What are the treatment options for uterine prolapse?

Treatment Options for Uterine Prolapse

Hysterectomy is the most definitive treatment for uterine prolapse in women who do not desire future fertility, providing complete resolution of prolapse-related symptoms, though less invasive options should be considered first due to potential long-term complications. 1

Evaluation and Classification

Before selecting treatment, proper evaluation is essential:

• Assess symptoms: pelvic heaviness/fullness, low back pain, protruding vaginal mass, bleeding from mucosal ulcerations, voiding difficulties, recurrent urinary infections
• Evaluate prolapse by compartment (anterior, apical, posterior)
• Document severity using POP-Q classification (stages 1-4)
• Rule out other pelvic pathologies that may mimic symptoms

Treatment Algorithm

First-Line Conservative Options

1. Pelvic Floor Muscle Training (PFMT)

   • Recommended as first-line therapy for mild to moderate prolapse 2
   • Evidence shows improvement in prolapse symptoms and severity 3
   • Benefits include improved pelvic floor muscle function and reduced urinary symptoms
   • Most effective when supervised for at least 6 months

2. Pessary Devices

   • Recommended as first-line therapy alongside PFMT 2
   • Mechanical support for prolapsed organs
   • Various types available (ring, Gellhorn, cube, donut)
   • Requires periodic removal and cleaning
   • Regular follow-up needed to prevent complications like vaginal erosion

3. Lifestyle Modifications

   • Weight loss if overweight/obese
   • Avoidance of heavy lifting
   • Treatment of chronic constipation
   • Smoking cessation

Surgical Options (for failed conservative management or severe prolapse)

1. Vaginal Approach

   • Vaginal hysterectomy with vault suspension

     • Preferred for small uterus and when patient has no desire for future fertility 1
     • Careful ligation of uterosacral and cardinal ligaments required
     • Cul-de-sac obliteration necessary to reduce enterocele risk
     • Shorter recovery time compared to abdominal approach
     • Lower complication rates than abdominal hysterectomy

   • Vaginal repair with autologous tissue

     • Recommended particularly for elderly or frail patients 2
     • Addresses associated cystocele/rectocele
     • Colpocleisis (vaginal closure) is an option for those who will not be sexually active

2. Abdominal Approach

   • Abdominal hysterectomy

     • Consider when uterus is large or patient has extensive pelvic adhesions 1
     • Higher complication rates than vaginal approach
     • Longer recovery time

   • Laparoscopic sacrocolpopexy

     • Recommended for apical and anterior prolapse 2
     • Uses mesh to suspend the vaginal apex to the sacrum
     • Lower recurrence rates than vaginal repairs
     • Mesh placement requires multidisciplinary team consultation

Important Considerations

• Surgical Risks: Hysterectomy, even with ovarian conservation, is associated with increased risk of cardiovascular disease, mood disorders, osteoporosis, and potentially dementia 1

• Mesh Complications: Decision to use mesh should be made by a multidisciplinary team due to potential complications 2

• Post-Treatment Follow-up: All patients should be reassessed by the surgeon after surgery, even in absence of symptoms 2

• Fertility Preservation: For women desiring future fertility, pessary and PFMT are the primary options

Common Pitfalls to Avoid

1. Inadequate assessment: Failing to evaluate all compartments of prolapse can lead to incomplete treatment

2. Overlooking associated conditions: Prolapse often coexists with urinary incontinence, which may worsen after prolapse correction

3. Choosing inappropriate surgical approach: Selection should consider patient age, comorbidities, sexual activity status, and severity of prolapse

4. Ignoring patient preferences: Treatment should align with patient goals regarding fertility, sexual function, and invasiveness of intervention

5. Insufficient follow-up: Regular monitoring is essential, especially with pessary use, to prevent complications

The evidence strongly suggests that conservative approaches should be tried before proceeding to surgery, but when surgery is indicated, the least invasive approach that adequately addresses the prolapse should be selected.