What is the recommended evaluation and management of a retroverted uterus in asymptomatic and symptomatic women, including treatment options and considerations during pregnancy?

Retroverted Uterus: Evaluation and Management

Asymptomatic Retroverted Uterus

In asymptomatic women, a retroverted uterus is a normal anatomical variant found in 16-18% (1 in 6) of women and requires no treatment or intervention. 1

• The retroverted uterus is most commonly asymptomatic and should be considered a normal variant rather than a pathological condition 1
• Prevalence increases in the presence of pelvic floor dysfunction, but the retroversion itself does not necessitate treatment when asymptomatic 1
• The etiology is primarily developmental with limited acquired components, and there is a familial tendency 1

Symptomatic Retroverted Uterus

Clinical Presentation to Evaluate

When symptoms are present, focus on three key clinical domains: chronic pelvic pain/dyspareunia, voiding dysfunction, and defecatory dysfunction. 2, 1

• Pelvic pain symptoms: Chronic pelvic pain, dyspareunia (pain with intercourse), and dysmenorrhea may be associated with a retroverted uterus 2
• Urinary symptoms: Both acute and chronic voiding dysfunction can occur, including acute urinary retention (particularly dramatic in pregnancy) and chronic voiding difficulties 1
• Bowel symptoms: Defecatory dysfunction may be present, sometimes with cyclical patterns 1
• Physical examination: Pain should be reproducible by palpation of the retroverted uterus during bimanual examination 2

Diagnostic Workup for Symptomatic Cases

• Ultrasound imaging should be performed to identify any uterine or ovarian abnormalities and rule out other pathology 2
• The degree of retroversion should be assessed, including whether retroflexion of the uterine fundus is additionally present 1
• Evaluate for associated pelvic floor dysfunction, as the retroverted uterus has significant associations with uterine/pelvic organ prolapse and some types of vaginal prolapse 1

Management of Symptomatic Retroverted Uterus

Conservative Management

For symptomatic retroverted uterus without prolapse, surgical uterine suspension should be considered when symptoms are clearly attributable to uterine position and reproducible on examination. 2

• Laparoscopic uterine suspension (UPLIFT procedure) using the Carter-Thomason needle point suture passer repositions the uterus to a mildly anteverted position 2
• In a series of 75 patients, pain with menses decreased from 8.4 to 1.7 (scale 0-10), and pain with intercourse decreased from 8.1 to 1.5 (P < .01) 2
• For patients where retroverted uterus was the only significant pathologic finding, 90% (18/20) had immediate and sustained relief from symptoms 2
• The procedure takes an average of 12 minutes, is performed as outpatient surgery with same-day discharge, and has minimal complications (7% delayed postoperative pain requiring analgesia) 2

Management of Symptomatic Prolapsed Retroverted Uterus

• Symptomatic cases with a prolapsed retroverted uterus may require surgical relief 1
• Standard prolapse repair techniques should be employed based on the degree and type of prolapse present 1

Special Consideration: Retroverted Gravid Uterus

Acute Urinary Retention in Pregnancy

Acute urinary retention secondary to retroverted gravid uterus is a medical emergency requiring immediate bladder catheterization followed by manual replacement of the uterus into an anterior position. 3, 4

• The pathophysiology involves the cervix being displaced superiorly and anteriorly by the impacted retroverted uterus, compressing the lower bladder and obstructing the internal urethral orifice 4
• The urethra itself is not compressed or distorted; the obstruction occurs at the bladder level 4
• Initial treatment consists of bladder catheterization followed by manual replacement of the uterus 3
• Alternative management includes chronic bladder drainage until the uterus ascends out of the pelvis spontaneously 3

Prevention of Recurrent Urinary Retention in Pregnancy

After initial treatment, implement these specific preventive measures 4:

• Limit fluid intake before sleep 4
• Change from supine to prone position before getting up 4
• Avoid Valsalva maneuver during voiding 4
• Perform Credé maneuver (manual bladder compression) during voiding 4
• These measures successfully prevented recurrence in all but one case (4/5 patients) 4

Common Pitfalls to Avoid

• Do not attribute all pelvic pain to uterine retroversion without ruling out other pathology: Always perform ultrasound to exclude uterine fibroids, ovarian masses, or endometriosis 2
• Do not assume retroversion is pathological in asymptomatic women: The vast majority of retroverted uteri are normal variants requiring no intervention 1
• Do not miss acute urinary retention in pregnant women with retroverted uterus: This obstetric emergency requires immediate recognition and treatment 3, 4
• Do not perform uterine suspension surgery without confirming symptoms are reproducible on examination: Pain should be clearly attributable to uterine position before proceeding with surgical intervention 2