In uterine prolapse the uterus drops down into the vagina because the pelvic floor muscles and ligaments have weakened, most often after vaginal births, with aging and after menopause. It ranges from a mild descent to a uterus that comes fully outside the vaginal opening.
Key symptoms
- Feeling of a bulge or something coming down in the vagina
- Pelvic heaviness or pressure, worse at the end of the day or after standing
- Urine leakage, slow stream or feeling the bladder does not empty
- Trouble passing stool; may need to press on the vagina to empty the bowel
- Discomfort during sex or a low backache
What you find on exam
- Pelvic exam at rest and while bearing down, standing if needed
- Cervix seen moving down toward or past the vaginal opening
- Stage with the POP-Q system; check the front and back vaginal walls too
- Ulcers or thickened skin on an exposed cervix; pelvic floor muscle strength
Tests
- Diagnosis is clinical from the exam
- Urinalysis and post-void residual with a bladder scanner for urinary symptoms
- Urodynamic testing before surgery in selected patients
- Pelvic ultrasound or biopsy only if bleeding or a mass suggests another problem
Treatment basics
- Mild and not bothersome: reassurance and observation
- Pelvic floor muscle training, weight loss, treat constipation and chronic cough
- Vaginal pessary fitted to support the uterus; vaginal estrogen for thin tissue
- Surgery: hysterectomy with apical suspension or a uterus-sparing repair
Red flags
- Unable to urinate, or kidney swelling (hydronephrosis) from a kinked ureter
- Prolapse that cannot be pushed back, with pain or dark tissue
- Bleeding or an ulcer on prolapsed tissue that does not heal
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.