Uterine Prolapse Surgery

The uterus is normally kept in position by muscles, ligaments, and tissues within the pelvis. However, during pregnancy or childbirth or with aging, these supports become weaker. This leads to conditions such as uterine prolapse, in which the uterus protrudes out of the vaginal opening. Such a condition is classified as pelvic organ prolapse, which includes the sagging of the bladder, rectum, or even the vagina itself. Females with a history of childbirth have a higher chance of uterine prolapse or one of the pelvic organs prolapse by the age of 50-79.

Uterine prolapse surgery is a surgical intervention performed to correct the displacement of the uterus and restore its proper position within the pelvis. The specific surgical approach may vary depending on the severity of the prolapse, the patient's overall health, and the surgeon's expertise.

Stages of Uterine Prolapse

The process of uterine prolapse occurs when the uterus falls into the vaginal canal. There are typically four stages, which are classified according to severity.

• Stage I: The uterus descends far into the upper part of the vagina.
• Stage II: The uterus descends to a point approaching the opening of the vagina.
• Stage III: The uterus comes out through the opening of the vagina.
• Stage IV: The uterus is outside the vagina completely.

Symptoms of Uterine Prolapse

There are various ways in which uterine prolapse may present. Some women may have none. For those who do, symptoms can be very limiting in their quality of life. Some common symptoms include:

• Heavy or pressured sensation in the pelvis or vagina: This is probably the most common symptom, usually described as the feeling of something dropping out.
• A feeling or seeing a bulge or lump in or protruding from the vagina: This is a more advanced symptom, indicating that the uterus has descended fairly far.
• Feeling like sitting on a little ball: This feeling is partially done by the prolapsed uterus knocking against the base of the vagina.
• Lower back pain: The prolapse puts a lot of strain on the lower back, which tends to produce the discomfort experienced.
• Problems with urination: This may occasionally manifest as urinary incontinence (leaking of urine), difficulty emptying the bladder, or necessitate frequent urination.
• Problems with bowel movements: Such as constipation or difficulty having a bowel movement.
• Discomfort or pain during sexual intercourse: Prolapse is also disruptive or painful during sexual activities.
• Vaginal bleeding or increased vaginal discharge: In some cases, prolapse can result in an irritation that can lead to bleeding or discharge.

Cause of Uterine Prolapse

Uterine prolapse occurs when the muscles of the pelvic floor become weak, and several causes result in the uterus dropping out of its normal position.

• Childbirth: Vaginal delivery, especially with repeated pregnancies, weakens pelvic floor muscles, particularly in cases of traumatic or difficult deliveries with large infants and prolonged labor, increasing the risk.
• Aging and Menopause: Muscle sagging occurs because of depleting estrogen levels during or following menopause, leading to thinning and weakening of pelvic structures.
• Chronic increase in abdominal pressure: Some of the leading causes of health in this pressure category can include chronic cough, chronic constipation, obesity, and the resumption of heavy lifting.
• Other Causes: Some women have a genetic predisposition for weak connective tissue, along with a history of previous surgery in the pelvic area.

Uterine Prolapse Diagnosis

Diagnosing uterine prolapse usually involves the health care provider's thorough pelvic examination. The following is how the diagnosis works:

• Pelvic Exam: Visually inspecting and feeling the pelvic organs would be the main diagnostic method. The greater the woman can seem to tighten those muscles during childbirth, the more obvious it will be as to their integrity.
• Medical History: The patient would find out that the doctor inquires a lot about the history of childbirth as well as the reported symptoms, pelvic operations, and other health conditions.
• Additional Tests: Urodynamic testing might be used to evaluate the performance of the bladder in terms of urinary incontinence. MRI imaging can be performed to provide detailed images of the pelvic organs.
• Cystourethroscopy: This involves examining the urethra and bladder by introducing a thin, flexible tube with a camera (cystoscope) inside the urethra and bladder.

Risk Factors and Complications

Understanding of risk factors and complications associated with uterine prolapse would be important for prevention and management. Rots are:  

Risk Factors:

• Higher likelihood of a vaginal delivery; having multiple births; difficult deliveries; and high birth-weight babies lead to increased risks.
• Aging induces weakness of pelvic floor muscles because of reduced estrogen levels, which thins the tissues.
• Abdominal pressure increases due to chronic cough, chronic constipation, obesity, and heavy lifting.
• Genetic predisposition is a weakness in connective tissue, particularly after a history of previous pelvic surgery.
• Some studies have shown that women of White and Hispanic descent are at greater risk. 
• Surgical removal of the uterus, especially when this is associated with the supporting structures being sacrificed, may raise the likelihood of vault prolapse.

Complications:

• Prolapse of Other Pelvic Organs: When the bladder or rectum bulb into the vagina, causing worsening urinary and bowel troubles such as cystocele and rectocele.
• Ulceration: The protruding prolapsed uterus may cause ulceration in the vaginal tissue.
• Infection: Ulcers may lead to an increase in infection.
• Discomfort and Pain: Chronic pelvic pain, lower back pain, and pain during intercourse.
• Urinary Problems: The problems include the inability to empty the bladder properly, urinary incontinence, and increased frequency in urinating. 
• Bowel Problems: Difficulty in passing stool and constipation.
• Having an Impact on Quality of Life: The symptoms of uterine prolapse can adversely affect the physical and emotional status of a woman. 
• Recurrent Prolapse: They may show signs of recurrence after surgical correction, which may be more likely if causative factors remain uncorrected.
• Sexual Dysfunction: Some women may have experienced discomfort and pain during copulation due to uterine prolapse.

Uterine Prolapse Prevention

Preventive measures against uterine prolapse are primarily about pelvic-strengthening exercises to minimize any strain that might be put upon the musculoskeletal system. Below are the most relevant preventive measures:  

• Kegel exercises for pelvic muscle strength and consistency do matter.
• Keep your weight healthy to keep extra pressure away from the pelvic floor.
• Increase fiber and activity to fight constipation.
• Always lift with the legs, not with the back. 
• Receive good prenatal care for some of the risk factors that may be related to uterine prolapse during pregnancy.
• Reduce the burden of chronic cough with medical means. 
• Talk to the doctor regarding Hormone Replacement Therapy post-menopause.
• Give the body time to heal and apply postpartum rehabilitation exercises.
• Adopting a healthy lifestyle may include refraining from smoking and consuming a well-balanced diet.

The specific procedure for uterine prolapse surgery may vary, but here are some commonly performed surgical approaches:

1. Vaginal Approach (Vaginal Hysterectomy with Suspension):

a. Anesthesia: The patient is placed under general or regional anesthesia to ensure comfort during the procedure.
b. Incision: A surgical incision is made in the vagina to access the uterus and surrounding structures.
c. Removal of the Uterus (Hysterectomy): In cases where the uterus is no longer needed or is severely affected by prolapse, it may be removed.
d. Suspension of the Vaginal Vault: The remaining vaginal tissue is then attached to nearby ligaments or supportive structures to restore pelvic support and prevent future prolapse.

2. Abdominal Approach (Sacral Colpopexy):

a. Anesthesia: The patient is placed under general anesthesia to ensure comfort throughout the procedure.
b. Incision: An abdominal incision is made, typically below the belly button, to access the pelvic organs and structures.
c. Mesh Placement: A synthetic mesh is placed to create a supportive sling between the top of the vagina and the sacrum (lower part of the spine). This provides long-term support for the uterus and prevents prolapse.
d. Closure: The incisions are carefully closed using sutures or surgical staples.

3. Minimally Invasive Approach (Laparoscopic or Robotic Surgery):

a. Anesthesia: General anesthesia is administered, and the patient is positioned to allow for laparoscopic or robotic access.
b. Trocar Placement: Small incisions are made in the abdomen, through which trocars (long, thin instruments) are inserted.
c. Instrumentation and Visualization: Laparoscopic instruments or robotic arms are used to perform the procedure under high-definition visualization.
d. Mesh Placement or Ligament Suspension: Depending on the specific technique used, a synthetic mesh may be placed or supportive ligaments may be utilized to restore pelvic support.
e. Closure: The small incisions are closed with sutures or surgical glue.