Definition/Description

Uterine prolapse is the condition of the uterus collapsing, falling down, or downward displacement of the uterus with relation to the vagina.[1] It is also defined as the bulging of the uterus into the vagina.[2] [3]

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When in proper alignment, the uterus and the adjacent structures are suspended in the proper position by the uterosacral, round, broad, and cardinal ligaments. The musculature of the pelvic floor forms a sling-like structure that supports the uterus, vagina, urinary bladder, and rectum.[2] Uterine prolapse is a result of pelvic floor relaxation or structural overstretching of the muscles of the pelvic wall and ligamentous structures.

Uterine prolapse is characterized under a more general classification called pelvic organ prolapse which encompasses descent of the anterior, middle and posterior structures into the vagina.[5]

Those organs that bulge anterior into the vagina are the urinary bladder which is called a cystocele, the urethra, which is called a urethrocele or a combination, which is a cystourethrocele.[2],[5] The uterus and the vaginal vault, which is the apex of the vagina, make up the organs that constitute the middle portion descent into the vagina. The vaginal vault often prolapses as a result of a hysterectomy.[5] The rectal bulge is called a rectocele and a bulge of part of the intestine and peritoneum is called an enterocele, these make up the posterior portion of pelvic organ prolapse.[2],[5] The information from this point forward will focus on uterine prolapse.

Uterine prolapse is classified using a four part grading system: Grade 1: Descent of the uterus to above the hymen Grade 2: Descent of the uterus to the hymen

Grade 3: Descent of the uterus beyond the hymen Grade 4: Total prolapse.[5]
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Prevalence
Each source presents with a different prevalence depending on the researcher and the population used. One study stated that the prevalence of pelvic organ prolapse, a clinical classification for all of the pelvic structures prolapse into the vagina, was 50% for women who have give birth, though most women are asymptomatic.[5]Another article cited that 50% of the female population in the United States are affected by pelvic order prolapse with a prevalence rate that can vary from 30% to 93%, varying among different populations.[7] A questionnaire based study stated that 46.8% of the responses were positive for symptoms of pelvic organ prolapse and of the response group, 46.9% were vaginally examined with 21% having clinically relevant pelvic organ prolapse. [8]

Characteristics/Clinical Presentation
The primary symptoms of a uterine prolapse are backache, perineal pain, and a sense of "heaviness" in the vaginal area.[2] Pain associated with uterine prolapse can be located centrally or suprapubic, and can be described as "dragging" in the groin. This pain is due to stretching of the ligamentous supports and secondarily to abrasion of the prolapsed tissues.[1] If the prolapse has progressed into a grade three or third degree prolapse, the person may feel as though they have a lump at the vaginal opening and have irritation and abrasion of the exposed mucous membrane of the cervix and vagina. This is possible both during sexual intercourse and from wiping with toileting procedures. The person may report that the symptoms are relieved by lying down and exacerbated with prolonged standing, walking, coughing or straining. An associated and often common complication of uterine prolapse is urinary incontinence.[2] Other descriptions used are the feeling of sitting on a small ball and a report of repeated bladder infections.[9]

Summary from Differential Diagnosis for Physical Therapists:


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Lump in vaginal opening Pelvic discomfort, backache Abdominal cramping Symptoms relieved by lying down Symptoms made worse by prolonged standing, walking, coughing, or straining Urinary incontinence

Associated Co-morbidities
Obesity is a co-morbidity that often leads to progression and complication with uterine prolapse. In a study by the NIH over a five year period, 55.7% of the women in the study gained weight and the rate of prolapse increased from 40.9% to 43.8%. Looking specifically at uterine prolapse, when comparing participants with healthy BMIs to overweight and obese persons, the risk of prolapse increased by 43% and 69%, respectively. However, the loss of weight did not presuppose a reversal of the uterine prolapse.[7] Other associated diseases that exacerbate uterine prolapse are chronic constipation and chronic obstructive pulmonary disease (COPD) due to the relationship between increased intra-abdominal pressure (bearing down) with increase in severity of the prolapse.[11]

Medications

Hormone replacement therapy in the oral or vaginal form is indicated or a possible treatment to assist in maintaining elasticity of the pelvic floor musculature.[2][5]
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Women who have damage to tissue during childbirth do not frequently notice the laxity and pelvic relaxation until they enter menopause. Vaginal tissue and supporting structures depend on estrogen for their strength and elasticity. As estrogen levels decrease in certain situations (menopause and breast feeding mothers), the symptom become more apparent. Estrogen replacement can come in the form of pills, vaginal rings, patches, or vaginal creams and are often indicated for lower grades of prolapse as the primary form of treatment. More severe prolapse is less likely to respond to estrogen therapy alone, however, it can be used as an adjunct to other treatments. Estrogen replacement can also be used after surgery to maintain results of surgery and help to revitalize dry and thin vaginal tissue.[13]

Diagnostic Tests/Lab Tests/Lab Values

Observation is often the first means of diagnosis.[2] Physical examination is the primary means for diagnosis. A bimanual test is performed with a speculum while the person is at rest and when the person is straining. If prolapse is not apparent with the first method, the person repeats the test while standing with one foot on a chair. The person is then graded using a first through third degree categorization. A first degree prolapse is characterized by descent of the uterus to above the hymen. A second degree prolapse is to the level of the hymen and a third degree prolapse is below the level of the hymen and protrudes through the vaginal opening.[2] Urine culture is ordered if needed. If still unsure about the diagnosis, a pelvic ultrasonography or cystography can be ordered.[5]

Causes
Women most at risk for this condition are those who have had multiple pregnancies and deliveries in combination with obesity. Associated risk factors are trauma to the pudendal or sacral nerves when giving birth. The disorder has been attributed to prolonged labor, bearing down before full dilation, and forceful delivery of the placenta. Decreased muscle tone due to aging, excessive strain during bowel movement and complications of pelvic surgery have also been associated with prolapse of the uterus and adjacent organs.[2] Associated risk also exists with pelvic tumors and neurologic condition like spina bifida and diabetic neuropathy which interferes with innervation of pelvic musculature.[2] Genetics are suspected in this condition due to multiple familial relations and generations with this and related conditions.[13] A recent article has found that Cesarean section may lower the risk for pelvic organ prolapse.[14] Summary of Causes:

Multiple pregnancies and deliveries Obesity Trauma to pudendal or sacral nerves Aging related muscle changes Excessive strain during bowel movements Pelvic tumors Genetic predisposition

Systemic Involvement
The digestive and urinary system can be impacted by uterine prolapse if the uterus obstructs the bladder/urethra and the rectum, decreasing the ability to void.[15] The reproductive system can also be impacted by painful intercourse, decreasing the ability for reproduction.[1]

Medical Management (current best evidence)

Corrective Surgery Corrective surgery was a once popular first step for uterine prolapse but has fallen second choice to rehabilitation. When surgery is indicated, it is a management tool for second, third, and fourthdegree uterine prolapse.[2] Pelvic organ prolapse surgery has a success rate of 65% to 90% and has a repeated rate of operation at 30%. Patients who have more than one compartment involved may need a combination of surgeries and surgery can often predispose patients to prolapse in another compartment. Surgery can be either open or laparoscopic of the abdomen or can be in the vagina using fasciae, mesh, tape or sutures to suspend the organs. Another surgical procedure that is used in attempt to conserve the uterus is a sacrohysteropexy which is a Y-shaped graft that attaches the uterus to the sacrum.[5] One case study that examined the effectiveness in laparoscopic sacrohysteropexy, stated that this procedure maintains durable anatomic restoration, normal vaginal axis and sexual function. It also requires less time and less adhesion

formation due to the laparoscopic approach versus an abdominal route.[16] Vaginal hysterectomy, vesicourethral suspension, and abdominal hysterectomy are other possible approaches.[2] Important components for consideration of a surgical approach are:

Degree of prolapse Desire for future pregnancies Other medical conditions The woman's desire to retain vaginal function The woman's age and general health[9]
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Pessary A pessary is a shaped device made to support the uterus in the vagina. This is often a non-surgical approach used for both uterine prolapse and urinary incontinence. There is a supportive type for milder prolapse and a space-occupying type for more serious prolapse. The goal of the pessary is to find the largest fit that is comfortable. They are to be removed regularly for cleaning by the individual with correct education or by a health care professional.[5] There are rings, rings with a rubber support, cubes, donut shapes and inflatable balls. Depending on the degree of prolapse will determine the type that is chosen. [13]Patients who are not eligible for use of a pessary are those who cannot perform maintenance care of the pessary, those with vaginal ulcerations or lesions, severe atrophy of the vagina and women who develop recurrent vaginitis.[18] Signs of improper fit are: those who have pain when wearing the pessary, vaginal ulceration and infection, and the inability to have a bowel movement or urinate.[13]

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No Treatment Surgical treatment is not appropriate when the woman has recently had a baby. Tissue damaged during childbirth that has caused an associated prolapse, often begins to improve when undergoing tissue healing. A symptomatic prolapse in the first few weeks after delivery, especially in breastfeeding mothers have lower estrogen levels, does not necessarily predispose the mother to long term issues. Improvement tends to occur after discontinuation of nursing and the return of normal hormone levels. Other women and/or physicians do not elect for medical treatment for Stage 1 and Stage 2 prolapse and take a wait and see approach.[13]

Physical Therapy Management (current best evidence)

Pelvic floor strengthening exercise is currently the front line treatment before surgery and also following surgery, these include but are not limited to Kegel exercises.[2][5] Other methods currently used are pelvic floor musculature re-education, postural education, biofeedback and electrical stimulation.[2] Pelvic Floor Training Pelvic floor muscles are seventy percent slow-twitch muscle fibers, which assist in muscle endurance with generation of slow and sustained contractions. These muscles are designed to have a less intense contraction, whereas the other thirty percent, which are fast twitch, are designed for quick and forceful contraction. An example of fast twitch muscles are the muscles that close the urethra during increased intra-abdominal pressure.[20] Pelvic floor training is progressive resistive exercises for the pelvic floor that are often titled Kegel exercises. These exercises improve urethral resistance and pelvic visceral support by increasing the voluntary periurethral muscles. Pelvic floor exercises enhance the voluntary closing mechanisms. A thorough assessment of pelvic floor function is necessary to determine the muscular strength and endurance by manual muscle test. [21] Kegel exercises are often explained as contracting the muscles that stop the flow of urine. A sustained pelvic contraction for a minimum of two seconds is likely to ensure a better response to physical therapy. A five point rating scale is used to describe the contractile strength during pelvic musculature examination.

Five-Point Rating Scale Grade Description 0 1 2 3 No contraction

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Flicker, only with muscles stretched Weak squeeze, 2 second hold Fair squeeze with definite "lift" (in which the contraction can be felt to move in an upward direction) Good squeeze, good hold with lift (the contraction must be able to be repeated a few times) Strong squeeze, good lift, repeatable

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One important observation with success of Kegel exercise is the identification of the correct musculature contraction by a specialized Physical Therapist. Approximately 19% to 31% of women who believe they perform Kegels actually perform them correctly. The woman is instructed to contract her muscles around the examiners fingers while the examiner determines if the patient is using auxiliary muscles like the abdomen, gluteals, or thighs. Bearing down is a common mistake when asked to perform a pelvic muscle contraction. Once the women has achieved holding the outer layer of the pelvic floor (bulbocavernosus and ischiocavernosis) in conjunction with higher level muscles like the levator ani, she should attempt to hold both for ten seconds.[22] An article by Lianne Herbruck listed a chart of instructions that summate the correct Kegel exercise procedure for pelvic floor muscle training.

Proper Performance of Kegel Exercises for Pelvic Floor Muscle Training Kegel exercises are performed to strengthen the muscles of the pelvic floor to help increase support
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of the bladder and the urethra. They also can be used postpartum to facilitate circulation to the perineum, which promotes faster healing and increases pelvic floor muscle tone. Have the woman contract the muscles in the perineum/pelvic floor as if she is trying to prevent passage of intestinal gas. (The old adage of "stopping the flow of urine" can actually encourage retention and cause dysfunction of the micturation reflex). She should feel the muscles draw upward and inward. She should avoid straining or bearing-down motions while performing the contractions. (This can be avoided by exhaling gently with an open mouth as she contracts the muscles.) Contractions should be intense, but should not involve abdomen, thighs, or buttocks. The woman should be able to hold this contraction for 5 to 10 seconds, but may need to work up to that. The woman should rest for 10 seconds between contractions. Kegels should be performed at least 10 times, 3 times a day, or from 30 to 80 times a day.
Current research prescribes a frequency of 30 contraction per day with an emphasis on increasing the strength and intensity of the contraction. A greater emphasis is placed on devoting a particular time to exercise and gradually increasing the amount and intensity of the exercise.[22] Though these exercises can improve function, they cannot reverse a Grade 3 or 4 uterine prolapse.[23] These exercises are often indicated as treatment for stress urinary incontinence, pelvic organ prolapse, pelvic pain and defecatory dysfunction.[22] Vaginal Cones This exercise is used as a adjunct to contraction exercises of the pelvic floor. The patient inserts weighted cones into the vagina and is instructed to maintain the position of the weighted cone. This method provides proprioceptive feedback to desired pelvic sustained contraction. [21] This is thought to help improve the tone through active and sustained muscle contraction.[20] Colpexin Sphere The Colpexin Sphere is an intravaginal device that provides support to the pelvic floor musculature and assists in elevation for more effective pelvic floor musculature exercises. "The Colpexin Sphere is a smooth, round sphere made of medical grade polycarbonate plastic with an attached braided nylon string for easy removal. It provides dual benefits for the management of pelvic organ prolapse and improvement of pelvic floor muscle weakness. The Colpexin Sphere is available only by prescription."[24] This is especially helpful for those who have urinary incontinence in association with uterine prolapse. This device is appropriate for candidates who prefer a conservative approach to pelvic floor prolapse management and urinary incontinence.[20] [24]

Biofeedback Biofeedback is used to detect and amplify internal physiological events and conditions using a monitoring instrument. This training helps to develop conscious control over these body processes. The objectives are to assist patients in gaining greater awareness and voluntary control over muscular control and contraction. This allows for a refined control of pelvic floor musculature for functional training. This technique uses a color video screen connected to a computerized unit which monitors different channels using intravaginal probe or surface electrodes depending on the muscles being selected.[21] The identification of the levator ani is important with contraction during the Kegel exercises. If they are weak or absent, physical therapy is indicated.[20] Behavioral modification This technique is used to bring attention to the possible interactions between the patient's symptoms and their environment and provide techniques for behavioral modification. Such techniques consist of conditioning, fluid intake regulation, and use of devices. Bladder training is used for patients with associated incontinence for bladder prompted training, bladder drills, bladder habit training, and bladder retraining. In bladder retraining the patient is to keep a record of voiding activity over seven days and gradually increase increments between urination toward a normal three hour interval. The patient attempts to resist the urge to urinate by squeezing the pelvic floor and sphincter muscles until the urge resolves.[21] Electrical Stimulation Electrical stimulation is used to inhibit the micturition reflex and contract pelvic floor muscles. Using a vaginal or anal probe, the electrical stimulation produces a contraction of the levator ani muscle. Electrical stimulation is also used based on the theory that low-level electrical currents might re-innervate the pelvic floor and change the ratio of slow-to-fast-twitch muscle fibers.[20] Electrostimulation is used in treatment of stress incontinence, enhancing the periurethral sphincter and urge incontinence, inhibiting the overactive detruser muscle. There are no sideeffects except some discomfort but it is contraindicated for pregnancy, vaginal infection, retention and demand pacemaker.[21] Education Education is an important aspect of treatment, especially education on positions of irritation and management of pain. Education plays an important role during exercise and discussion of sexual intercourse with gravity assisted positions. Supine with a pillow or wedge support under the pelvis can be useful position for rest, pelvic floor exercise performance and during intercourse.[1] Education is also important to help the patient understand why maintaining an ideal body weight limits the pressure the abdominal content places on the pelvic floor. Patients also be

instructed to squeeze or perform a Kegel contraction when they are lifting or straining. Discussing bowel habits where the patient does not strain using the pelvic floor when having a bowel movement is an important component of bowel movement retraining. Women should also be advised on correct posture to aid in preventing strain on the pelvic floor muscles.[22]

Currently, there is no treatment protocol that has been shown to be the most effective. Most physical therapist who treat pelvic organ prolapse use pelvic floor muscle training defined as explanation of the anatomy and physiology, verbal explanation of pelvic floor muscle training technique in combination with educational material, biofeedback and electrical stimulation. Most outcome measures are patient-reported symptoms, pelvic floor muscle strength and quality of life. Fewer physical therapist are currently using a prolapse grading system than the above listed outcome measures.[25]

In a study by Jarvis et al., preoperative and postoperative physical therapy was found to improve outcomes (quality of life questionnaire, urinary symptoms, and maximum pelvic floor muscle squeeze on mamometry) compared to a surgical group without per-operative physical therapy. This is an important indicator that physical therapy can play both a preventative role for surgical intervention but also plays an important role when surgery is indicated as the primary treatment.[26]

Alternative/Holistic Management (current best evidence)

Methods considered in association with pelvic floor muscle strengthening are:

weight loss for preventative measures smoking cessation treatment of constipation to decrease intra-abdominal pressure[5] adequate hydration increased fiber intake developing regular bowel habits regular exercise hormone replacement therapy.[2] Education for the use of tight undergarments to help support and relieve symptoms of the prolapse.[22]

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