What are the treatment options for uterine prolapse?

Treatment Options for Uterine Prolapse

For symptomatic uterine prolapse, vaginal hysterectomy with vault suspension is the recommended surgical approach, while pessaries serve as the primary conservative option for women who decline surgery or have medical contraindications. 1

Conservative Management

Pessary Therapy

• Pessaries are the first-line conservative treatment for women with symptomatic prolapse who prefer to avoid surgery or have significant medical comorbidities 2, 3
• Effective for reducing symptoms of pelvic heaviness, fullness, and low back pain that typically worsen with exertion 2
• Should be tried before proceeding to surgical intervention in most cases 2

Observation

• Asymptomatic prolapse requires no treatment, as many women with pelvic organ prolapse do not experience symptoms 3
• Mild first-degree prolapse without symptoms can be managed expectantly 2

Lifestyle Modifications

• Weight loss, reduction of heavy lifting, and treatment of constipation should be addressed, though evidence for prevention is limited 3
• Note: No high-quality randomized controlled trial evidence currently supports pelvic floor muscle training or other physical therapy interventions specifically for prolapse management 4

Surgical Management

Vaginal Approach (Preferred for Most Cases)

Vaginal hysterectomy with apical suspension is the recommended procedure per the American College of Obstetricians and Gynecologists 1

Specific Vaginal Techniques:

• Uterosacral vaginal vault suspension - requires careful ligation of uterosacral and cardinal ligaments with cul-de-sac obliteration to prevent subsequent enterocele 5, 2
• Sacrospinous ligament fixation 5
• Iliococcygeus fascia suspension 5
• McCall or Mayo culdoplasty 5

Patient Selection for Vaginal Approach:

• Older patients 6
• Primary or less severe prolapse 6
• Patients at increased surgical risk 6
• Small uterus 2

Abdominal/Laparoscopic Approach

Sacral colpopexy (preferably minimally invasive) with polypropylene mesh is recommended for:

• Younger women 6
• More severe prolapse 6
• Recurrences after vaginal surgery 6
• Prolapsed, short vaginas 6
• Large uterus or extensive pelvic adhesions/endometriosis 2

Uterine Preservation Options

For women desiring uterine preservation:

• Manchester procedure 5
• Sacrospinous hysteropexy 5
• Laparoscopic sacral hysteropexy 5
• Laparoscopic uterosacral vault suspension 5

Obliterative Procedures

For older women with severe prolapse not interested in sexual activity:

• Obliterative operations are highly effective with high satisfaction rates 6
• Should be offered as an option during informed consent discussions 6

Critical Surgical Principles

Essential Technical Requirements:

• Any apical prolapse surgery MUST include a specific apical support procedure to be effective 6
• The uterosacral and cardinal ligaments must be carefully ligated and tied together 2
• The cul-de-sac must be obliterated to reduce risk of subsequent enterocele and properly suspend the vaginal vault 2

Adjunctive Considerations:

• Grafts should be used selectively - may improve cure rates but increase complication risk 6
• Slings should be added selectively to reduce postoperative stress incontinence 6
• Concomitant cystocele, rectocele, and enterocele must be addressed 2

Clinical Decision-Making Algorithm

1. Assess symptom severity and patient goals

   • Asymptomatic → observation 3
   • Symptomatic but surgery-averse → pessary trial 2

2. For surgical candidates, determine approach based on:

   • Age (older → vaginal; younger → abdominal) 6
   • Prolapse severity (mild-moderate → vaginal; severe/recurrent → abdominal) 6
   • Uterine size (small → vaginal; large → abdominal) 2
   • Desire for uterine preservation (yes → hysteropexy options) 5
   • Sexual activity plans (no → consider obliterative) 6

3. Route selection:

   • Vaginal hysterectomy with vault suspension for most primary cases 1
   • Minimally invasive sacral colpopexy for younger patients or recurrences 6

Important Caveats

• No definitive gold standard procedure exists - optimal surgery depends on specific defects, patient factors, and surgeon expertise 5
• Interactive consent is mandatory regarding route of surgery, hysterectomy decision, use of grafts/slings, and impact on sexual function 6
• Consider referral to Female Pelvic Medicine and Reconstructive Surgery specialists for complex or recurrent cases 6
• Hysterectomy can be performed for uterine prolapse when treating concomitant conditions like fibroids, adenomyosis, or cervical dysplasia 7