The choice of therapy is based on the degree of severity of uterine prolapse. In milder cases, it is sufficient to implement simple control measures, in order to keep the situation stable. In more serious cases, however, more invasive remedies must be used, including surgery.
Preventive measures, as usual, are essential.
If the pelvic floor weakens and no longer offers the same support, ailments of a different nature, both physical and sexual, can appear.
THE POSITION OF THE UTERUS
The uterus is the female genital organ, which serves to accommodate the fetus during a pregnancy. It is located in the small pelvis, precisely between the bladder (anteriorly), the rectum (posteriorly), the intestinal loops (above) and the vagina (below).
The shape of the uterus resembles that of an inverted pear, in which two areas can be identified: a larger portion, called the body of the uterus, and a narrower portion, called the neck of the uterus or cervix. The uterine cervix protrudes. , to a minimal extent, inside the vagina. This protrusion is also called the tench snout.
What exactly determine these events within the pelvic floor?
PATHYSIOLOGY
When any of the above conditions occur, the pelvic floor structures (muscles, ligaments, and connective tissue) undergo a strain, or trauma, which weakens and tears them. The occurrence of a single circumstance (for example, a birth) is unlikely to result in uterine prolapse; however, the probability increases when events repeat or overlap one another, acting in concert.
RISK FACTORS
Several risk factors have been observed.
- The first, in importance, is the number of vaginal deliveries: a woman who has given birth several times is more prone to uterine prolapse. This is caused by the sum of the contractions of multiple labor.
- The second factor relates to aging. A woman, after the menopause, produces less estrogen and this weakens the pelvic floor muscles.
- The third factor is related to previous pelvic organ surgery. Women who have been affected have a weaker pelvic floor.
- The fourth factor is genetic. Some women suffer from congenital (i.e. present from birth) collagen diseases (collagenopathies), which make the pelvic floor more loose and prone to tearing.
- The last factor is linked to chronic obstructive pulmonary disease. It, in fact, determines chronic cough, which is one of the main causes of uterus prolapse.
N.B: collagen is a fundamental protein of connective tissue.
evident, so much so that they can go unnoticed. Instead, the symptoms and signs of moderate to severe uterine prolapse are clear. In these situations, the patient complains:
- Feeling of heaviness in the pelvic area
- More or less evident leakage of the uterus from the vagina
- Loss of urine
- Urinary retention and subsequent bladder infection
- Abdominal pain
- Sensation of bowel movement when sitting down
- Pain during intercourse
- Bleeding and increased vaginal discharge
WHEN TO CONTACT THE SPECIALIST?
The lack of explicit symptoms, in 1st degree prolapses, leads to underestimate the problem. However, the situation can progressively degenerate. It is therefore recommended to consult a gynecologist as soon as the symptoms appear more evident. This is to avoid any complications and surgical interventions.
COMPLICATIONS AND ASSOCIATED DISEASES
Prolapse of the uterus includes two complications, which can occur for different reasons. They consist of vaginal ulcers and prolapse of other pelvic organs.
- The vaginal ulcer occurs in the most severe cases of prolapse, in which the leaking uterus irritates the walls of the vagina by rubbing. Although rarely, the ulcer can also become infected.
- Prolapses of other pelvic organs, such as the bladder (cystocele) or the rectal portion of the intestine (rectocele), occur, instead, due to the fragility of the pelvic floor. Often, these disorders are considered associated pathologies, as the underlying causes they are the same.
PELVIC EXAMINATION
The pelvic exam is essential to determine whether it is a prolapse of the uterus or another pelvic organ. Using a speculum and with the patient in a lying position, the gynecologist examines the vaginal canal and the position of the uterus. In addition, he asks the patient if, sitting down, she feels a movement of the bowels. This detail is important to understand if it is a matter of severe uterine prolapse.
The specialist also assesses the muscle strength of the pelvic floor. This analysis consists in making the patient's pelvic muscles contract, as if to block the flow of urine; if the answer is no, it means that the pelvic floor has weakened.
EVALUATION QUESTIONNAIRE
Using a specific questionnaire, the specialist further explores the data collected with the pelvic examination. The questions concern the degree of pain felt and how much this affects the lives of the patients.
ULTRASOUND AND NUCLEAR MAGNETIC RESONANCE
Ultrasound and magnetic resonance imaging are two tests performed very rarely, since they are not necessary. The pelvic examination, in fact, is more than exhaustive.
However, your doctor may advise you to do them if there is any doubt about the severity of uterine prolapse or if other pelvic organ prolapses are suspected.
The other remedies consist of reducing body weight, in the case of overweight women, and avoiding lifting heavy objects.
The practice of these behaviors is essential if you want to keep the situation constant. Otherwise, the chances of worsening uterine prolapse increase significantly.
NON-SURGICAL TREATMENT OF MODERATE-SEVERE CASES
If the prolapse is moderate to severe, the two main non-surgical remedies are a pessary and estrogen-based hormone therapy (indicated for postmenopausal women).
What is it and what is it for?
The pessary
It is a rubber or plastic ring that is inserted into the vagina. It serves to block the prolapse of the pelvic organs, which overhang the vagina. The specialist teaches the patient how to clean it and how to apply it. There are pessaries of different sizes, according to needs.
Estrogen
Menopause leads to a reduction in estrogen production. Their decrease weakens the pelvic muscles. Therefore, with the intake of synthetic estrogen, the muscles of the pelvic floor are strengthened, in order to block the prolapse of the pelvic organs.
These therapeutic countermeasures serve to relieve symptoms, but their use is temporary. Very often, in fact, they are used for a defined time, waiting for the definitive surgical intervention, because they could have side effects. For example, prolonged use of the pessary irritates the internal cavity of the vagina.
It is advisable, even in such circumstances, to practice Kegel exercises, control body weight and avoid heavy lifting.
SURGICAL TREATMENT
Surgery is essential when the pain felt by the patient is unbearable and the signs of prolapse are evident, or when prolapses of other pelvic organs (bladder and rectum) are found.
There are two possible intervention procedures:
- Hysterectomy
- Suspension of the uterus
The hysterectomy is the removal of the uterus. It can be done in three different ways. A first method involves the incision of the abdomen. A second method is carried out through the vaginal route. Finally, the third and final approach takes place through a minimally invasive laparoscopic route.
The suspension of the uterus, on the other hand, consists in bringing the uterus back to its original position and in reinforcing, by means of a tissue transplant or thanks to synthetic material, the ligaments of the weakened pelvic floor.
The choice of one procedure, rather than the other, depends on the case in question and on the surgeon's experience in the practice of the different operative techniques.
SURGERY AND PREGNANCY
Clearly, a woman with uterine prolapse who wishes to have children or who is pregnant cannot undergo a hysterectomy. pessary.
