Description

• Uterine prolapse occurs when the integrity of pelvic supporting structures is lost. This allows the uterus to descend into the vagina. In advanced cases, complete protrusion with inversion of the vagina occurs, known as procidentia.
• Before menopause, the degree and severity of prolapse are usually related to the number of pregnancies and the difficulty of childbirth. After menopause, atrophy and loss of tissue integrity can lead to further prolapse.
• System(s) affected: Gastrointestinal; Renal/Urologic; Reproductive
• Synonym(s): Uterine prolapse; Genital prolapse; Genital relaxation; Uterine descensus; Total or partial procidentia; Dropped uterus

Geriatric Considerations
This is largely a disease of aging, and incidence will be much higher as the median age of the population increases.

Pediatric Considerations
Prolapse in newborns has been reported, but it is rare and usually associated with congenital disorders and neuropathies.

Epidemiology

• Annual incidence ∼2%
• Predominant age: Perimenopausal and postmenopausal women
• Predominant sex: Female only

Prevalence
∼30–50% of women experience some degree of prolapse.

Risk Factors

• Childbirth, particularly multiple parity
• Vaginal delivery, especially operative vaginal delivery
• Advancing age
• Caucasian or Hispanic (4–5-fold increased risk compared to African Americans)
• Tobacco use
• Occupations requiring heavy lifting
• Various connective tissue and neurogenic disorders
• Conditions resulting in increased intra-abdominal pressure (e.g., obesity, abdominal or pelvic tumors, pulmonary disease with chronic coughing, chronic constipation)
• Estrogen-deficient state

• More common among Caucasians
• Less common among Asians and African Americans, and particularly uncommon in South African Bantus and West Africans

General Prevention

• Kegel exercises increase the strength of the pelvic diaphragm muscles and may provide some pelvic support.
• Weight loss and proper management of conditions that increase abdominal pressure help to prevent prolapse.
• Tobacco cessation
• Postmenopausal estrogen replacement therapy

Etiology

• Advancing age and vaginal childbirth are the most important factors.
• Incidence of prolapse increases with frequency and difficulty of vaginal deliveries (e.g., operative vaginal delivery); <2% of prolapse occurs in nulliparous women.
• Although this disorder in large part results from the distension and distortion of supporting tissues with vaginal childbirth, pregnancy, regardless of mode of delivery, may contribute to prolapse.
• Other less common causes of prolapse include connective tissue disorders with lax tissue (e.g., Marfan syndrome), neurogenic disorders (e.g., multiple sclerosis), cloacal agenesis, chronic constipation, pelvic tumors or ascites, and chronic coughing resulting from chronic lung disease.
• Patients who have undergone radical vulvectomy with loss of the external supporting structures have a higher rate of prolapse.

Commonly Associated Conditions

Cystocele, rectocele, enterocele, and vaginal vault prolapse are often associated with uterine prolapse.