hpv-vaccino-cancro-utero Prolasso utero-vaginale

Utero-vaginal prolapse: what is the indicated treatment?

By Cristiano Antonino On Nov 21, 2022

Utero-vaginal prolapse is an extremely topical pathology because, as the average age of women has increased, more and more women are confronted with this gynaecological pathology

Failure of the supporting structures of the female genital apparatus leads to a series of problems that affect a woman’s quality of life

In fact, prolapse causes discomfort when the woman walks, sits or during sexual intercourse; it also interferes with the function of the bladder and rectum, leading, in the first case, to urinary incontinence, difficulty urinating and recurrent urinary infections, and in the second case to altered bowel movements, such as difficulty defecating.

This requires a new awareness of the problem on the part of the woman and a new approach on the part of the gynaecologist in assessing the woman’s characteristics in order to identify the most appropriate therapeutic treatment, which may be pharmacological, rehabilitative and/or surgical.

The therapeutic programme cannot, however, be stereotyped, but must be customised, quantifying the objective entity of the prolapse and evaluating above all the subjective importance of the disorders.

It is clear that mild asymptomatic uterine-vaginal prolapse should not be treated surgically, as surgery could lead to a worsening of the quality of life, causing symptoms that were initially non-existent.

It will then be intervened with appropriate medication or exercises to restore the muscular function of the pelvic floor, which is fundamental in supporting the pelvic viscera.

There is no age limit to surgery today: thanks to advances in perioperative procedures and anaesthesiological techniques, even elderly women, often over 80, undergo surgery when disabled by prolapse.

The four degrees of utero-vaginal prolapse

Utero-vaginal prolapse is the downward descent of the uterus and vaginal walls, associated with the bladder and rectum.

Depending on the extent of the descent of the viscera, four degrees of prolapse are distinguished:

1st degree: when the organ is still contained in the vaginal canal;

2nd degree: when it protrudes into the vaginal introitus;

3rd grade: when it protrudes outside the introitus;

4th grade: when it is completely outside.

Prolapse represents one of the most frequent pathologies affecting women, since more than 50% of them show a deficit of pelvic support and in 10-20% of these cases significant clinical symptoms are present.

Normally, these pelvic viscera are held in their anatomical position by two types of supports; a support system, represented by the pelvic floor muscles, especially the elevator muscle of the anus; and a suspension system, constituted by the connective tissue of the endopelvic fascia, especially the cardinal and uterosacral ligaments.

These supports in the course of life can be altered by traumatic insults or cellular ageing.

Utero-vaginal prolapse: what are the causes

The most common causes of utero-vaginal prolapse are childbirth and menopause.

In fact, prolapse is more frequent in multiparous women, while it is rare in nulliparous women; moreover, it tends to occur mainly after the menopause.

In the case of childbirth, during the expulsive period, the fetal head in its progression along the vaginal canal can produce lesions of both muscular and connective structures.

During the menopause, with the cessation of the functional activity of the ovaries, there is a progressive loss of collagen and elastic fibres, resulting in a weakening of the fascial support.

In addition, there are other factors that lead to a chronic increase in abdominal pressure such as coughing, chronic constipation, heavy work activity.

The symptoms of utero-vaginal prolapse

The symptoms of prolapse are related to the degree of prolapse itself and vary from woman to woman.

The most frequently reported symptom is the sensation of the uterus and vagina falling downwards, like a foreign body.

If a cystocele or rectocele is present, other complaints are associated.

The cystocele causes difficulty urinating and often forces the woman to urinate in a semi-sitting position until she has to manually reposition the prolapse to urinate; at other times there is an involuntary loss of urine with exertion; in other cases there may be urinary urgency, with or without incontinence, frequent daytime and nighttime urination.

The rectocele is almost always asymptomatic although high degrees may cause some difficulty in defecation, forcing the woman to reposition the rectocele in order to defecate.

Often a problem in sexual intercourse, with or without pain, is also reported by the woman.

Urinary incontinence, when present, is the most serious disorder from a hygienic-social point of view.

It is of fundamental importance, for an adequate therapeutic approach, to distinguish between urge incontinence (IUS), i.e., loss of urine after an effort such as a cough, a sneeze, etc., and urge urinary incontinence, i.e., loss of urine following an intense urge to urinate.

In fact, stress incontinence, in general, is treated, in the first instance, with pelvic floor rehabilitation and only after failure of the latter, with surgical correction (mini-slinging); urge incontinence, on the other hand, has no surgical indication, but only medical-rehabilitation.

In particularly complex cases or in women who are to undergo surgery, a further instrumental evaluation through urodynamic examination is necessary, which allows us to better characterise the patient’s urinary function.

Finally, it is important to consider the possibility of stress urinary incontinence, masked by the prolapse, which must be detected with repositioning manoeuvres of the prolapse itself, during the uro-gynaecological evaluation.

In fact, the presence of a voluminous cystocele determines a kneeling of the urethra that prevents the escape of urine on exertion, masking incontinence, which may occur after surgical repair of the prolapse.

Utero-vaginal prolapse treatment and pelvic floor rehabilitation

The aim of utero-vaginal prolapse treatment is to restore a satisfactory quality of life for the woman.

The objectives of the therapy are essentially four

eliminate symptoms
restore anatomy
re-establish normal function
ensure a lasting result.

The challenge is to achieve these results without resorting to surgery.

The 3 fundamental steps to achieve this are

pelvic floor rehabilitation combined with postural rehabilitation;

local oestrogen therapy or, very recently, prasterone vaginally, in menopausal women;

use of the new silicone pessaries, both cube and ring, for women with utero-vaginal prolapse, or the use of bowl pessaries with urethral support for women with prolapse and associated or masked IUS.

Pelvic floor rehabilitation includes Biofeedback, Functional Electrostimulation and Kinesiotherapy

Biofeedback allows the woman to become aware of a part of the body that is normally unfamiliar (1 in 2 women cannot move her pelvic floor in a coordinated manner on command).

Often during the contraction attempt she moves the abdominals, buttocks and adductors simultaneously: the aim of Biofeedback is to eliminate antagonistic (abdominals) and agonistic (adductors and buttocks) synergies.

This is done by inserting a probe into the vagina and two adhesive electrodes on the abdomen: a device connected to the transducers shows the patient the result of the muscular contraction, so the woman learns to separate the perineal contraction from the abdominal contraction.

In cases where there is little control of the muscles, Functional Electrostimulation can be used, with the aim of determining a passive contraction of the pelvic floor muscles that the patient gradually learns to control.

When pelvic floor muscle awareness is achieved, we proceed with Perineal Kinesiotherapy, which is the cornerstone of rehabilitation therapy.

The patient is taught a series of muscle contraction and relaxation exercises that she can perform at home.

Crucially, the woman then uses the pelvic floor every time she has to exert herself, in order to support the pelvic viscera and correct the IUS associated or not with prolapse.

Postural rehabilitation should always be associated with this perineal care: in the standing woman, correct pelvic tilt allows the discharge of endo-abdominal forces into the sacral concavity.

When this inclination is altered, due to phenomena of increase or reduction of the physiological lumbar lordosis, the resultant vector of the endo-abdominal forces is anteriorised and discharges on the uro-genital hiatus, a weak point of the pelvic floor, determining, in subjects who already have sub-clinical fascial lesions, a progressive descensus of the endopelvic viscera with the appearance or aggravation of utero-vaginal prolapse and/or IUS.

In postmenopausal women, the use of local oestrogens is then fundamental, which allow the restoration of optimal vaginal trophism, with disappearance of vaginal dryness and consequent discomfort during intercourse, marked improvement in irritative urinary disorders and resolution of the sense of weight and bulk in initial prolapses.

New therapeutic strategies

But the innovation that has revolutionised the therapeutic strategy in utero-vaginal prolapse is the new silicone pessaries, ring or cube-shaped.

In our Urogynaecology Centre, thanks to the use of these devices, it has been possible to reduce surgical interventions by more than half, and we currently only operate on women who refuse the pessary or those who, despite several attempts with different pessaries, do not have a satisfactory restoration of their quality of life.

The cube pessary consists of a silicone cube, of various sizes, which is inserted by the patient in the morning and removed in the evening.

The prolapse is a problem related to standing: when the woman is in bed, she does not need the pessary because the prolapse falls back into place.

The advantage of removing it at night is that the small erosions associated with the persistence of a pessary in the vagina for months, which occurs with the ring pessary, are eliminated.

For women who have difficulty putting on and taking off the cube pessary, a silicone ring can be proposed that is removed by the doctor every 6 months and reinserted after a 20-30 day break.

Women who report IUS with these pessaries can be treated with urethral-supported bowl pessaries, which obviate the reported discomfort.

Treatment with pessaries can last a lifetime without any major side effects and can be used at any age: it allows one to perform any activity without having any prolapse-related discomfort.

Surgical treatment for utero-vaginal prolapse

It is important to consider that the best results are obtained from the integration of the three mentioned methods (rehabilitation, oestrogen and pessaries) with a complete restoration of the quality of life.

As for surgery, it should only be reserved for failures of conservative management or for women who require surgery.

There are more than 120 operations described for the treatment of utero-vaginal prolapse, with different approaches, vaginal, laparoscopic and robotic, and with often very variable results and complications.

In our School, the prolapse to be operated on is treated 98% of the cases vaginally and only 2% of the cases are managed laparoscopically (essentially very young women, 35 to 50 years old, and/or wishing to preserve the uterus) with Dubuisson’s operation (hysterocystoplasty using titanised polypropylene mesh suspended ‘tension-free’ from the fascia of the oblique muscles of the abdomen.

For the correction of total prolapse, the surgery we propose is a colpohysterectomy with a minimally invasive technique, urethrocystoplasty according to Lahodny modified with Prolene Mesh, Nichols-type rectopexy and colpoperineoplasty.

Thanks to this type of surgery, which we have been performing for more than 20 years, with the necessary technological evolutions implemented over time, we have a cure rate on prolapse of around 90% and on IUS associated or masked by prolapse of around 85%.

All the new surgical proposals, prosthetic or not, laparoscopic or robotic that have come out in these 20 years, have not yet given better results than these at an average follow-up of about 10 years.

The risks of operations to correct a utero-vaginal prolapse are the general risks associated with surgical operations: anaesthesiological, haemorrhagic, infectious, thrombo-embolic risks and iatrogenic bladder, ureteral, intestinal and rectal injuries.

In addition, the typical risks of prolapse surgery must be considered:

prolapse recurrence, which usually appears after a short time, when the factors that caused its onset persist;
urination abnormalities: permanence or appearance of urinary incontinence;
appearance of obstructive phenomena or urinary retention in the case of overcorrection (10-15% of cases);
appearance of areflex bladder, often linked to denervation of the bladder;
disturbance in sexual intercourse, due to loss of vaginal ability, resulting in dyspareunia.

Which approach to choose?

The treatment of utero-vaginal prolapse should always be conservative, also in deference to our famous aphorism “Primum, non nocere”.

The results of surgery, in expert hands, are very good, but unfortunately there always remains a certain unavoidable significant percentage of possible complications and/or prolapse recurrences.

Therefore, given the total absence of complications and the high cure rate of conservative treatment, I always recommend an initial rehabilitative approach, with the associated use of pessaries and local oestrogen, when indicated, reserving the operating theatre only for selected cases in which, the patient’s will or the failure of pessaries, necessitates a surgical response.