Prolapsed uterus

The uterus (womb) is an organ of the female reproductive system. It is shaped like an upside down pear and is located inside the pelvis. The uterus, bladder and bowel are supported by a hammock of muscles located between the tailbone (coccyx) and the pubic bone within the pelvis. These muscles are known as the pelvic floor, or the levator ani muscles. Ligaments and connective tissue also suspend the uterus and pelvic organs in place. If these muscles or connective tissues are weakened or damaged, the uterus can drop down into the vagina. This is known as prolapse.

Common causes of uterine prolapse include vaginal childbirth, obesity, severe coughing, straining on the toilet and hormonal changes after menopause which can damage the pelvic organ support structures. First line treatment should include pelvic floor muscle strengthening exercises, taught by a pelvic floor physiotherapist.

A pessary can be inserted to support the uterus and reduce the symptoms associated with the prolapse. Pelvic floor exercises are still helpful when a pessary is in place. Surgery may be needed in severe cases.

Symptoms of prolapse of the uterus

The symptoms of uterine prolapse include:

• a sensation of heaviness and pressure in the vagina
• a distinct lump or bulge within the vagina
• a bulge protruding out of the vagina
• painful sexual intercourse.

Degrees of uterine prolapse

Uterine prolapse is described in stages, indicating how far it has descended. Other pelvic organs (such as the bladder or bowel) may also be prolapsed into the vagina.,. The four categories of uterine prolapse are:

• Stage I – the uterus is in the upper half of the vagina
• Stage II – the uterus has descended nearly to the opening of the vagina
• Stage III – the uterus protrudes out of the vagina
• Stage IV – the uterus is completely out of the vagina.

Causes of uterine prolapse

The pelvic floor and associated supporting connective tissues can be weakened or damaged in many ways including:

• pregnancy, especially in the case of multiple births (such as twins or triplets), or multiple pregnancies
• vaginal childbirth, especially if the baby was large or delivered quickly, or if there was a prolonged pushing phase
• obesity
• straining on the toilet to pass a bowel motion
• low levels of the sex hormone oestrogen after menopause
• severe coughing associated with conditions such as chronic bronchitis or asthma
• fibroids
• in rare cases, pelvic tumour.

Treatments for uterine prolapse

Treatments for uterine prolapse include surgical and non-surgical options, the choice of which will depend on general health, the severity of the condition and plans for a future pregnancy. Treatment options include:

• pelvic floor exercises
• vaginal pessary
• vaginal surgery.

Pelvic floor exercises

Stage I and II uterine prolapse in particular can be helped by pelvic floor muscle exercises, but they need to be done correctly and practised long enough to strengthen the muscles. Although the following information may give you some ideas about how to do PF exercises, it is imperative to seek professional help from a pelvic floor physiotherapist if you have a prolapse.

Familiarising yourself with the muscles of the vagina, urethra and anus gives you a better chance of performing the exercises correctly.

To identify your pelvic floor muscles, try the following:

• Insert one or two fingers into the vagina and try to squeeze them.
• Imagine you are passing urine, and try to stop the flow midstream (do not do this while urinating).
• Squeeze the muscles inside the anus as if you are trying to stop yourself from breaking wind.

Consult with your doctor or pelvic floor physiotherapist to ensure correct performance.

You can perform these exercises lying down, sitting or standing. Ideally, aim for five or six sessions every day while you are learning the exercises. After you have a good understanding of how to do the exercises, three sessions each day is enough.

Before you start, direct your attention to your pelvic floor muscles. Try to relax your abdominal muscles, buttocks and leg muscles. Don’t bear down or hold your breath. Squeeze and lift the urethra, vagina and anus and hold the tension for three seconds if you can. Release completely. Then perform the exercises, which include:

• Squeeze slowly and lift and hold as strongly as you can for 5 to 10 seconds while breathing normally. Release slowly. Repeat up to 10 times. Relax for 5 to 10 seconds between each one.
• Perform quick, short, strong squeezes. Repeat 10 times.
• Remember to squeeze and lift the muscles whenever you cough, sneeze, laugh or lift anything.

It’s okay to feel your lower abdomen gently tightening as you hold the pelvic floor muscle contraction.

Vaginal pessary

A pessary is a flexible device which can be fitted into the vagina to support the uterus. There are different shapes and sizes of pessary, which can be prescribed and fitted by a suitably trained health professional. Women can be taught to remove and re-insert their pessary much like a tampon. However, regular reviews with your gynaecologist or doctor are necessary.

Vaginal pessaries can be an effective way of reducing the symptoms of a prolapse, but they will not be appropriate for everyone. Together with pelvic floor exercises, they may provide a non-surgical solution to manage a uterine prolapse.

Vaginal surgery

In moderate to severe cases, the prolapse may have to be surgically repaired. In laparoscopic surgery, instruments are inserted through the navel. The uterus is pulled back into its correct position and reattached to its supporting ligaments. The operation can also be performed with an abdominal incision.

Surgery may fail and the prolapse can recur if the original cause of the prolapse, such as obesity, coughing or straining, is not addressed. Consult your pelvic floor physiotherapist for help with this.

Prevention techniques

Some women are at increased risk of uterine prolapse. Simple preventive measures include:

• pregnancy – pelvic floor exercises throughout pregnancy
• vaginal childbirth – post-partum pelvic floor exercises
• post-menopause – oestrogen cream to boost flagging hormone levels, and pelvic floor exercises
• obesity – loss of excess abdominal fat with dietary modifications and regular exercise
• chronic constipation – it’s ideal if you have big, soft, formed stools. Usually, eating lots of fruit, vegetables and fibre, and drinking plenty of water will help. Avoid straining when using your bowels. Manage chronic constipation in consultation with your doctor
• other conditions – treat underlying disorders (such as asthma and chronic bronchitis) in consultation with your doctor.

Where to get help

• Your doctor
• Family planning clinic
• Australian Physiotherapy Association Tel. 1300 306 622
• Sexual Health Victoria (SHV). To book an appointment call SHV Melbourne CBD Clinic: (03) 9660 4700 or call SHV Box Hill Clinic: (03) 9257 0100 or (free call): 1800 013 952. These services are youth friendly.
• Continence Foundation Australia