of the structures mentioned above that help hold the uterus in place. Weakening of the levator ani muscles can occur during vaginal childbirth, in which portions of the muscle can detach from the bony pelvis, or through age-related changes to musculature, and this can lead to a loss of support for the uterus. Pregnancy, vaginal childbirth, or injury can also stretch and weaken the uterosacral ligaments, leading to poor suspension or positioning of the uterus so that it is no longer supported by pelvic floor muscles. Problems with the vaginal wall, such as trauma or loss of smooth muscle support in the wall, can lead to the uterus collapsing downward due to a loss of support. When the uterus prolapses, it also drags the upper portion of the vagina (the apical vagina) along with it due to its anatomic relationship with the apical vagina. Additionally, the pelvic musculature and connective tissues are estrogen sensitive and respond to changes in estrogen level. Estrogen deficiency, which can occur during menopause, can affect the production of collagen that is needed to build connective tissue that makes up ligaments and fascia, which can contribute to uterine prolapse. This is also a reason that connective tissue disorders can predispose certain people to uterine prolapse. ==Diagnosis and management==

Diagnosis Diagnosis of uterine prolapse is based on a history of symptoms, which may include symptom questionnaires, and a physical exam. Pessaries are a mechanical treatment that supports the vagina and elevates the prolapsed uterus to its anatomically correct position. Pessaries are frequently offered as a first-line management option for uterine prolapse, especially amongst people who cannot or do not wish to undergo surgery, due to their affordability and low-risk profile compared to more invasive procedures. Surgical There are many surgical options available for the treatment of uterine prolapse, which may be performed through a vaginal procedure or through the abdomen. Generally, vaginal procedures are considered to be less invasive, offer a quicker recovery, and have a shorter operative time compared to abdominal procedures, but abdominal procedures offer longer-term results and potentially reduce risk of postoperative vaginal pain with intercourse. Laparoscopic and robotic approaches to abdominal procedures in prolapse surgery have become more common as they require smaller incision sites, result in less blood loss, and have shorter hospital stays. If a hysterectomy is performed, a vaginal vault suspension (known as colpopexy), in which the upper portion of the vagina is surgically connected to another structure in the pelvis, is commonly performed to prevent vaginal vault prolapse in the future. Forms of colpopexy include sacrocolpopexy, in which the vaginal vault is attached to the sacrum using a surgical mesh; sacrospinous ligament fixation, in which the upper vagina is attached to the sacrospinous ligaments using sutures; and uterosacral ligament vaginal vault suspension, in which the upper vagina is attached to the uterosacral ligaments using sutures. Colpopexy can be performed with or without a hysterectomy. If performed without a hysterectomy, the procedure is known as a hysteropexy. Hysteropexy procedures include sacrohysteropexy and sacrospinous hysteropexy. In severe cases of prolapse where the person no longer desires vaginal intercourse and has contraindications to more invasive surgery, vaginal closure procedures may be offered. These include LeFort partial colpocleisis and complete colpocleisis, in which the vagina is sutured closed. Also taken into consideration prior to surgery is use of native, or one's own, tissue versus a synthetic mesh. Generally, mesh may be considered in instances where the connective tissue is weak or absent, if there is an empty space at the surgical site that needs to be bridged, or if there is a high risk of prolapse recurrence. Synthetic mesh is indicated and used for sacrocolpopexy and sacrohysteropexy procedures. However, the use of synthetic mesh transvaginally, or within the vaginal tissue itself, is not indicated and is not routinely used for apical vaginal or uterine prolapse due to a lack of safety and effectiveness data, higher rate of mesh exposure compared with native tissue repair, and lack of data regarding long-term outcomes and complication rates. == Outcomes ==

Overall, it appears that quality of life was found to be significantly improved for people with pelvic organ prolapse after surgical or pessary management. Additionally, the surgical approach, for instance vaginal versus abdominal, also affects recurrence rate. The rates of reoperation following pelvic organ prolapse surgery ranges from 3.4% to 9.7%. Reoperation rates appear to be higher with transvaginal mesh repair compared to other procedures, due in part to complications such as mesh exposure. == Epidemiology ==

Numerical values regarding prevalence of uterine prolapse differ based on whether the epidemiologic study in question uses a physical exam or a symptom questionnaire to determine the presence of prolapse. in one study and 3.8% in another) compared to a symptom-based determination in which the prevalence of any type of prolapse, including uterine prolapse, was 2.9% to 8% in the U.S. Using Women's Health Initiative data, the incidence of grades 1 to 3 uterine prolapse was approximately 1.5/100 women-years and progression of uterine prolapse was found to be about 1.9%. == History ==

The first mention of uterine prolapse in medical literature was in the Kahun papyrus, circa 1835 B.C.E, which read, "of a woman whose posterior, belly, and branching of her thighs are painful, say thou as to it, it is the falling of the womb." The treatment at the time, documented on the Ebers papyrus, was to rub the afflicted person with a mixture of "oil of the earth [and] fedder", Towards the end of the 16th century, pessaries became more common in the management of uterine prolapse, due in part to advances in anatomic knowledge of the female genitourinary tract earlier in the century. Pessaries were usually made out of wax, metal, glass, or wood. Charles Goodyear's invention of volcanized rubber in the mid-1800s made it possible to produce pessaries that would not decompose. However, even into the 1800s, alternative practices were still used, such as the use of sea-water douches, postural exercises, and leeching. Although the use of surgery in the treatment of uterine prolapse had been described previously, the 19th century saw advances in surgical techniques. During the mid to late 1800s, surgical attempts to manage uterine prolapse included narrowing the vaginal vault, suturing the perineum, and amputating the cervix. In 1877, LeFort described the process of a partial colpocleisis. In 1861, Choppin in New Orleans reported the first instance in which vaginal hysterectomy was performed for uterine prolapse. Prior to that, vaginal hysterectomies were mainly performed for malignancies. Following Alwin Mackenrodt's 1895 publication of a comprehensive description of the female pelvic floor connective tissue, Fothergill began working on the Manchester-Fothergill surgery with the belief that the cardinal and uterosacral ligaments were key support structures for the uterus. In 1907, Josef Haban and Julius Tandler theorized that the levator ani muscles were also very important for uterine support. Combined with a better understanding of female pelvic floor connective tissue, these ideas would go on to influence surgical approaches for the treatment of uterine prolapse. By the early 20th century, different techniques for vaginal hysterectomies had been described and performed. As a result, post-hysterectomy vaginal vault prolapse became more common and a growing concern for some surgeons, and new techniques to correct this complication were attempted. In 1957, Arthure and Savage of London's Charing Cross Hospital, suspecting that uterine prolapse could not be cured with hysterectomy alone, published their surgical technique of sacral hysteropexy. Their technique is still used in modern practice with the addition of a graft. ==Society and culture==

Vaginal mesh kits were introduced to the U.S. market in 2004 through the U.S. Food and Drug Administration (FDA) pathway that did not require companies to demonstrate both safety and efficacy of the product if they were able to demonstrate that their product was similar to previous products already in the market. However, there was concern over reports of increased rates of postoperative complications over the next several years. That, in addition to the lack of available data that transvaginal mesh products were superior to other forms of surgical intervention This does not include surgical mesh used during sacrocolpopexy, sacrohysteropexy, or transurethral sling procedures. == References ==