Uterine prolapse is caused by weakness of the perineal and pelvic muscles, which causes the uterus to slip downwards and may appear at the vaginal entrance or, in more severe cases, even protrude outwards.

Uterine prolapse can occur at any age, but is more common in menopausal women who have had one or more difficult births, increased foetal weight above 4000gr and years of hard, physical work.

No treatment is needed for minor uterine prolapse. Treatment should be considered when the prolapse starts to limit a woman's quality of life and daily activities.
 

Simptoms

A minor prolapse of the uterus usually does not cause complaints. More severe prolapse may present with one or more of the following symptoms:

• A feeling of heaviness or pulling in the pelvis
• May be able to touch the genitals at the entrance to the vagina 
• Involuntary leakage (incontinence) or retention of urine
• Discomfort with bowel movements 
• Feeling as if you were sitting on something 
• Discomfort during sexual intercourse

Complaints usually worsen in the evening, especially if the work involves standing or physical exertion.

When to seek help

Help should be sought when any of these symptoms start to have a significant impact on quality of life.

Causes

• Complications during childbirth 
• Large foetus in labour
• Overweight 
• Heredity related to the characteristics of collagen in the tissues
• Chronic constipation
• Chronic cough or bronchitis (typical of prolonged smoking)
• Heavy, physical work

Complications

Uterine prolapse is often combined with prolapse of adjacent organs:

• Weakness of the anterior wall of the vagina, or cystocele, in which the posterior wall of the bladder slides into the vagina. This is caused by a weakness of the connective tissue that separates the bladder from the anterior wall of the vagina.
• In the case of a weakness of the posterior wall of the vagina, or rectocele, the posterior wall of the vagina is dislocated and the rectum slides into the vagina. Occasionally, loops of small intestine can also slip into the pelvis and are then called enterocele.
• In the case of severe uterine prolapse, the uterus can protrude completely outwards from the body and cause abrasions of the vaginal mucosa.

Prevention

To reduce the risk of uterine prolapse, we recommend:

• Regular Kegel exercises. 
• To treat and prevent constipation. Drink plenty of fluids and give preference to fibre-rich foods.
• Avoid heavy lifting.
• Treat chronic cough, quit smoking.
• Normalise body weight.

• For the prevention of prolapse and mild prolapse of the vaginal wall, various aids can be used to strengthen the perineal musculature. These weights, which can be inserted into the vagina from 15min per day to 2-3 hours per day, allow gradual, non-traumatic strengthening of the perineum. They are a variety of round or oval shaped weights from 20-120g designed for this very purpose. The effect of the weights depends directly on the regularity of the exercises. These weights are inserted into the vagina by the woman, resulting in a reflex contraction of the perineal musculature. The use of such weights for 20-30 minutes a day allows the pelvic muscles to be strengthened within a few months. However, it should be noted that strengthening of the perineal muscles using beads or Kegel exercises is more effective in premenopausal women.  

Diagnostics

Uterine prolapse is very easy to spot during a gynaecological examination, when you can visually see the anterior or posterior wall of the vagina, the low position of the uterus in the pelvis or, in more severe cases, falling out. 
During the pelvic examination, the doctor may sometimes ask you to "squeeze" or, on the contrary, squeeze the perineal muscles.
In the case of severe urinary incontinence, dynamic urography is needed to exclude urinary disorders of other origins than perineal muscle weakness.

Treatment

Treatment tactics in case of a prolapse will depend on the severity of the prolapse.
If the slip does not cause significant complaints, then reducing the provoking factors is very important to prevent the situation from worsening. Prevention requires regular Kegel exercises, normalisation of weight, prevention of constipation and cough. 
The next step is the use of various pessaries. Several types of pessaries are available, both in shape and size.
The vaginal pessary is a rubber ring that can be of different diameters and is tailored to the individual woman. The pessary is inserted into the vagina in a compressed form and released after insertion. In this way, the pessary in the vagina mechanically pushes against the vaginal walls and holds the uterus in the pelvis. The main problem with pessaries is hygiene, as they need to be cleaned once a week. The main inconvenience is the insertion and removal of the pessary in women who have regular sex. Pessaries are not comfortable for younger women with an active sexual life.

Surgical treatment

In cases where uterine prolapse is pronounced, surgery will be the most effective treatment. This surgery is minimally invasive, involving laparoscopic fixation of the prolapsed vaginal opening and the uterus or cervix with various types of mesh. The choice of surgery for uterine prolapse can vary widely and will be influenced by the patient's constitution and the condition of the vaginal walls.

In case of severe prolapse, uterine removal followed by placement of a mesh may be offered. For this purpose, the doctors at our clinic prefer the mesh manufactured by Dynamesh, as it causes less inflammatory response in the body with subsequent fibrosis and shrinkage of the mesh. During surgery, the mesh is sutured to the cervical or vaginal trunk and fixed to the spine or pelvic fascia. The surgery is performed entirely laparoscopically and takes approximately 90 minutes.

In this case, after the uterus has been removed, the anterior wall of the vagina on the abdominal side is covered with prolene mesh and sutured in several places with non-absorbable Premicron 2/0 thread.

The prolene-covered vaginal trunk is then fixed to the part of the spine where the spine passes into the sacrum (above the promontorium), at the fascia. The mesh is then covered with peritoneum, restoring the natural surfaces of the abdominal cavity and preventing the small bowel loops from coming into contact with the surface of the mesh.
 

The best way to decide on the treatment options for a prolapse is to consult a doctor in person.

Kegel's exercises

We recommend Kegel exercises only for premenopausal women up to the age of 50 and only for mild, initial slips. In the case of pronounced slippage and in menopausal women, Kegel exercises will not give the expected results, so a more serious solution is needed in these situations and can be achieved by surgically inserting the aforementioned meshes.

How to do the Kegel exercises?

• Tighten the muscles at the base of the pelvis as if you were trying to hold back a gas leak or abdominal outlet
• This tension should be maintained for five seconds, followed by a five-second pause during which the perineal muscles should be relaxed. If the five-second tension is too difficult, it is acceptable to start with a 2-second tension and 3-second pauses
• The aim is to achieve 10 seconds of tension for each contraction
• These contractions should be performed 10 times in one go. In total, 3 such sessions should be performed during the day, e.g. 10 contractions of 10 seconds each with a pause between each contraction in the morning, then at lunchtime and a final one in the evening. 
• The best way to learn Kegel exercises is from a physiotherapist, but it is also possible to learn the exercises on your own.