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UTERINE PROLAPSE

SUBMITTED BYBHARAT MALHOTRA

Definition
Uterus (womb in which a fetus develops) is normally held in place inside pelvis with various muscles, tissue, and ligaments. Sometimes-because of childbirth or difficult labor and delivery-these muscles weaken. As a woman ages and with a natural loss of the hormone estrogen, her uterus can collapse into the vaginal canal, causing the condition known as a prolapsed uterus.

Types
Muscle weakness or relaxation may allow the uterus to sag or come completely out of the body to a variable extent. Prolapsed uterus can be described in the following stages: First degree: The cervix remains into the vagina. Second degree: A descent of cervix in introitus, which may protrude further on straining, with the possibility of damage, infection & ulceration. Third degree: (procidentia): The entire uterus descends outside the introitus of body, causing total inversion of vagina.

Associated Conditions
Other conditions are usually associated with prolapsed uterus. They weaken the muscles that hold the uterus in place: Cystocele: A herniation (or bulging) of the upper front vaginal wall where a part of bladder bulges into the vagina, which may lead to urinary frequency, urgency, retention, and incontinence. Enterocele: The herniation of the upper rear vaginal wall where a small bowel portion bulges into the vagina. Standing leads to a pulling sensation and backache and is relieved when lying down.

Rectocele: The herniation of the lower rear vaginal wall where the rectum bulges into the vagina. This makes bowel movements difficult to the point that the woman may need to push on the inside of the vagina to empty the bowel.

Who Gets Uterine Prolapse?


Uterine prolapse most often occurs in women who have had more than one baby through normal vaginal delivery and in post-menopausal women. Menopause occurs when a woman's ovaries stop producing the hormones that regulate her monthly menstrual cycle, and she stops having regular menstrual periods. One of these hormones, estrogen, helps keep the pelvic muscles strong.

Causes
The following conditions can cause a prolapsed uterus: Pregnancy/multiple childbirths with normal or complicated delivery through the vagina Weakness in the pelvic muscles with advancing age Weakening and loss of tissue tone after menopause and loss of natural estrogen

Conditions leading to increased pressure in the abdomen such as chronic cough (with bronchitis and asthma), straining (with constipation), pelvic tumors (rare), or an accumulation of fluid in the abdomen Being overweight or obese with its additional strain on pelvic muscles Major surgery in the pelvic area leading to loss of external support Other risk factors include: Excess weight lifting Being Caucasian: Caucasian women more commonly affected; African Americans and Asians are affected less often.

Symptoms
Symptoms of a prolapsed uterus include:

A feeling of fullness or pressure in pelvis (may describe it as a feeling of sitting on a small ball) Low back pain
Feeling that something is coming out of vagina Painful sexual intercourse Difficulty with urination or moving your bowels

Difficulty walking

Repeated bladder infections Feeling of heaviness or pulling in the pelvis

Vaginal bleeding
Increased vaginal discharge Many of the symptoms are worse when standing or sitting for long periods of time.

Diagnosis
If a woman experiences symptoms associated with prolapse she should consult her doctor. The doctor will take her medical history and then perform a vaginal examination. A rectal examination may also be performed if a rectocele or enterocele is suspected. The woman may be asked to cough or push down during the examination as this raises the pressure in the abdomen and pushes any prolapse downwards, making it easier to see or feel. Coughing or pushing down can also help identify any associated stress incontinence.

These examinations may also been conducted while the woman is in a standing position. The doctor will also carry out a thorough abdominal examination to ensure there are no other pelvic problems. If a woman also has incontinence it may be necessary to conduct other tests to fully investigate the cause/s of this.

Treatment
There are surgical and non-surgical options for treating uterine prolapse. The treatment chosen will depend on the severity of the condition, as well as the woman's general health, age and desire to have children. Treatment generally is effective for most women. Treatment options include the following:

Non-Surgical Options
Exercise Special exercises, called Kegel exercises, can help strengthen the pelvic floor muscles. This may be the only treatment needed in mild cases of uterine prolapse. To do Kegel exercises, tighten your pelvic muscles as if you are trying to hold back urine. Hold the muscles tight for a few seconds and then release. Repeat 10 times. You may do these exercises anywhere and at any time (up to four times a day).

Vaginal pessary A pessary is a rubber or plastic doughnut-shaped device that fits around or under the lower part of the uterus (cervix), helping to prop up the uterus and hold it in place. A health care provider will fit and insert the pessary, which must be cleaned frequently and removed before sex.

Estrogen replacement therapy (ERT) Taking estrogen may help to limit further weakness of the muscles and other connective tissues that support the uterus.

Surgical Options
Hysterectomy Uterine prolapse may be treated by removing the uterus in a surgical procedure called hysterectomy. This may be done through an incision made in the vagina (vaginal hysterectomy) or through the abdomen (abdominal hysterectomy). Hysterectomy is major surgery, and removing the uterus means pregnancy is no longer possible.

Uterine suspension This procedure involves putting the uterus back into its normal position. This may be done by reattaching the pelvic ligaments to the lower part of the uterus to hold it in place. Another technique uses a special material that acts like a sling to support the uterus in its proper position. Recent advances include performing this with minimally invasive techniques and laparoscopically (through small band aid sized incisions) that decrease post operative pain and speed recovery.

Prognosis
Most women with mild uterine prolapse do not have bothersome symptoms and don't need treatment. Vaginal pessaries can be effective for many women with uterine prolapse. Surgery usually provides excellent results, however, some women may require treatment again in the future.

Prevention

While women have little control over some contributing factors to prolapse (eg., having a long labour or giving birth to a large infant), there are a number of other steps they can take to reduce their risk. Perform pelvic floor exercises regularly, particularly during pregnancy after childbirth and into menopause. Avoid constipation and straining during a bladder and bowel movement. Treat the cause of any chronic cough (if it is smokingrelated seek assistance in quitting). Maintain a healthy weight. Avoid lifting heavy objects frequently. If lifting heavy objects, make sure to bend at the knees and keep the back straight.

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