Management of Vaginal Erosions Due to Uterine Prolapse
For vaginal erosions secondary to uterine prolapse, initiate conservative management with pessary removal (if present), topical estrogen therapy, and local wound care, reserving surgical intervention for cases that fail conservative treatment or present with severe complications.
Initial Assessment and Conservative Management
Immediate Interventions
Remove any pessary immediately if one is in place, as pessaries are a common cause of vaginal erosions in prolapse patients and ongoing mechanical trauma prevents healing 1, 2.
Measure vaginal pH at the erosion site, as alkaline pH (>4.5) is strongly associated with erosions and indicates disrupted vaginal microbiota 2.
Initiate topical estrogen therapy to promote epithelial healing and restore the vaginal environment, particularly in postmenopausal women where tissue atrophy contributes to erosion development 2.
Apply local wound care with gentle cleansing and consideration of topical antimicrobials if signs of secondary infection are present, as erosions show increased gram-negative bacteria and decreased lactobacilli 2.
Conservative Treatment Protocol
Reduce the prolapse manually if possible, using Trendelenburg positioning and gentle manipulation to decrease mechanical trauma to the eroded tissue 3.
Consider topical application of granulated sugar or hypertonic solutions (50% dextrose or 70% mannitol) to reduce edema of prolapsed tissue, creating a hyperosmolar environment that facilitates reduction 3.
Prescribe vaginal acidification therapy to lower pH and restore normal lactobacilli-dominant microbiota, as erosions are associated with significantly higher vaginal pH and altered bacterial diversity 2.
Implement a 4-6 week trial of conservative management before considering surgical options, allowing time for epithelial healing with estrogen therapy and removal of mechanical irritation 2.
Surgical Management Indications
When to Proceed with Surgery
Operate immediately if erosions are associated with strangulated prolapse showing signs of gangrene, perforation, or hemodynamic instability 3.
Consider definitive prolapse repair if erosions fail to heal with 4-6 weeks of conservative management or if the patient has recurrent erosions despite optimal medical therapy 3, 4.
Base surgical approach (abdominal vs. vaginal) on patient characteristics including age, surgical risk, activity level, and extent of prolapse in all compartments 4, 5.
Surgical Considerations
Avoid synthetic mesh in the presence of active erosions or recent healing, as synthetic materials placed in compromised tissue carry significantly higher risks of mesh erosion (5-8% vaginal extrusion rates) and infection 3, 4.
Use native tissue repair as first-line surgical approach when operating in the setting of recent erosions, reserving mesh-augmented repairs for cases with healed tissue and high risk of recurrence 4.
Perform complete anatomic assessment of all pelvic compartments (anterior, posterior, apical) preoperatively, as multi-compartment prolapse is common and requires comprehensive surgical planning 6, 4.
Common Pitfalls to Avoid
Do not delay pessary removal in the presence of erosions, as continued mechanical trauma prevents healing and risks progression to ulceration, bleeding, or perforation 3, 1.
Do not place synthetic mesh in patients with concurrent vaginal erosions, urethrovaginal fistula, or recent tissue injury, as this dramatically increases risk of mesh-related complications 3.
Do not assume single pessary failure means pessary management is impossible—double pessary technique can successfully manage severe prolapse in women requiring conservative treatment 1.
Do not ignore vaginal pH assessment, as alkaline pH indicates disrupted microbiota requiring targeted therapy beyond simple estrogen replacement 2.
Postoperative Management (If Surgery Performed)
Measure post-void residual volume routinely after prolapse surgery to identify urinary retention, which occurs in 3-8% of patients depending on technique 6, 7.
Implement multimodal, opioid-sparing analgesia with scheduled ibuprofen and acetaminophen for adequate pain control 6.
Remove urinary catheters early after a short drainage period to reduce recatheterization rates and bladder infections 6.
Perform pelvic examination at follow-up using POP-Q staging to document anatomic outcomes in all compartments 6.