Uterine prolapse

Disease Description (Causes and Symptoms)

• Definition: Uterine prolapse is a condition in which part or all of the uterus descends due to weakening of the pelvic support tissues that support the uterus (pelvic floor muscles, uterosacral ligaments, uterine ligaments, etc.), protruding through the vagina or pushing against the vaginal walls.
• Pathophysiology: It occurs when damage to the levator ani (pelvic floor muscles) or relaxation of the ligaments prevents support of the uterus and vaginal walls. Risk factors include repeated pregnancies and deliveries, difficult labor, chronic cough, chronic constipation, obesity, aging, and family history.
• Main symptoms:
  • A feeling of a lump inside or outside the vagina, a feeling of “sitting on an egg,” or a sensation that something is falling out of the vagina
  • Pelvic or lower abdominal pressure or heaviness (especially worsening after standing for a long time or in the afternoon)
  • Urinary problems: urinary frequency, urinary urgency, urinary incontinence, difficulty urinating, and urinary retention (inability to pass urine)
  • Bowel problems: difficulty defecating and constipation
  • Pain or discomfort during sexual intercourse
  • May be asymptomatic
• Diagnostic points: A gynecological examination (pelvic examination) is used to determine the degree of prolapse and classify it using systems such as POP-Q (pelvic organ prolapse quantification). If urinary incontinence is present, urodynamic testing or a post-void residual urine test may be performed.

Treatment Methods

• Non-surgical treatment
  • Pelvic floor muscle strengthening exercises (Kegel exercises): Help relieve symptoms and delay progression. Consistent performance is necessary.
  • Pessary insertion: A device inserted into the vagina to support the uterus and vaginal walls. Useful for older patients, those who do not want surgery, or symptom control before surgery. Regular care is required (removal and cleaning are necessary).
  • Topical estrogen (vaginal preparation): If vaginal atrophy is present after menopause, it may help improve the condition of the vaginal tissues and increase tolerance of the pessary (use under a doctor's instructions).
• Surgical treatment
  • Vaginal hysterectomy and anterior/posterior colporrhaphy
  • If uterine preservation is desired, uterine suspension through the vagina or uterine suspension by laparoscopy/open surgery (e.g., sacrocolpopexy)
  • Colpocleisis may be considered for older patients who are not sexually active
  • Use of synthetic reinforcing mesh: Used in some procedures, but individual assessment of risks and benefits is necessary because of concerns about long-term complications (perforation, pain, and foreign-body reaction)
• Medication: There is no medication that treats the prolapse itself. Symptomatic treatment (such as antibiotics) may be used for pain or infection.
• Lifestyle management and precautions
  • Limit activities that increase lower abdominal pressure, such as lifting heavy objects, standing for long periods, and squatting
  • Treat chronic cough and constipation, and manage weight
  • When using a pessary, undergo regular examinations (to check for infection and ulcers)
• In emergencies: Immediate emergency medical care is necessary in cases of severe pain, heavy bleeding, inability to urinate (urinary retention), or sudden discoloration of the prolapsed area or suspected necrosis.

Outpatient Visit Checklist (Including Example Questions)

• Items to prepare
  • A list of medications currently being taken (prescription drugs, OTC medications, and supplements)
  • Records of previous gynecological surgery or delivery history (number of births and whether there was difficult labor)
  • A record of when recent symptoms began and how they have changed (symptom photographs or notes may be useful)
  • Notes on urination and bowel movement patterns (frequency, feeling of incomplete emptying, and whether urinary incontinence is present)
  • Weight changes, smoking status, and history of chronic cough or constipation
• Items to show the doctor during the outpatient visit
  • Medication list and results of previous tests (ultrasound or urinalysis), if available
• Example questions (items for the patient to check personally)
  • When and how did the symptoms begin? (Changes over time of day)
  • In which positions do the symptoms worsen?
  • Is sexual activity uncomfortable?

Examples of General Questions to Ask the Doctor

• How severe is this condition (what is its grade)? Is treatment absolutely necessary?
• Can non-surgical treatment (pessary or Kegel exercises) improve the condition? What is the approximate success rate?
• If surgery is recommended, which procedure is appropriate, and what are the recovery period and possible complications?
• What is the risk of recurrence after surgery, and what additional treatment options are available if it recurs?
• What are the role and side effects of medications (such as topical estrogen)?

Examples of Condition-Specific Questions

• If considering pessary use:
  • “Which type of pessary is suitable for me, and how often should it be managed and replaced?”
  • “If the symptoms are not adequately controlled with a pessary, what is the next step in treatment?”
• If considering surgery:
  • “Considering my age, delivery history, and sexual activity, which is more recommended: uterine-preserving surgery or hysterectomy? What are the advantages and disadvantages of each?”

(Note: The choice of treatment should be decided after consultation with the attending doctor, taking into account the severity of symptoms, the patient's age, preferences, and comorbidities, as well as plans for future pregnancy.)