A dropped uterus, also known as a prolapsed uterus or uterine prolapse, is a condition wherein a woman’s uterus is displaced downward and the vagina is everted. Causes of a dropped uterus include childbirth and damage to the pelvic floor during labor, impaired nerve transmission to the pelvic floor muscles, genital atrophy, lack of estrogen or hypoestrogenism, and other medical conditions that increase intra-abdominal pressure or decrease the elasticity of collagen. This condition can cause impaired function and is usually treated surgically.
Together with the upper part of the vagina, a healthy uterus is supported by a muscle called levator ani and fibrous structures collectively called endopelvic fascia. The levator muscles and the endopelvic fascia are also called the pelvic floor because they support the pelvic and abdominal contents. A woman with a dropped uterus has a weakening of this support system and a defect in the upper part of the vagina, leading to vaginal eversion and dropping or descent of the uterus through the vaginal canal.
There are various causes of a dropped uterus. Women who have given birth several times are at an increased risk because childbirth loosens or tears the levator muscle, endopelvic fascia, or perineal body. A problem with the pudendal nerve and associated nerves may cause impaired nerve transmission, leading to weakness of the pelvic floor and subsequent uterine prolapse. Women who have chronic pulmonary disease that leads to excessive coughing, constipation, and obesity may also suffer from a dropped uterus due to an increased intra-abdominal pressure that weakens the pelvic floor. Connective tissue diseases, such as Marfan syndrome, also predispose women to having a dropped uterus.
The need for treating a dropped uterus is usually dependent on the degree of prolapse. In first-degree prolapse the uterus descends into the upper vagina but is not seen externally, while in second-degree prolapse the cervix is already near or outside the vagina. A third-degree or total prolapse is a condition wherein the entire uterus is already outside the vagina. While minimal or first-degree uterine prolapse may not cause symptoms, the effects of a second- or third-degree dropped uterus include vaginal fullness, back pain, spotting, ulceration, pain or difficulty during sexual intercourse, and urinary or fecal incontinence or retention. Women who have mild uterine prolapse without symptoms do not need treatment.
Important considerations in treatment include the age of the patient, desire for conception, degree of prolapse, severity of symptoms, other medical conditions, presence or absence of nerve problems, previous surgical history, and patient’s choice. If the patient decides that her reproductive function has to be preserved, ultrasound imaging and endometrial biopsy are recommended. Pelvic exercises, vaginal support devices such as pessaries, and topical estrogen are considered conservative medical treatment. Severe cases are best treated with surgical procedures, such as colpectomy, colpocleisis, abdominal sacral colpopexy, sacral uteropexy, sacrospinous ligament fixation, iliococcygeus fascia suspension, and uterosacral ligament fixation. A pap smear is recommended prior to surgery.
