Introduction

Uterine prolapse most commonly occurs as a delayed result of childbirth injury to the pelvic floor (particularly the transverse cervical and uterosacral ligaments). Unrepaired obstetric lacerations of the levator musculature and perineal body augment the weakness. Attenuation of the pelvic structures with aging and congenital weakness can accelerate the development of prolapse.

In slight prolapse, the uterus descends only part way down the vagina; in moderate prolapse, the corpus descends to the introitus and the cervix protrudes slightly beyond; and in marked prolapse (procidentia), the entire cervix and uterus protrude beyond the introitus and the vagina is inverted. Inability to walk comfortably because of protrusion or discomfort from the presence of a vaginal mass is an indication that surgical treatment should be considered.

Treatment

The type of surgery depends upon the extent of prolapse and the patient’s age and her desire for menstruation, pregnancy, and coitus. The simplest, most effective procedure is vaginal hysterectomy with appropriate repair of the cystocele and rectocele. If the patient desires pregnancy, a partial resection of the cervix with plication of the cardinal ligaments can be attempted. For elderly women who do not desire coitus, partial obliteration of the vagina is surgically simple and effective. Uterine suspension with sacrospinous cervicocolpopexy may be an effective approach in older women who wish to avoid hysterectomy but preserve coital function. A well-fitted vaginal pessary (eg, inflatable doughnut type, Gellhorn pessary) may give relief if surgery is refused or contraindicated.

Preference:
Hefni M et al: Sacrospinous cervicocolpopexy with uterine conservation for uterovaginal prolapse in elderly women: an evolving concept. Am J Obstet Gynecol 2003;188:645.
Poma PA: Nonsurgical management of genital prolapse. a review and recommendations for clinical practice. J Reprod Med 2000;45:789.