What are the treatment options for uterine prolapse?

Treatment Options for Uterine Prolapse

The most effective treatment approach for uterine prolapse should be individualized based on prolapse severity, patient symptoms, age, desire for future sexual activity, and surgical risk factors, with options ranging from conservative management with pessaries to surgical intervention.

Conservative Management Options

Pelvic Floor Muscle Training (PFMT)

• Recommended as first-line therapy for mild to moderate uterine prolapse 1
• Can improve pelvic floor strength and potentially reduce prolapse symptoms 2
• Should be combined with management of modifiable risk factors such as weight loss, reduction of heavy lifting, and treatment of constipation 3

Pessary Use

• Effective non-surgical option for all stages of uterine prolapse, including severe cases 1
• Various types available including ring, Gellhorn, Shaatz, and inflatable pessaries 4
• For severe (grade 4) prolapse that cannot be managed with a single pessary, double pessary technique can be effective 4
• Requires regular follow-up for cleaning and to check for complications such as erosion or vaginitis 4

Surgical Management Options

Transvaginal Approaches

• Recommended for:
  • Older patients with primary or less severe prolapse 5
  • Patients with increased surgical risk 5
  • Women with disabling symptoms related to significant prolapse (stage 2 or more) who have failed conservative management 1
• Procedures may include:
  • Vaginal hysterectomy with vault suspension 6
  • Native tissue repairs without mesh 1

Abdominal/Laparoscopic Approaches

• Sacral colpopexy with polypropylene mesh is recommended for:
  • Younger women 5
  • Patients with more severe prolapse or recurrences after vaginal surgery 5
  • Women with prolapsed, short vaginas who desire sexual function 5
• Laparoscopic approach is preferred when available due to reduced recovery time 1

Obliterative Procedures

• Colpocleisis is highly effective for older women with severe prolapse who are not interested in maintaining vaginal sexual function 5, 1
• Has high satisfaction rates and lower complication rates compared to reconstructive procedures 5

Treatment Algorithm

1. Initial Assessment:

   • Evaluate prolapse severity, compartment involvement, and associated symptoms 1
   • Assess impact on quality of life 1

2. First-Line Treatment:

   • Conservative management with PFMT and/or pessary 1
   • Address modifiable risk factors (weight, constipation, heavy lifting) 3

3. If Conservative Management Fails:

   • For sexually active women:
     • Younger patients or those with severe/recurrent prolapse: Laparoscopic sacral colpopexy 5, 1
     • Older patients or those with primary/less severe prolapse: Transvaginal repair 5
   • For women not interested in sexual activity: Consider obliterative procedures 5

Special Considerations

• Pessaries require regular follow-up and cleaning to prevent complications 4
• The decision to use mesh should involve multidisciplinary consultation due to potential complications 1
• Post-surgical follow-up is essential even in asymptomatic patients 1
• For severe prolapse that cannot retain a single pessary, double pessary technique can provide symptomatic relief without surgical intervention 4

Common Pitfalls to Avoid

• Failing to address associated conditions like urinary incontinence or bowel dysfunction 1
• Not considering patient's age, comorbidities, and sexual function desires when selecting treatment 5
• Overlooking the importance of long-term follow-up after both conservative and surgical management 1
• Assuming all patients with anatomical prolapse require intervention—many women with mild prolapse are asymptomatic and do not need treatment 3