Relaxation of Pelvic Supports. In Current Obstetric and Gynecological Diagnosis and Treatment

Uterine Prolapse

Essentials of Diagnosis

• Firm mass in the lower vagina; cervix projecting through the vaginal introitus; vaginal inversion, with the cervix and uterus projecting between the legs.
• Sensation of vaginal fullness or pressure; lower abdominal pulling or aching; low backache.

General Considerations

Uterine prolapse (pelvic floor hernia, pudendal hernia) (Fig 40-12) is abnormal protrusion of the uterus through the pelvic floor aperture or genital hiatus. Like cystocele, rectocele, and enterocele – conditions with which it is usually associated – uterine prolapse occurs most commonly in multiparous white women as a gradually progressive result of childbirth injuries to the endopelvic fascia (and its condensations, the uterosacral and cardinal ligaments) and lacerations of muscle, especially the levator muscles and those of the perineal body. Uterine prolapse may also be the result of pelvic tumor; sacral nerve disorders, especially injury to S1-4 (as in spina bifida); diabetic neuropathy; caudal anesthesia accidents; and presacral tumor. Additional factors promoting uterine prolapse are (1) systemic conditions, including obesity, asthma, chronic bronchitis, and brochiectasis; and (2) local conditions such ascites and large uterine and ovarian tumors.

A congenital type of uterine prolapse is seen rarely in newborn infants during vigorous crying or vomiting. It is also seen occasionally in nulliparous, even virginal, females with intact, strong levator muscles and a narrow genital hiatus; apparently, prolapse in these cases is the result of an inherent weakness of the endopelvic fascial supports of the uterus and vagina. As a rule, in uterine prolapse of the common type, symptomatic status is not reached until many years after the causative event (e.g., traumatic delivery). This finding suggests that aging and involutional attenuation of the supporting structures play an important role.

A uterus that is in a retroverted position is especially subject to prolapse; with the corpus aligned with the axis of the vagina, anything increasing intra-abdominal pressure exerts a pistonlike action on the uterus, driving it down into the vagina.