A prolapsed uterus is when the uterus (womb) moves downward from its normal position - this can happen when the tissues that normally support the uterus (the pelvic floor muscles and ligaments) become stretched and weak. Prolapsed uterus (also called uterine prolapse) is a common condition that can affect a woman's physical and sexual activity as well as her quality of life.
The uterus, along with other organs of the pelvis, is normally supported by layers of pelvic floor muscles which are slung like a hammock from the public bone to the tailbone from front to back and also from side to side across the bottom of the pelvis. With a uterine prolapse, these muscles, as well as ligaments and other pelvic tissues, don’t provide their normal support, and the uterus may push downwards.
The uterus can drop down into the vagina, and even sit close to the vaginal opening, occasionally protruding through it. The bladder and bowel can also protrude into the vagina - this is known as pelvic organ prolapse.
Doctors classify uterine prolapse into 4 stages:
- Stage 1 – the uterus is in the upper part of the vagina
- Stage 2 – the uterus has moved down to the opening of the vagina
- Stage 3 – part of the uterus is bulging out of the vagina
- Stage 4 – the uterus is completely out of the vagina
You may have no symptoms if your uterine prolapse is only mild.
The most common symptom of a prolapsed uterus is the awareness of a heaviness in the vagina and a sensation of 'something coming down'. Sometimes a woman can feel a distinct lump or bulge in her vagina or even have tissue protruding through the vaginal opening. These symptoms usually improve when lying down and are less noticeable in the morning, getting worse during the course of the day or after exertion.
Uterine prolapse may also cause:
- urinary problems such as difficulty passing urine or emptying the bladder completely;
- problems holding urine (bladder leakage or urinary incontinence);
- frequent urinary tract infections;
- discomfort or pain during sexual intercourse; or
- difficulty having bowel movements.
In some women, the vagina, bladder or bowel prolapse - this is called pelvic organ prolapse. You can have more than one type of prolapse at the same time.
The bladder can prolapse or bulge into the front wall of the vagina (this is called a cystocoele) or the bowel can prolapse into the back wall of the vagina (called a rectocoele or enterocoele). In severe cases the pelvic organs can prolapse outside the vaginal entrance.
What causes a prolapsed uterus?
Prolapsed uterus is caused by weakness of the pelvic floor muscles and ligaments that hold the uterus in place. Factors that increase the risk of uterine prolapse include the following.
- Giving birth vaginally is probably the single biggest risk factor for developing a uterine prolapse. This risk is increased if the baby was large, if the pushing stage during labour was prolonged, or if the delivery was by forceps or resulted in a third-degree tear (a tear into the tissues of the anus or back passage). The risk is also increased if you’ve had multiple vaginal births.
- Pregnancy, which puts a significant strain on the pelvic floor, is also a risk factor.
- Being overweight or obese increases your risk of prolapsed uterus.
- Deterioration of muscles, ligaments and connective tissue that occurs with age and low levels of oestrogen after menopause. This can affect the tissues that hold the uterus in place.
- Increased pressure within the abdomen, which often occurs with constipation and straining on the toilet, chronic (ongoing) cough and frequent heavy lifting.
- An inherited tendency to weakness in the ligaments and other connective tissues.
Tests and diagnosis
Your doctor will probably be able to diagnose uterine prolapse based on your symptoms and a vaginal examination. They may refer you to a gynaecologist (specialist in conditions affecting a woman’s reproductive organs) or urogynaecologist (a gynaecologist that sub-specialises in problems with the pelvic floor and bladder) for further assessment and treatment.
Imaging tests, such as a special pelvic floor ultrasound, may be done to assess the degree of prolapse and the state of the pelvic floor muscles. This type of ultrasound involves the transducer (the hand-held device that generates the images) being applied to the labia or perineum (the area of skin between your vagina and anus).
An advanced prolapsed uterus can cause trouble emptying the bladder. A bladder ultrasound can show if there is any urine remaining after trying to empty the bladder. If you have significant urinary symptoms, your doctor may recommend that you have special tests of your bladder function (urodynamic tests).
Treatment for uterine prolapse
Treatment for prolapsed uterus will depend on your symptoms and the degree of prolapse. Women with no symptoms may not need any specific treatment.
Self-care measures are often all that is needed for women with mild prolapse and few symptoms. Self-care measures that your doctor may suggest include:
- regularly doing pelvic floor muscle exercises, which can help improve symptoms and prevent worsening prolapse;
- losing weight if you are overweight;
- avoiding and treating constipation; and
- avoiding anything that makes the condition worse, such as heavy lifting.
You can also see a physiotherapist who specialises in pelvic floor muscle exercises and treatment to ensure that you are doing the exercises properly and for further tips on strengthening your pelvic floor.
Uterine prolapse can be treated with a vaginal pessary - a flexible device that is inserted into the vagina to help keep prolapsed pelvic organs in place. A pessary may be recommended for women with uterine prolapse symptoms who wish to have more children, or for those who are not well enough or do not wish to have an operation. Vaginal pessaries are usually effective at relieving symptoms.
There are many types of pessary available, but ring pessaries, which are shaped like a doughnut, are often recommended. The pessary is individually fitted and positioned to prop up the cervix and the uterus. You shouldn’t be able to feel the pessary when it is the right size, and you can have sex when it is in place. Your doctor may recommend using vaginal oestrogen cream while using the pessary, as well as taking it out at night once a week.
There are few side effects associated with vaginal pessaries. It is possible for a pessary that is not the right size to come out of the vagina. Rarely, pessaries can cause a pressure area in the vagina. Let your doctor know if you have any discomfort, unusual vaginal bleeding or discharge while using the pessary.
Pessaries generally need to be changed regularly - about every 3 to 6 months. Some women can change their own pessary, while others need to have it done by a healthcare professional.
Surgery for prolapsed uterus
Surgery may be recommended if other treatment options have failed. Doctors usually only recommend surgery if you do not wish to have any future pregnancies.
There are different types of surgery used for pelvic organ prolapse. Surgery may involve tissue repair or reconstructive surgery to support the pelvic organs. The uterus is may also be removed (hysterectomy). Laparoscopic (keyhole) surgery is often an option.
Some surgeries involve the use of synthetic mesh to hold the pelvic organs in place. Currently, there is no scientific evidence to support the use of polypropylene mesh repairs due to the increased risk of side effects with this type of surgery and a lack of evidence of long-term effectiveness.
Even after surgery, prolapse can happen again, with either the same or a different type of prolapse. Surgery can also cause new symptoms, such as stress incontinence (leakage of urine when coughing or straining). However, for many women, surgery improves their quality of life.
Prevention of prolapsed uterus
You may not be able to prevent uterine prolapse, but you can reduce your risk by:
- keeping your weight in the normal range;
- practising pelvic floor exercises regularly, preferably daily;
- avoiding constipation and straining with bowel movements by eating a balanced diet that contains adequate fibre; and
- avoiding heavy lifting.
If you have a lung or breathing condition that can cause frequent coughing, talk to your doctor to make sure that your treatment is optimised to limit coughing, if possible.
446-452. http://www.racgp.org.au/afp/2015/july/pelvic-organ-prolapse-%E2%80%93-a-review/ (accessed Sep 2017).
2. MayoClinic.com. Uterine prolapse (updated 2 Aug 2017). http://www.mayoclinic.org/diseases-conditions/uterine-prolapse/home/ovc-20343708 (accessed Sep 2017).
3. Royal Australian and New Zealand College of of Obstetricians and Gynaecologists (RANZCOG). Polypropylene vaginal mesh implants for vaginal prolapse (November 2016). https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Polypropylene-vaginal-mesh-implants-for-vaginal-prolapse-(C-Gyn-20)-Review-November-2016.pdf?ext=.pdf (accessed Sep 2017).
4. BMJ Best Practice. Uterine prolapse (updated 25 Jan 2016). http://bestpractice.bmj.com/best-practice/monograph/659.html (accessed Sep 2017).
5. Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Brown J. Surgery for women with anterior compartment prolapse. Cochrane Database of Systematic Reviews 2016, Issue 11. Art. No.: CD004014. DOI: 10.1002/14651858.CD004014.pub6. http://www.cochrane.org/CD004014/MENSTR_surgical-management-pelvic-organ-prolapse-women (accessed Sep 2017).