Causes of ovarian prolapse and methods of treating pathology. estrogen hormone replacement therapy

When the vagina is lowered, one of its walls hangs down into the lumen of the vagina. Due to the fact that the bladder is located in front of the vagina, when its front wall hangs down, the bladder also begins to descend. This condition is called a cystocele. The rectum is located behind the vagina, therefore, when the posterior wall of the vagina is lowered, a prolapse of the rectal wall, or rectocele, is also observed.

When the uterus is lowered, its downward displacement is observed, and with a pronounced prolapse, the uterus can even “fall out” of the vagina. Of course, when we talk about “prolapse”, we do not mean that at one moment the uterus will come off the body and fall to the floor. Despite everything, the uterus remains securely attached to the body, however, when the uterus prolapses, it begins to “peep” out of the vagina.

Why does the prolapse of the vagina and uterus occur?

Normally, the pelvic organs (ovaries, fallopian tubes, uterus, vagina, bladder, and rectum) are kept in suspension by the muscles and ligaments of the pelvis, which in turn are attached to the skeleton. The design is quite complex, and the structure of the pelvic floor (the structure that holds all of the listed organs in place) can be the subject of a separate lecture on anatomy. But we will not go into details, it is enough just to understand that the vagina and uterus occupy the place assigned to them by nature, not just like that, but thanks to the muscles and ligaments of the small pelvis.

With age, the tone of the pelvic floor muscles decreases significantly, and the ligaments can stretch, so with menopause, prolapse of the vagina or uterus is often observed. Among other things, the decrease in the level of estrogen in the blood, observed with, also contributes to relaxation and sprain.

Who can develop prolapse of the vagina and uterus?

An increased risk of genital prolapse during menopause is observed if:

• The woman has given birth many times or had multiple pregnancies (twins, triplets, etc.)
• Is overweight or obese.
• There are frequent constipation.
• There is a chronic cough (chronic bronchitis, bronchial asthma).
• The woman smokes.
• There is a violation of the liver with the accumulation of fluid in the abdominal cavity (ascites).
• There is marked enlargement of the spleen.
• A woman lifts weights.

Is there a prolapse without symptoms?

It happens, and even more than that: in most cases, there are no symptoms in the early stages of prolapse of the vagina and uterus. There is no need to doubt the correctness of the diagnosis if the gynecologist found a prolapse, and you have no signs of this disease.

How is the prolapse of the vagina and uterus manifested?

• Sensation of a foreign body in the vagina, as if there were a small ball deep in the vagina.
• Dull pain in lower abdomen.
• Sensation as if something were falling out of the vagina.
• Difficulty walking.
• Difficulty in urination and defecation.

With a cystocele (drooping of the bladder wall), symptoms such as frequent urination, urinary incontinence, involuntary urination, and urinary retention may appear. .

With a rectocele (drooping of the wall of the rectum), there are difficulties in defecation, when more effort is needed to empty the intestines than before.

What are the degrees of uterine prolapse?

1 degree of prolapse of the uterus: the cervix is ​​not above the vagina, as it should be normal, but descends into the vagina.

2nd degree of prolapse of the uterus: the cervix descends to the entrance to the vagina.

3 degree of prolapse of the uterus: the cervix "peeps" out of the vagina.

4 degree of prolapse of the uterus: the entire uterus "peeps" out of the vagina. This condition is also called uterine prolapse.

What tests are needed?

The diagnosis of prolapse of the genital organs can be made during the examination by a gynecologist. The doctor will examine you in the supine position and in the standing position. Because the prolapse of the vagina or uterus becomes more noticeable when the intra-abdominal pressure increases, the doctor will ask you to cough or strain.

The gynecologist may also order the following tests:

• Ultrasound of the uterus
• If there is a malfunction of the bladder, the doctor will prescribe an ultrasound or x-ray of the kidneys
• General urine analysis

What to do if the vagina or uterus is prolapsed?

Vaginal or uterine prolapse does not always need to be treated. If you do not feel any symptoms, nothing bothers you, and the gynecologist found a slight or moderate prolapse, then no treatment is prescribed. The gynecologist will recommend some exercises that strengthen the muscles and ligaments of the small pelvis, and recommend that you return for a follow-up examination in 6-12 months.

If you have symptoms of prolapse, then you will need treatment: some you can do at home on your own, and some can be done by your doctor.

What can be done at home

If you have a prolapse of the walls of the vagina or uterus, heed the following advice from gynecologists:

• Avoid prolonged standing. If this is unavoidable (for example, you need to stand in line), it is better to take a leisurely walk or sit down.
• Before getting up from a chair or lifting anything, inhale, tighten your pelvic muscles (as if you are trying to hold in gases), draw in your stomach a little and exhale slowly perform the desired action.
• Avoid constipation. If you have frequent constipation, consult a gastroenterologist: until you get rid of constipation, prolapse of the vagina or uterus cannot be cured.
• During a bowel movement, you can not strain or push hard. If you are having trouble passing a bowel movement, on the exhale, "inflate" your belly so that it becomes round and say "shhh", but don't hold your breath. Give yourself enough time to go to the toilet so you don't rush anywhere, but don't spend more than 15 minutes on the toilet. If you have not had a bowel movement within 15 minutes, try again later.
• If you are overweight, you need to get rid of it.
• Do Kegel exercises. .

What can a doctor do

When the vagina or uterus is prolapsed, conservative treatment (pessaries and hormone replacement therapy) or surgery may be prescribed.

Pessary

Your gynecologist may recommend that you wear a special device that props up your uterus and prevents it from dropping below a certain level. Such devices are called "pessaries", or simply uterine rings (although there are other forms of pessaries, not only in the form of rings).

If the gynecologist considers that you can remove and install the pessary yourself, then he will teach you how to do it correctly. In some cases, the pessary has to be worn all the time, in other cases it will need to be removed at bedtime. With a slight prolapse of the vagina or uterus, the pessary will need to be installed only before long walks, physical exertion, etc.

A pessary does not cure prolapsed uterus, but it can help relieve the symptoms of the condition and make your life much easier.

estrogen hormone replacement therapy

Surgery for prolapse of the vagina and uterus

If conservative treatment does not help, or there is a prolapse of the uterus of 3-4 degrees, then an operation is prescribed. The operation can be performed through an incision in the abdomen or through the vagina.

During the operation, the doctor can install a special implant - a structure that will hold the pelvic organs where they are supposed to be normal. In some cases, the gynecologist may recommend removal of the uterus. Our website has .

After the operation, you will not be able to lift weights for at least 6 weeks, and for another 3 months you should avoid any situations that increase the prolapse of the genital organs: constipation, coughing, smoking, weight gain.

How to prevent prolapse of the vagina and uterus during menopause?

• Maintain a normal weight for your height.
• Eat right to avoid constipation.
• Do Kegel exercises.
• Do not lift heavy objects (more than 5 kg).

Sometimes a woman feels an incomprehensible heaviness in the pubic area, pain in the vagina. The gynecologist, after examination, establishes that the cause of the ailment is a weakening of muscle tone, as a result of which the uterus prolapsed. Pathology can be insignificant, but it can also have unpleasant consequences. Omission occurs more often in older women, in young women this condition is also possible. Because of it, serious complications and consequences arise, so treatment is necessary.

Content:

Prolapse of the uterus, its stages

The uterus is held in the cavity of the small pelvis by the muscles of the pelvic floor (a group of muscles in the perineum) and its own ligaments. Normally, it is located in the center of the pelvic cavity between the rectum and the bladder. The cervix is ​​tilted slightly backward, so that an angle of approximately 100° is formed between the body of the uterus and the cervix.

If the muscle tone weakens, and the ligaments are stretched (the so-called genital prolapse occurs), then the normal location of the uterus is disturbed, it descends: the upper part, from which the tubes depart (the bottom of the uterus), descends, and the cervix moves closer to the inlet of the vagina. Uterine prolapse may occur when the cervix protrudes. Violations in the ligamentous apparatus cause prolapse of the vagina, as well as the rectum, bladder, and kidneys.

Omission occurs more often in women over 55 years of age, but this condition is often found in young people. There are several degrees of development of the disease.

1 degree. There is a prolapse of the body of the uterus, while its cervix approaches the inlet of the vagina, but does not go beyond it, even if the woman is pushing.

2 degree. The uterus descends so much that its neck is shown out if the woman pushes, coughs, lifts a heavy object. This condition is called prolapse and incomplete prolapse of the uterus.

3 degree. Incomplete prolapse occurs: the cervix and part of the body of the uterus protrude beyond the vagina.

4 degree. The body and the bottom of the uterus go beyond the genital gap, the so-called complete prolapse occurs.

Such a pathology does not pose a mortal threat, but as it progresses, more and more unpleasant symptoms of uterine prolapse and disruption of its functioning appear, which makes the woman disabled.

Causes of organ prolapse

The reason for the weakening of the muscles and ligaments that hold the uterus and other organs of the small pelvis are:

• ruptures of the muscles of the perineum that occur during childbirth: during the extraction of the child with the help of obstetric forceps, the use of vacuum extraction, as well as during the breech presentation of the fetus;
• damage to ligaments and muscles during operations on the genitals;
• injuries causing rupture of the perineum;
• violation of the sensitivity of nerve endings located in the organs of the genitourinary system, the impossibility of normal regulation of muscle contractility by the central nervous system;
• congenital disorders of the structure of organs, muscles and ligaments located in the small pelvis;
• hereditary pathology of connective tissue development (genetic disorder of collagen production) - connective tissue dysplasia.
• decrease in the elasticity of muscles and ligaments as a result of age-related changes in hormonal levels, a decrease in estrogen levels (during the menopausal period).

The risk of developing pathology is increased in women involved in weightlifting, forced to perform heavy physical work. Often, prolapse and prolapse of the uterus occurs in women who have given birth many times, as well as in those suffering from constipation.

Development is facilitated by the formation of tumors in the abdominal cavity. Increased intra-abdominal pressure leading to organ prolapse occurs in women with chronic diseases that cause severe coughing. It can also occur with obesity.

Video: Causes and consequences of uterine prolapse

Symptoms and possible complications

Pathology may not bother a woman for many years. Symptoms of uterine prolapse begin to appear more and more as it progresses. A woman has a feeling of the presence of a foreign body in the vagina or in the perineum, pulling pains in this area, aggravated by walking or sitting. Disturbed by pain in the sacrum and lower back.

Pain, discomfort appear during sexual intercourse. In the last stages of prolapse, sexual intercourse becomes impossible.

When the uterus descends, it puts pressure on the bladder, so urination becomes frequent, difficult and painful, and urinary incontinence may occur. Stagnation of urine causes cystitis, inflammation of the kidneys, urolithiasis.

The omission of the uterus entails the prolapse of the intestines, as a result of which the woman develops constipation and flatulence. Sometimes there is fecal incontinence.

May increase leucorrhea, the appearance of bloody vaginal discharge. Menstruation becomes profuse and protracted. With a strong prolapse or prolapse of the uterus, a woman cannot become pregnant.

The prolapsed part of the uterus is constantly injured when walking, so bleeding ulcers form on it and inflammation occurs. Blood circulation in the small pelvis is disturbed, varicose veins of the lower extremities occur, swelling of the tissues and mucous membrane of the uterus appears.

With the omission and prolapse of the uterus, complications such as bedsores in the vagina, infringement of the prolapsed uterus and intestinal loops may appear.

Diagnosis of uterine prolapse

A doctor can detect prolapse and, moreover, prolapse of the uterus already during an external examination of the genital organs. The degree of manifestation is checked at rest of the woman and when trying to strain. To determine the stage of development of the pathology and diagnose concomitant diseases, an examination is carried out, according to the results of which the doctor determines what treatment is required, whether a surgical operation is necessary.

The following diagnostic methods are used:

1. Colposcopy of the uterus. Allows you to study the state of the cervix and uterine cavity, detect folds, areas of inflammation, examine the state of the endometrium and mucous membranes of the cervix.
2. Hysterosalpingoscopy is an ultrasound examination of the patency of the fallopian tubes.
3. Ultrasound of the uterus and other pelvic organs.
4. Pap test. Cytological examination of a smear from the vagina and cervix to detect atypical cells.
5. Microscopic examination of the smear to determine the composition of the microflora, as well as culture of the contents of the smear to determine the type of bacteria present in it.
6. Urine culture. It is carried out to determine the presence of infection in the urinary organs.
7. MRI or CT of the pelvic organs. These methods make it possible to diagnose uterine prolapse or prolapse, which, by external signs, may be similar to such pathologies as the “birth” of a myomatous node, uterine inversion, vaginal cyst.

Consultations are held with a proctologist and urologist to identify pathologies of the intestines and urinary organs.

Treatment

There are 2 ways to treat uterine prolapse and prolapse: conservative and surgical. When choosing the direction of therapy, the doctor takes into account the stage of development of the pathology and the symptoms of its manifestation.

Conservative treatment

It is used in the case when the first stage of prolapse is observed, the functioning of neighboring organs is not impaired. Drug therapy is used with drugs that increase the content of estrogen in the blood. This helps to strengthen the ligaments and increase muscle tone. Such drugs are also in the form of ointments injected into the vagina.

A gynecological massage of the uterus is prescribed to improve blood circulation and eliminate blood stasis and edema. Elderly patients are prescribed the use of pessaries - special elastic rubber rings filled with air. The elastic ring supports the uterus, prevents it from descending into the vagina. The disadvantage is that prolonged use of the pessary leads to the appearance of bedsores in the vagina. Therefore, they are used for 3-4 weeks, then taking a break for half a month. A mandatory procedure is daily douching with antiseptic solutions of furacilin, potassium permanganate or chamomile infusion.

Warning: Starting treatment, a woman should give up heavy physical exertion, switch to lighter work, follow a diet that allows you to eliminate constipation.

Types of Surgery

If conservative therapy is ineffective, and the degree of organ displacement is high, a surgical method of treatment is used. Elimination of pathology is possible using the following methods:

1. Vaginoplasty. The posterior wall of the vagina is sutured, as well as the rectum, muscles of the anus and perineum. In the presence of urinary incontinence, an "anterior colporrhaphy" is performed (removal of a hernia of the bladder, formed as a result of its prolapse).
2. Shortening of the uterine ligaments and fixing them in the anterior and posterior wall of the uterus. The method is not effective enough, as the ligaments stretch again over time.
3. Sewing links together. After such an operation, a woman will not be able to give birth to a child, since the uterus is not able to stretch and contract normally.
4. Fixation of the uterus to the bones and ligaments of the pelvic floor. Such an operation allows a woman to preserve her ability to bear children.
5. Strengthening ligaments with plastic materials. Possible rejection of plastic, relapse of the disease, the appearance of fistulas in the pelvic organs.
6. Narrowing of the lumen of the vagina.
7. Hysterectomy is the complete removal of the uterus. It is carried out in case of uterine prolapse in women who have passed their childbearing age.
8. Combined method: simultaneously fixing the uterus, strengthening the ligaments and suturing the vagina.

Operations are performed through the vagina or by laparoscopy (through punctures in the abdominal wall). Sometimes you have to resort to open abdominal surgery.

After surgical treatment of uterine prolapse, anti-inflammatory therapy and painkillers are prescribed. If the uterus is preserved, if necessary, hormone replacement therapy with estrogen-containing drugs is performed.

Video: Surgical treatment of prolapse of internal organs

Prevention of uterine prolapse

The legislation provides for a limit on the weight of items that are allowed to be lifted and carried by a woman at work (no more than 20 kg). She must strictly adhere to the established norm. A girl from a young age must be introduced to the consequences of heavy physical exertion.

An important preventive measure is the proper care of the genitals, especially after childbirth. Such a measure is necessary to prevent inflammatory processes in the vagina. It is also important to timely treat diseases of the genital and other pelvic organs.

Of great importance is the correct management of childbirth, careful stitching of gaps. After childbirth, doctors recommend that you definitely do exercises to restore the elasticity of the muscles and ligaments of the uterus. In the presence of birth injuries, laser therapy or electrical stimulation of the pelvic muscles is prescribed.

You need to eat right to avoid constipation.

Exercises to strengthen the pelvic and vaginal muscles

A good way to prevent prolapse of the uterus and vagina are yoga classes using special postures. There is also a set of special exercises that help strengthen the muscles of the pelvic floor and vagina.

Some of them are performed in a sitting position: drawing in the muscles of the vagina and lower abdomen, followed by their "pushing out", contraction and relaxation of the sphincter. Other exercises are performed in a standing or lying position, such as walking in a circle with a ball sandwiched between the legs, crawling forward and backward.

Also useful is an exercise that a woman should perform lying on her back with her legs bent at the knees, with her feet pressed to the floor: it is necessary to spread her legs as much as possible, and then bring them together, squeezing the muscles of the vagina. With the same starting position, you can raise the pelvis by pinching the muscles. Exercises are performed 10 times. The effectiveness of such gymnastics is guaranteed.

Video: Exercises to prevent uterine prolapse

If the ovary is soldered to the uterus, then this indicates the presence of an adhesive process, as a result of which the appendage fuses with the reproductive organ. At the same time, scars are formed and blood supply processes are disrupted, which prevents conception.

The main reason for the displacement of the appendage is in the small pelvis. The following factors influence the occurrence of an adhesive process in which the right ovary (or left) is affected:

1. Gynecological operations (abortion, caesarean section), when the integrity of the appendage is violated, which provokes deviations in the processes of blood clotting and cell renewal. Instead of regeneration, connective tissue is formed that glues the organs together.
2. Concomitant pathologies of the reproductive sphere (, endometritis, etc.). Due to the affected cells, the stroma of the appendages suffers, the processes of local blood supply are disturbed. Abnormal cells begin to divide, pathological tissues grow, which leads to the appearance of scars.
3. The ovary is pulled to the uterus under the influence of the following factors:

• violation of the rules for the introduction of an intrauterine device;
• venereal diseases;
• in which the tissue of the uterine membrane goes beyond its limits;
• ectopic pregnancy;
• the use of antibacterial agents;
• breaks during labor;
• hypothermia;
• performing hysteroscopy.

Symptoms that the ovary is soldered to the uterus

If the left ovary (or right) is located close to the uterus, then at the initial stage of the pathology there may be no symptoms. Sometimes the clinical picture unfolds several years after the start of the process. This causes the following symptoms:

• pulling pain in the lower abdomen, migrating to the lumbar region;
• disruption of the menstrual cycle;
• discomfort during sports, intimacy;
• painful periods;
• disorders in the functioning of the intestine;
• increase in body temperature;
• bloody or yellow-green discharge.

A woman has a slight pain in the lower abdomen on the right or left. Changes in unilateral localization and an increase in the severity of the symptom often indicate a complication - a violation of the patency of the fallopian tubes. In this case, menstruation is often delayed by 2-3 months.

In some patients, with adhesions, the ovary prolapses to the bottom of the uterus. Sometimes an episiotomy causes a change in the position of the reproductive organ itself.

Diagnosis of pathology

To find out that the ovary is behind the uterus, only a gynecological examination is not enough. Conduct required. If this method does not allow to identify the adhesive process, then laparoscopy is performed. Additionally, MRI is used, which allows you to detect small changes in the reproductive system.

Displacement of the ovary is also diagnosed by other methods, for example, hysterosalpingography, an x-ray examination in which a contrast agent is injected into the cavity of the reproductive organ and fallopian tubes. The procedure is performed from 5 to 11 days of the cycle. Additionally, the patient is recommended to take a smear from the vagina for microflora.

Treatment of pathology

If the ovary is located behind the uterus, at the initial stage of the pathology, it is possible to use drugs:

• antibiotics;
• suppositories (for example, Longidases);
• drugs that eliminate inflammation;
• enzymes;
• vitamins and microelements.

It is useful to undergo physiotherapeutic procedures (electrophoresis with the introduction of magnesium, calcium and zinc through the skin). Thanks to this treatment, the adhesions become thinner and stretched. The patient may be prescribed sanatorium treatment (including mineral waters).

When the ovary is close to the uterus, physical activity is recommended. In advanced cases, it is carried out, the purpose of which is to separate and eliminate tissues connected to each other. After the operation, a special film is applied to the appendages. In addition, a barrier fluid is used to prevent the formation of new adhesions.

In the rehabilitation period, antibiotics and drugs are used, the action of which is aimed at preventing the formation of blood clots. Then the effectiveness of the surgical intervention is evaluated. At the discretion of the doctor, physiotherapy procedures are prescribed. Laparoscopy does not give a 100% guarantee that the adhesive process will not return again and the ovary will not move again.

Other treatments:

• laser therapy based on the effects of special rays;
• electrosurgery aimed at the elimination of damaged tissues with high-frequency current;
• aquadissection, in which adhesions are dissected using a water stream.

If the ovary has gone beyond the uterus, then gymnastics is advisable, aimed at eliminating the adhesive process. Since the pathology is quite serious, it is better to use the methods of official medicine, and use exercises with them in combination.

chances of pregnancy

As mentioned earlier, the bending of the ovary behind the uterus (left or right) is often a manifestation of the adhesive process. Difficulties with the onset of pregnancy are due to a violation of the anatomically correct location of the reproductive organs.

A woman who found out that her ovary went behind the uterus, of course, doubts the possibility of conception. To normalize the condition of the reproductive organs, the help of a qualified gynecologist is required.

To get pregnant, you need to undergo treatment. If it is not effective, then IVF is performed. Since adhesions increase the risk of attachment of the fetal egg outside the reproductive organ, it is necessary to direct all efforts to eliminate it.

Possible Complications

First of all, the gynecologist must assess how mobile the ovaries are and identify the true cause of the displacement. Once a definitive diagnosis is made, treatment is required. Otherwise, the following complications may occur:

• the transition of the adhesive process to neighboring organs, which is fraught with their displacement;
• violation of the relationship between the uterus and appendages;
• deterioration of the patency of the fallopian tubes;
• ectopic pregnancy;
• problems with ovulation;
• bending of the uterus;
• infertility.

In addition, if the ovary is close to the uterus, then this can lead to its prolapse. With the timely initiation of therapy, serious consequences can usually be avoided, therefore, it is recommended that every woman undergo preventive examinations by a gynecologist and not delay a visit to the doctor if symptoms are suspicious.

Prolapse of the uterus- incorrect position of the uterus, displacement of the fundus and cervix below the anatomical and physiological border due to weakening of the pelvic floor muscles and uterine ligaments. It is manifested by a feeling of pressure, discomfort, pulling pains in the lower abdomen and in the vagina, urination disorder (difficulty, frequent urination, urinary incontinence), pathological discharge from the vagina. May be complicated by partial or complete prolapse of the uterus.

The most common variants of the incorrect location of the internal genital organs of a woman are the prolapse of the uterus and its prolapse (uterocele). When the uterus is lowered, its cervix and bottom are displaced below the anatomical boundary, but the cervix is ​​not shown from the genital slit even when straining. The exit of the uterus beyond the genital gap is regarded as a prolapse. The downward displacement of the uterus precedes its partial or complete prolapse. In most patients, prolapse and prolapse of the uterus is usually accompanied by a downward displacement of the vagina.

Prolapse of the uterus is a fairly common pathology that occurs in women of all ages: it is diagnosed in 10% of women under 30 years old, at the age of 30-40 years it is detected in 40% of women, and after the age of 50 it occurs in half. 15% of all operations on the genitals are performed for prolapse or prolapse of the uterus.

The prolapse of the uterus is most often associated with a weakening of the ligamentous apparatus of the uterus, as well as the muscles and fascia of the pelvic floor, and often lead to displacement of the rectum (rectocele) and bladder (cystocele), accompanied by a disorder in the functions of these organs. Often, uterine prolapse begins to develop even in childbearing age and always has a progressive course. As the uterus descends, the accompanying functional disorders become more pronounced, which brings the woman physical and moral suffering and often leads to partial or complete disability.

The normal position of the uterus is its location in the small pelvis, at an equal distance from its walls, between the rectum and the bladder. The uterus has an anterior inclination of the body, forming an obtuse angle between the neck and the body. The cervix is ​​tilted backwards, forms an angle of 70-100° with respect to the vagina, its external os is adjacent to the posterior wall of the vagina. The uterus has sufficient physiological mobility and can change its position depending on the filling of the rectum and bladder.

The typical, normal location of the uterus in the pelvic cavity is facilitated by its own tone, interposition with adjacent organs, the ligamentous and muscular apparatus of the uterus and pelvic floor. Any violation of the architectonics of the uterine apparatus contributes to the prolapse of the uterus or its prolapse.

Classification of prolapse and prolapse of the uterus

There are the following stages of prolapse and prolapse of the uterus:

• prolapse of the body and cervix - the cervix is ​​​​determined above the level of the entrance to the vagina, but does not protrude beyond the genital gap;
• partial prolapse of the uterus - the cervix is ​​shown from the genital gap during straining, physical exertion, sneezing, coughing, lifting weights;
• incomplete prolapse of the body and bottom of the uterus - the cervix and partly the body of the uterus protrude from the genital gap;
• complete prolapse of the body and the bottom of the uterus - the exit of the uterus beyond the genital gap.

Causes of prolapse and prolapse of the uterus

Anatomical defects in the pelvic floor, which develop as a result of:

• damage to the muscles of the pelvic floor;
• birth injuries - when applying obstetric forceps, vacuum extraction of the fetus or extracting the fetus by the buttocks;
• transferred surgical operations on the genitals (radical vulvectomy);
• deep ruptures of the perineum;
• violations of the innervation of the urogenital diaphragm;
• congenital malformations of the pelvic region;
• estrogen deficiency that develops in menopause;
• connective tissue dysplasia, etc.

Risk factors in the development of uterine prolapse and its subsequent prolapse are numerous births in history, heavy physical labor and heavy lifting, advanced and senile age, heredity, increased intra-abdominal pressure caused by obesity, tumors of the abdominal cavity, chronic constipation, cough.

Often, the interaction of a number of factors plays a role in the development of uterine prolapse, under the influence of which the weakening of the ligamentous-muscular apparatus of the internal organs and the pelvic floor occurs. With an increase in intra-abdominal pressure, the uterus is forced out of the pelvic floor. The prolapse of the uterus entails the displacement of anatomically closely related organs - the vagina, rectum (rectocele) and bladder (cystocele). The rectocele and cystocele are enlarged by internal pressure in the rectum and bladder, causing further prolapse of the uterus.

Symptoms of prolapse and prolapse of the uterus

If untreated, uterine prolapse is characterized by a gradual progression of displacement of the pelvic organs. In the initial stages, uterine prolapse is manifested by pulling pains and pressure in the lower abdomen, sacrum, lower back, sensation of a foreign body in the vagina, dyspareunia (painful sexual intercourse), the appearance of leucorrhoea or bloody discharge from the vagina. A characteristic manifestation of uterine prolapse are changes in menstrual function such as hyperpolymenorrhea and algomenorrhea. Often, with the prolapse of the uterus, infertility is noted, although the onset of pregnancy is not excluded.

In the future, urological disorders are added to the symptoms of uterine prolapse, which are observed in 50% of patients: difficult or frequent urination, the development of a symptom of residual urine, stagnation in the urinary organs and further infection of the lower and then upper urinary tract - cystitis, pyelonephritis develop , urolithiasis disease. Prolonged prolapse and prolapse of the uterus leads to overstretching of the ureters and kidneys (hydronephrosis). Often the displacement of the uterus from top to bottom is accompanied by urinary incontinence.

Proctological complications in the prolapse and prolapse of the uterus occur in every third case. These include constipation, colitis, fecal and gas incontinence. Often, it is the painful urological and proctological manifestations of uterine prolapse that make patients turn to related specialists - a urologist and a proctologist. With the progression of uterine prolapse, the leading symptom is a formation that is independently detected by a woman, protruding from the genital slit.

The protruding part of the uterus looks like a shiny, dull, cracked, sore surface. In the future, as a result of constant traumatization when walking, the bulging surface often ulcerates with the formation of deep bedsores, which can bleed and become infected. With the prolapse of the uterus, a violation of blood circulation in the pelvis develops, the occurrence of congestion, cyanosis of the uterine mucosa and swelling of the adjacent tissues.

Often, when the uterus is displaced below the physiological boundaries, sexual life becomes impossible. Patients with uterine prolapse often develop varicose veins, mainly of the lower extremities, due to impaired venous outflow. Complications of prolapse and prolapse of the uterus can also be infringement of the prolapsed uterus, bedsores of the walls of the vagina, infringement of intestinal loops.

Diagnosis of prolapse and prolapse of the uterus

Prolapse and prolapse of the uterus can be diagnosed at a gynecological consultation during a gynecological examination. To determine the degree of uterine prolapse, the doctor asks the patient to push, after which, with a vaginal and rectal examination, he determines the displacement of the walls of the vagina, bladder and rectum. Women with a displacement of the genital organs are registered in the dispensary. Without fail, patients with such a pathology of the uterus undergo colposcopy.

In cases of prolapse and prolapse of the uterus, requiring organ-preserving plastic surgery, and with concomitant diseases of the uterus, additional examination methods are included in the diagnostic complex:

• hysterosalpingoscopy and diagnostic curettage of the uterine cavity;
• ultrasound diagnostics of the pelvic organs;
• taking smears for flora, the degree of purity of the vagina, bacterial culture, as well as for determining atypical cells;
• urine culture to rule out urinary tract infections;
• excretory urography to rule out urinary tract obstruction;
• computed tomography to clarify the condition of the pelvic organs.

Patients with uterine prolapse are examined by a proctologist and urologist to determine the presence of rectocele and cystocele. They are assessing the condition of the sphincters of the rectum and bladder to detect incontinence of gases and urine during stress. Omission and prolapse of the uterus should be distinguished from uterine eversion, vaginal cysts, born myomatous node and differential diagnosis should be carried out.

Treatment of uterine prolapse and prolapse

When choosing a treatment strategy, the following factors are taken into account:

1. The degree of prolapse or prolapse of the uterus.
2. The presence and nature of gynecological diseases associated with uterine prolapse.
3. The need and possibility of restoring or maintaining menstrual and reproductive functions.
4. The age of the patient.
5. The nature of violations of the functions of the sphincters of the bladder and rectum, colon.
6. The degree of anesthetic and surgical risk in the presence of concomitant diseases.

Taking into account the totality of these factors, the treatment tactics is determined, which can be both conservative and surgical.

Conservative treatment of uterine prolapse and prolapse

When the uterus is lowered, when it does not reach the genital gap and the functions of adjacent organs are not impaired, conservative treatment is used, which may include:

• physiotherapy exercises aimed at strengthening the muscles of the pelvic floor and abdominals (gymnastics according to Kegel, according to Yunusov);
• gynecological massage;
• estrogen replacement therapy, which strengthens the ligamentous apparatus;
• local introduction into the vagina of ointments containing metabolites and estrogens;
• transferring women to lighter physical work.

If it is impossible to carry out surgical treatment for prolapse or prolapse of the uterus in elderly patients, the use of vaginal tampons and pessaries, which are thick rubber rings of various diameters, is indicated. Inside the pessary contains air, giving it elasticity and resilience. After insertion into the vagina, the ring provides support for the displaced uterus. When inserted into the vagina, the ring rests against the vaults of the vagina and fixes the cervix in a special hole. The pessary should not be left in the vagina for a long time because of the risk of developing bedsores. When using pessaries for the treatment of uterine prolapse, it is necessary to carry out daily vaginal douching with a decoction of chamomile, solutions of furacilin or potassium permanganate, and show a gynecologist twice a month. Pessaries can be left in the vagina for 3-4 weeks, then taking a break for 2 weeks.

Surgical treatment of uterine prolapse and prolapse

A more effective radical treatment for uterine prolapse or prolapse is a surgical operation, the indications for which are the ineffectiveness of conservative therapy and a significant degree of displacement of the organ. Modern operative gynecology for uterine prolapse and prolapse offers many types of surgical operations that can be structured according to the leading feature - anatomical education, which is used to correct and strengthen the position of organs.

The first group of surgical interventions includes vaginoplasty - plastic surgery aimed at strengthening the muscles and fascia of the vagina, bladder and pelvic floor (for example, colpoperineolevathoroplasty, anterior colporrhaphy). Since the muscles and fascia of the pelvic floor are always involved in the prolapse of the uterus, colpoperineolevathoroplasty is performed in all types of operations as the main or additional stage.

The second large group of operations involves the shortening and strengthening of the round ligaments supporting the uterus and their fixation to the anterior or posterior wall of the uterus. This group of operations is not so effective and gives the greatest number of relapses. This is due to the use for fixation of the round ligaments of the uterus, which have the ability to stretch.

The third group of operations for the prolapse and prolapse of the uterus is used to strengthen the fixation of the uterus by stitching the ligaments together. Some operations of this group deprive patients of the ability to bear children in the future. The fourth group of surgical interventions are operations with fixation of displaced organs to the walls of the pelvic floor (sacrum, pubic bone, pelvic ligaments, etc.).

The fifth group of operations includes interventions with the use of alloplastic materials used to strengthen the ligaments and fix the uterus. The disadvantages of operations of this type include a significant number of relapses of uterine prolapse, rejection of the alloplast, and the development of fistulas. The sixth group of operations for this pathology includes surgical interventions that lead to a partial narrowing of the vaginal lumen. The last group of operations includes the radical removal of the uterus - hysterectomy, in cases where there is no need to preserve the childbearing function.

Preference at the present stage is given to combined surgical treatment, including both fixation of the uterus, and plastic surgery of the vagina, and strengthening of the ligamentous-muscular apparatus of the pelvic floor in one of the ways. All types of operations used in the treatment of uterine prolapse or prolapse are performed by vaginal access or through the anterior abdominal wall (cavitary or laparoscopic access). After the operation, a course of conservative measures is necessary: ​​exercise therapy, diet therapy to eliminate constipation, exclusion of physical activity.

www.krasotaimedicina.ru

Prevalence

According to modern foreign studies, the risk of prolapse requiring surgical treatment is 11%. This means that at least one in 10 women will undergo surgery for this disease during their lifetime. In women after surgery, in more than a third of cases, a recurrence of genital prolapse occurs.

The older the woman, the more likely she is to have this condition. These conditions occupy up to a third of all gynecological pathology. Unfortunately, in Russia, after the onset of menopause, many patients do not go to the gynecologist for many years, trying to cope with the problem on their own, although every second of them has this pathology.

Surgical treatment of the disease is one of the frequent gynecological operations. Thus, in the United States more than 100 thousand patients are operated on annually, spending 3% of the entire healthcare budget on this.

Classification

Normally, the vagina and cervix are tilted back, and the body of the organ itself is tilted forward, forming an angle open to the front with the axis of the vagina. The bladder is adjacent to the anterior wall of the uterus, the posterior wall of the cervix and vagina is in contact with the rectum. From above the bladder, the upper part of the body of the uterus, the intestinal wall are covered with peritoneum.

The uterus is held in the pelvis by the force of its own ligamentous apparatus and by the muscles that form the perineal region. With the weakness of these formations, its omission or loss begins.

There are 4 degrees of the disease.

1. The external uterine os descends to the middle of the vagina.
2. The cervix, along with the uterus, moves down to the entrance to the vagina, but does not protrude from the genital gap.
3. The external pharynx of the cervix moves outside the vagina, and the body of the uterus is higher without going out.
4. Complete prolapse of the uterus into the perineum.

This classification does not take into account the position of the uterus, it determines only the most prolapsed area, often the results of repeated measurements differ from each other, that is, there is poor reproducibility of the results. These shortcomings are deprived of the modern classification of genital prolapse, adopted by most foreign experts.

Appropriate measurements are taken with the woman lying on her back during straining, using a centimeter tape, uterine probe or forceps with a centimeter scale. Point prolapse is evaluated relative to the plane of the hymen (the outer edge of the vagina). Measure the degree of prolapse of the vaginal wall and shortening of the vagina. As a result, uterine prolapse is divided into 4 stages:

• Stage I: the most drop-down zone is more than 1 cm above the hymen;
• Stage II: this point is within ±1 cm of the hymen;
• Stage III: the area of ​​maximum prolapse is more than 1 cm below the hymen, but the length of the vagina is reduced by less than 2 cm;
• Stage IV: complete prolapse, reduction in the length of the vagina by more than 2 cm.

Causes and mechanism of development

The disease often begins at the woman's fertile age, that is, before the onset of menopause. Its course is always progressive. As the disease develops, there are dysfunctions of the vagina, uterus, and surrounding organs.

For the appearance of genital prolapse, a combination of two factors is necessary:

• increased pressure in the abdominal cavity;
• weakness of the ligamentous apparatus and muscles.

Causes of uterine prolapse:

• a decrease in estrogen production that occurs during menopause and postmenopause;
• congenital weakness of the connective tissue;
• trauma to the muscles of the perineum, in particular, during childbirth;
• chronic diseases accompanied by impaired blood circulation in the body and increased intra-abdominal pressure (intestinal diseases with constant constipation, respiratory diseases with prolonged severe coughing, obesity, tumors of the ovaries, kidneys, liver, intestines, stomach).

These factors in various combinations lead to weakness of the ligaments and muscles, and they become unable to hold the uterus in a normal position. Increased pressure in the abdominal cavity "squeezes" the organ down. Since the anterior wall is connected to the bladder, this organ also begins to follow it, forming a cystocele. The result is urological disorders in half of the women with prolapse, for example, urinary incontinence when coughing, physical effort. The posterior wall, when lowered, "pulls" the rectum behind it with the formation of a rectocele in a third of patients. Often there is a prolapse of the uterus after childbirth, especially if they were accompanied by deep muscle ruptures.

Increase the risk of disease multiple births, intense physical activity, genetic predisposition.

Separately, it is worth mentioning the possibility of vaginal prolapse after amputation of the uterus for another reason. According to different authors, this complication occurs in 0.2-3% of operated patients with a removed uterus.

Clinical picture

Patients with pelvic organ prolapse are mostly elderly and senile women. Younger patients usually have early stages of the disease and are in no hurry to see a doctor, although the chances of successful treatment in this case are much greater.

• feeling that there is some kind of formation in the vagina or perineum;
• prolonged pain in the lower abdomen, in the lower back, tiring the patient;
• protrusion of a hernia in the perineum, which is easily injured and infected;
• painful and prolonged menstruation.

Additional signs of uterine prolapse arising from the pathology of neighboring organs:

• episodes of acute urinary retention, that is, the inability to urinate;
• urinary incontinence;
• frequent urination in small portions;
• constipation;
• in severe cases, fecal incontinence.

More than a third of patients experience pain during sexual intercourse. This worsens the quality of their life, leads to tension in family relationships, negatively affects the woman's psyche and forms the so-called pelvic descent syndrome, or pelvic dysynergy.

Often develops varicose veins with swelling of the legs, cramps and a feeling of heaviness in them, trophic disorders.

Diagnostics

How to recognize uterine prolapse? To do this, the doctor collects an anamnesis, examines the patient, prescribes additional research methods.

A woman needs to tell the gynecologist about the number of births and their course, surgeries, diseases of internal organs, mention the presence of constipation, bloating.

The main diagnostic method is a thorough two-handed gynecological examination. The doctor determines how much the uterus or vagina has sunk, finds defects in the muscles of the pelvic floor, performs functional tests - a test with straining (Valsalva test) and cough. A rectovaginal examination is also carried out to assess the condition of the rectum and structural features of the pelvic floor.

An ultrasound examination of the uterus, appendages and bladder is prescribed. It helps to determine the extent of surgery. In the early stages of the disease, colposcopy is performed. Magnetic resonance imaging helps to assess the altered anatomy of the small pelvis.

To diagnose urinary incontinence, urologists use a combined urodynamic study, but when organs are prolapsed, its results are distorted. Therefore, such a study is optional.

If necessary, endoscopic diagnostics is prescribed: hysteroscopy (examination of the uterus), cystoscopy (examination of the bladder), sigmoidoscopy (study of the inner surface of the rectum). Typically, such studies are necessary for suspected cystitis, proctitis, endometrial hyperplasia or polyp, cancer. Often, after the operation, a woman is referred to a urologist or proctologist for conservative treatment of identified inflammatory processes.

Treatment

Conservative treatment

Treatment of uterine prolapse should achieve the following goals:

• restoration of the integrity of the muscles that form the bottom of the small pelvis, and their strengthening;
• normalization of the functions of neighboring organs.

Prolapse of the uterus of the 1st degree is treated conservatively on an outpatient basis. The same tactic is chosen for uncomplicated genital prolapse of the 2nd degree. What to do with the prolapse of the uterus in mild cases of the disease:

• strengthen the muscles of the pelvic floor with the help of therapeutic exercises;
• refuse heavy physical activity;
• get rid of constipation and other problems that increase intra-abdominal pressure.

Is it possible to pump the press when the uterus is lowered? When lifting the body from a prone position, intra-abdominal pressure increases, which contributes to further pushing the organ out. Therefore, therapeutic exercises include tilts, squats, leg swings, but without straining. It is carried out in a sitting and standing position (according to Atarbekov).

At home

Treatment at home includes a diet rich in vegetable fiber, reduced in fat. It is possible to use vaginal applicators. These small devices produce electrical stimulation of the muscles of the perineum, strengthening them. There are developments in SCENAR therapy aimed at improving metabolic processes and strengthening ligaments.

Massage

Gynecological massage is often used. It helps to restore the normal position of the organs, improve their blood supply, and eliminate discomfort. Usually, from 10 to 15 massage sessions are performed, during which the doctor or nurse, with the fingers of one hand inserted into the vagina, lifts the uterus, and with the other hand, circular massage movements are made through the abdominal wall, as a result of which the organ returns to its normal place.

However, all conservative methods can only stop the progression of the disease, but not get rid of it.

Is it possible to do without surgery? Yes, but only if the prolapse of the uterus does not lead to its prolapse outside the vagina, does not impede the function of neighboring organs, does not cause the patient trouble associated with an inferior sex life, and is not accompanied by inflammatory and other complications.

Surgery

How to treat uterine prolapse III-IV degree? If, despite all conservative methods of treatment or due to the patient's late request for medical help, the uterus has gone beyond the vagina, the most effective method of treatment is prescribed - surgical. The purpose of the operation is to restore the normal structure of the genital organs and correct the disturbed functions of neighboring organs - urination, defecation.

The basis of surgical treatment is vaginopexy, that is, fixing the walls of the vagina. With urinary incontinence, the strengthening of the walls of the urethra (urethropexy) is simultaneously performed. If there is weakness of the muscles of the perineum, they are plastic (recovered) with strengthening of the neck, peritoneum, supporting muscles - colpoperineolevathoroplasty, in other words, suturing of the uterus during prolapse.

Depending on the required volume, the operation can be performed using transvaginal access (through the vagina). This is how, for example, removal of the uterus, suturing the walls of the vagina (colporrhaphy), loop operations, sacrospinal fixation of the vagina or uterus, strengthening the vagina with the help of special mesh implants are performed.

With laparotomy (an incision of the anterior abdominal wall), the operation for prolapse of the uterus consists in fixing the vagina and cervix with its own tissues (ligaments, aponeurosis).

Sometimes laparoscopic access is also used - a low-traumatic intervention, during which it is possible to strengthen the walls of the vagina and suture defects in the surrounding tissues.

Laparotomy and vaginal access do not differ in long-term results. Vaginal is less traumatic, with less blood loss and the formation of adhesions in the pelvis. The use of laparoscopy may be limited due to the lack of necessary equipment or qualified personnel.

Vaginal colpopexy (cervical strengthening by access through the vagina) can be performed under conduction, epidural anesthesia, intravenous or endotracheal anesthesia, which expands its use in the elderly. This operation uses a mesh-like implant that strengthens the pelvic floor. The duration of the operation is about 1.5 hours, the blood loss is insignificant - up to 100 ml. Starting from the second day after the intervention, the woman can already sit down. The patient is discharged after 5 days, after which she undergoes treatment and rehabilitation in the clinic for another 1-1.5 months. The most common long-term complication is erosion of the vaginal wall.

Laparoscopic surgery is performed under endotracheal anesthesia. During it, a mesh prosthesis is also used. Sometimes amputation or extirpation of the uterus is performed. The field of operation requires early activation of the patient. An extract is carried out on the 3-4th day after the intervention, outpatient rehabilitation lasts up to 6 weeks.

Within 6 weeks after the operation, a woman should not lift weights of more than 5 kg, sexual rest is required. Within 2 weeks after the intervention, physical rest is also necessary, then you can already do light housework. The average period of temporary disability is from 27 to 40 days.

What to do in the long term after the operation:

• do not lift weights more than 10 kg;
• normalize stool, avoid constipation;
• treat respiratory diseases accompanied by cough in time;
• long-term use of estrogen suppositories (Ovestin) as prescribed by a doctor;
• do not engage in certain sports: cycling, rowing, weightlifting.

Features of the treatment of pathology in the elderly

Treatment of uterine prolapse in the elderly is often difficult due to comorbidities. In addition, often this disease is already in an advanced stage. Therefore, doctors face significant difficulties. To improve the results of treatment, at the first signs of pathology, a woman should contact a gynecologist at any age.

In the initial stages of the disease in elderly patients, when the uterus is prolapsed, a gynecological ring is used. This is the so-called pessary made of synthetic material, which is inserted deep into the vagina and supports its arch, preventing the uterus from descending. The ring is removed at night and washed well, and in the morning the woman sets it back. The gynecological pessary does not have a therapeutic effect. When using it, inflammatory complications are possible - colpitis, vaginitis, cervicitis, as well as erosion (you can read about cervical erosion here).

Therefore, a bandage will provide significant assistance to a woman when the uterus is lowered. It can also be used by younger patients. These are special supportive panties that tightly cover the abdominal area. They prevent prolapse of the uterus, support other organs of the small pelvis, reduce the severity of involuntary urination and pain in the lower abdomen. Choosing a good bandage is not easy, a gynecologist should help with this.

A woman must perform therapeutic exercises.

With a significant prolapse, a surgical operation is performed, often this is the removal of the uterus through a vaginal access.

Effects

If the disease is diagnosed in a woman of fertile age, she often has the question of whether it is possible to become pregnant with the prolapse of the walls of the uterus. Yes, there are no special obstacles to conception in the early stages if the disease is asymptomatic. If the omission is significant, then before the planned pregnancy it is better to be operated on 1-2 years before conception.

Preservation of pregnancy with proven uterine prolapse is fraught with difficulties . Is it possible to bear a child with this disease? Of course, yes, although the risk of pregnancy pathology, miscarriage, premature and rapid birth, bleeding in the postpartum period is significantly increased. In order for the pregnancy to develop successfully, you need to constantly be observed by a gynecologist, wear a bandage, use a pessary if necessary, engage in physiotherapy exercises, and take medications prescribed by a doctor.

What threatens the prolapse of the uterus in addition to possible problems with carrying a pregnancy:

• cystitis, pyelonephritis - infections of the urinary system;
• vesicocele - saccular dilation of the bladder, in which urine remains, causing a feeling of incomplete emptying;
• urinary incontinence with irritation of the skin of the perineum;
• rectocele - expansion and prolapse of the ampulla of the rectum, accompanied by constipation and pain during bowel movements;
• infringement of intestinal loops, as well as the uterus itself;
• eversion of the uterus with its subsequent necrosis;
• deterioration in the quality of sexual life;
• a decrease in the overall quality of life: a woman is embarrassed to go out into a public place, because she is constantly forced to run to the toilet, change incontinence pads, she is exhausted by constant pain and discomfort when walking, she does not feel healthy.

Prevention

The prolapse of the walls of the uterus can be prevented in this way:

• minimize prolonged traumatic childbirth, if necessary, excluding the straining period or performing a caesarean section;
• timely identify and treat diseases accompanied by increased pressure in the abdominal cavity, including chronic constipation;
• in the event of ruptures or dissection of the perineum during childbirth, carefully restore the integrity of all layers of the perineum;
• recommend women with estrogen deficiency hormone replacement therapy, in particular, with menopause;
• assign patients at risk of genital prolapse special exercises to strengthen the muscles that form the pelvic floor.

gynekolog-i-ya.ru

Prevalence

Omission of the pelvic organs is quite widespread. For example, in India, this pathology is found in almost every woman, and in the United States, this disease is diagnosed in 15 million of the fairer sex.

The statistics on pelvic organ prolapse are striking:

• age up to 30 - the disease occurs in every tenth woman;
• age 30 - 45 years - pathology is diagnosed in 40 women out of a hundred;
• age over 50 years - every second woman suffers from prolapse of the pelvic organs.

According to an epidemiological study, every eleventh woman worldwide will be operated on for this pathology, due to the high risk of developing genital prolapse. The fact of recurrence of the disease, for which more than 30% of patients are operated on again, makes one think.

Location of the pelvic organs

The uterus is a hollow, pear-shaped organ of smooth muscle. The main task of the uterus is to carry and give birth to a child. Normally, it is located along the wire axis of the pelvis (in the center and along the line running down from the head to the legs). The body of the uterus is somewhat tilted anteriorly, forming an angle open towards the anterior abdominal wall (anteflexio position). The uterine fundus is at the level or outside the plane of the entrance to the small pelvis.

The second angle is formed between the cervix and the vagina, which is also open anteriorly. In front of the uterus is in contact with the bladder, and behind with the rectum. Both the uterus and the appendages have a certain physiological mobility, which is necessary for their normal functioning (the course of pregnancy / childbirth, the work of adjacent organs: the bladder / rectum). At the same time, the uterus in the small pelvis is securely fixed, which prevents its prolapse. Fixation of the uterus is carried out by the following structures:

• suspension ligaments (wide, round ligaments of the uterus, ovarian ligaments) - due to them, the uterus and appendages are fixed to the walls of the pelvis;
• muscles and fascia of the pelvic floor and the anterior wall of the abdomen (their normal tone ensures the correct location of the internal genital organs, and with the loss of muscles of elasticity and elasticity, prolapse of the pelvic organs develops);
• tight ligaments that attach the uterus to adjacent organs (urea / rectum), to the fascia and pelvic bones.

What is pelvic organ prolapse?

Omission (prolapse) of the pelvic organs is a disease in which there is a violation of the location of the uterus and / or vaginal walls, characterized by displacement of the genital organs either before entering the vagina, or their protrusion (falling out) beyond its borders. Often, genital prolapse leads to prolapse and protrusion of the bladder with the formation of a cystocele and / or rectum - rectocele. The disease is progressive and develops when the muscle layer of the pelvic floor fails, the ligaments that support the uterus are stretched, and intra-abdominal pressure increases. Prolapse of the pelvic organs for ease of understanding can be called a hernia.

The location of the uterus in the normal position and in pathology

Causes of prolapse

The omission of the genital organs is due to a number of reasons that can be divided into several groups:

• injury to the pelvic floor;
• violation of the synthesis of steroids (in particular estrogen);
• failure of connective tissue formations;
• chronic somatic diseases that are accompanied by impaired blood supply, metabolic processes or cause an increase in intra-abdominal pressure.

Pelvic floor trauma
The first group of reasons is mainly due to complicated childbirth. These can be ruptures of the perineum of 3-4 degrees, the use of obstetric forceps in the period of expulsion of the fetus, childbirth with a large fetus, rapid childbirth, childbirth with an incorrect position of the fetus (breech and foot presentation), multiple pregnancy. Often, trauma to the pelvic floor muscles during childbirth occurs in "old" primiparous women, when the perineum has lost its elasticity and ability to stretch, and during repeated births (short breaks between births or multiple births). Of no small importance in the development of prolapse of the pelvic organs is both hard physical work and the constant lifting of weights, which leads to a regular increase in intra-abdominal pressure.

Steroid production
The lack of estrogen production, as a rule, is observed in the pre- and postmenopausal periods, but may be due to hormonal disorders in women of reproductive age. Estrogens are responsible for the tone and elasticity of muscles, connective tissue structures and skin, their deficiency contributes to stretching of the ligaments and the muscle layer of the pelvic floor.

Connective tissue failure
The insolvency of connective tissue formations is said to occur when there is a "systemic" insufficiency of the connective tissue due to a genetic predisposition (congenital heart defects, astigmatism, hernias).

chronic diseases
Chronic diseases leading to disorders of microcirculation and metabolic processes (diabetes mellitus, obesity), as well as maintaining intra-abdominal pressure at a high level (pathology of the respiratory system - persistent cough) or diseases of the digestive tract (problems with defecation, constipation) also provoke the development of genital prolapse .

Classification

For practical activities, the following classification of genital prolapse is most convenient:

• 1 degree is determined by the prolapse of the cervix no further than up to ½ of the length of the vagina;
• at grade 2, the cervix and / or vaginal walls descend to the entrance to the vagina;
• 3 degrees are spoken in the case of the location of the cervix and vaginal walls outside the vagina, while the body of the uterus is located above;
• if the uterus and vaginal walls are determined outside the vagina, this is already grade 4.

Clinical picture, symptoms

The course of the disease is slow, but steadily progressive, although in some cases the process can develop relatively quickly, especially considering that in recent years there have been more and more women of young reproductive age among the contingent of patients. Prolapse of the genitals leads to functional disorders of almost all pelvic organs:

From the reproductive system

There is a feeling of a foreign body in the vagina, which is joined by heaviness and discomfort in the lower abdomen and lower back. Characteristically, after taking a horizontal position or after sleep, these complaints disappear, and their intensification occurs towards the end of the day or after heavy lifting / hard physical work. When the uterus and / or vagina prolapse, patients feel a “hernial sac” in the perineum, which not only makes it difficult to have sex (coitus is possible only after the organ is repositioned), but also walking. The uterus and vaginal walls, on examination, look either dull or shiny, with dry mucous membranes, on which there are numerous abrasions and cracks. At 3-4 degrees of diseases, trophic ulcers and bedsores often appear due to constant friction of the uterus and vaginal walls against clothing and impaired blood supply to them (venous congestion).

The appearance of trophic ulcers often provokes infection of nearby tissue with the development of purulent complications (parametritis and others). The downward displacement of the uterus leads to disruption of the normal blood flow in the small pelvis, which causes stagnation of blood in it and is accompanied by pain and a feeling of pressure from below in the abdomen, discomfort, pain in the sacral and lumbar regions, which are aggravated by walking. Due to congestion, the mucous membranes of the uterus and vagina become cyanotic and swell.

In addition, the menstrual function also suffers, which is manifested by algomenorrhea and hyperpolymenorrhea. Infertility often develops, although pregnancy is not excluded.

From the urinary system

The functions of the urinary system are also disturbed, which is manifested by difficult urination, the presence of residual urine and its stagnation. As a result, infection of the lower urinary tract (urethra, bladder), and then the upper ones (ureters, kidneys) occurs. If complete prolapse of the genitals exists long enough, then obstruction of the ureters (formed stones), the development of hydronephrosis and hydroureter are possible. Stress incontinence (coughing, sneezing, laughing) is also noted. Secondary complications are inflammation of the kidneys and bladder, urolithiasis, and so on. It should be noted that urological complications occur in every second patient.

From the large intestine

Prolapse of the pelvic organs is accompanied by the development of proctological complications, which is typical for every third patient. Constipation is often found, and it should be noted that, on the one hand, they act as the cause of the pathology, and on the other hand, the consequence and clinical sign of the disease. The function of the large intestine is also disturbed, which is expressed in the form of colitis. A rather painful and unpleasant manifestation of pathology is the inability to retain feces and gases. Gas / fecal incontinence is caused either by injury to the tissues of the perineum, the walls of the rectum and rectal sphincter (during childbirth) or the development of deep functional disorders of the pelvic floor muscles.

Phlebeurysm

Women suffering from genital prolapse often develop varicose veins, particularly in the lower extremities. The development of varicose veins is provoked by a violation of the outflow of blood from the veins, which occurred due to changes in the location of the pelvic organs and insufficiency of connective tissue structures.

Treatment

The treatment of pelvic organ prolapse is determined by several factors:

• the degree of prolapse of the genitals;
• concomitant gynecological pathology (endometrial polyps, endometriosis, uterine tumors, etc.);
• the desire and ability to maintain reproductive and menstrual functions;
• clinical manifestations of functional disorders of the large intestine and rectal sphincter;
• the age of the patient;
• concomitant somatic (general) diseases (risk degree of surgery and general anesthesia).

Treatment of pathology can be carried out conservatively and surgically.

Conservative therapy

Conservative therapy is carried out for women with 1 - 2 degree of the disease. It is recommended to give up heavy physical work and prohibit heavy lifting (no more than 3 kg). Also shown are therapeutic exercises according to Atarbekov, exercises that strengthen the abdominal muscles (“bicycle”, tilts in the prone position, lifting the legs in a horizontal position), Kegel exercises (compression and relaxation of the muscles of the perineum). You should also review the diet, giving preference to fermented milk products, vegetables and fruits (normalization of the intestines). With a lack of estrogen, intravaginal suppositories or a cream (Ovestin) are prescribed.

In case of contraindications (severe somatic diseases), it is recommended to wear a vaginal pessary (ring) made of plastic or rubber for surgical treatment. But prolonged wearing of a pessary aggravates the course of the disease, as there is an even greater stretching of the pelvic floor muscles.

Exercises for prolapse of the pelvic organs

Surgical intervention

Surgical intervention is performed with complete and incomplete prolapse of the uterus and vagina. Several types of operations have been developed:

• strengthening and maintaining the pelvic floor (colpoperineolevathoroplasty);
• shortening of the round ligaments and fixation of the uterus with them;
• strengthening the cardinal and sacro-uterine ligaments (suturing them, transposition, etc.);
• fixation of the uterus to the pelvic bones;
• strengthening the ligamentous apparatus of the uterus with alloplastic materials;
• partial obliteration of the vagina;
• extirpation of the uterus by the vaginal route (premenopausal and postmenopausal women).

Prevention

Prevention of the development of prolapse of the pelvic organs includes compliance with the following recommendations:

• Mode of physical labor and education
  Excessive physical work and especially heavy lifting should be avoided already in childhood, especially for adolescent girls, when menstrual and reproductive functions are formed.
• Pregnancy/delivery management
  Genital prolapse provokes not only a large number of births, but also the tactics of their management. When providing surgical aids in childbirth (imposition of obstetric forceps and a vacuum escochleator, pelvic aid, etc.), it contributes to the occurrence of intrapelvic injuries of the lumbosacral plexus (subsequently, paralysis of the obturator and sciatic nerves develops), deep ruptures of the soft tissues of the perineum involving the sphincter of the rectum and urethra which later leads to the formation of urinary and fecal incontinence. If possible, one should not allow a protracted course of the straining period, perform an episiotomy (if there is a threat of rupture of the perineum) and strive to correctly compare the soft tissues of the perineum when they are sutured in case of a rupture or incision.
• Rehabilitation in the postpartum period
  With special care after childbirth, prevention of the development of purulent-septic complications should be carried out (treatment of perineal wounds with antiseptics, perineal hygiene, if necessary, antibiotic therapy). Rehabilitation measures are also carried out to restore the functionality of the pelvic floor (special gymnastics, laser treatment, electrical stimulation of the muscles of the perineum).
• Nutrition and drinking regimen
  Eat a constipation-free diet (high in fiber). You should also drink up to 2.5 - 3 liters of fluid per day.

www.webmedinfo.ru

- displacement of the internal genital organs with their partial or complete exit outwards from the genital slit. When the uterus prolapses, pressure is felt on the sacrum, a foreign body in the genital gap, urination and defecation disorders, pain during intercourse, and discomfort when walking. Prolapse of the vagina and uterus is recognized during a gynecological examination. Treatment of uterine prolapse is surgical, taking into account the degree of prolapse and the age of the patient. If surgical treatment is impossible, women are shown the use of a pessary (uterine ring).

General information

It is considered as a hernial protrusion, which is formed when the functions of the closing apparatus - the pelvic floor - fail. According to the results of various studies conducted by gynecology, genital prolapse accounts for about 30% of gynecological pathology. Prolapse of the uterus and vagina rarely develops in isolation: the anatomical proximity and commonality of the supporting apparatus of the pelvic organs causes displacement after the genitals of the bladder (cystocele) and rectum (rectocele).

There are partial (incomplete) prolapse of the uterus, characterized by displacement of only the cervix, and complete prolapse, in which the uterus is entirely outside the genital gap. When the uterus prolapses, elongation of the cervix develops (lengthening). Usually, prolapse is preceded by a state of uterine prolapse - some displacement below the normal anatomical level within the pelvic cavity. Under the prolapse of the vagina is understood such a displacement, in which its anterior, posterior and upper walls are shown from the genital slit.

Causes of prolapse of the uterus and vagina

The leading role in the development of prolapse of the uterus and vagina belongs to the weakening of the ligaments and muscles of the diaphragm, pelvic floor, anterior abdominal wall, which become unable to hold the pelvic organs in their anatomical position. In situations of increased intra-abdominal pressure, the muscles cannot provide adequate resistance, which leads to a gradual downward displacement of the genital organs under the pressure of the acting forces.

The weakening of the ligamentous and muscular apparatus develops as a result of birth injuries, perineal ruptures, multiple pregnancies, multiple births, the birth of large children, radical interventions on the pelvic organs, leading to the loss of mutual support of the organs. Uterine prolapse is facilitated by an age-related decrease in estrogen levels after menopause, a weakening of the uterus's own tone, and exhaustion.

An additional load on the pelvic muscles develops with excess weight, conditions accompanied by an increase in intra-abdominal pressure (cough, chronic bronchitis, bronchial asthma, ascites, constipation, pelvic tumors, etc.). A risk factor for uterine prolapse is hard physical work, especially during puberty, after childbirth, in menopause. More often, prolapse of the uterus and vagina occurs in old age, but sometimes it develops even in nulliparous young women with congenital disorders of the innervation of the pelvic floor or muscle hypoplasia.

The position of the uterus plays a role in the development of genital prolapse. In the normal position (anteversion-anteflexia), the pelvic floor muscles, pubic bones, and bladder walls serve as a support for the uterus. With retroversion and retroflexion of the uterus, prerequisites are created for the emergence of a hernial ring, prolapse of the walls of the vagina, then the uterus with appendages. Due to stretching of the ligamentous apparatus, vascularization, trophism and lymph outflow are disturbed. Prolapse of the uterus and vagina is more likely to affect representatives of the Caucasian race; in African American and Asian women, the pathology is less common.

Classification of uterine and vaginal prolapse

According to the degree of displacement of the uterus, 4 degrees of prolapse are distinguished.

Diagnosis of uterine and vaginal prolapse requires the involvement of related specialists - a urologist and a proctologist. Urological examination of patients with uterine prolapse may include a study of a general urine test, bacteriological urine culture, excretory urography, ultrasound of the kidneys, chromocystoscopy, urodynamic studies. In the course of a proctological study, the presence and severity of rectocele, sphincter insufficiency, and hemorrhoids are clarified. Uterine prolapse is differentiated from vaginal cysts, uterine fibroids, and cervical changes from cervical cancer.

Treatment of uterine and vaginal prolapse

The only radical method to eliminate prolapse of the uterus and vagina in gynecology is surgical intervention. In preparation for the operation, ulceration of the mucosa is treated, and a thorough sanitation of the vagina is performed. The method of surgery for uterine prolapse depends on the degree of prolapse, the somatic status and age of the woman.

In the case of incomplete prolapse of the uterus in young women who have given birth, a "Manchester" operation can be performed, including anterior colporrhaphy with shortening of the cardinal ligaments and colpoperineolevatoroplasty, and with elongation and hypertrophy of the cervix, ruptures and erosions of the cervix - with its amputation. Another intervention option for women of childbearing age with uterine prolapse can be an operation that includes anterior colporrhaphy, colpoperineoplasty, exercise therapy aimed at strengthening muscles, constipation is prevented, heavy physical labor and stress are excluded.

Conservative therapy for uterine and vaginal prolapse is symptomatic and includes the use of a uterine ring (pessary), a hysterophore (supporting bandage attached to a belt), and large vaginal tampons. Such methods entail additional overstretching of the reduced vaginal walls, which over time increases the risk of uterine prolapse. In addition, prolonged use of a pessary can lead to the formation of pressure sores. The use of various supporting devices for uterine prolapse requires daily douching of the vagina and regular, twice a month, examination of the patient by a gynecologist.

Forecast and prevention of uterine and vaginal prolapse

Timely surgical intervention for uterine prolapse is prognostically favorable. Most women regain social activity and sexual life. After organ-preserving interventions, pregnancy is possible. The management of pregnancy in patients undergoing surgery for uterine prolapse carries additional risks and requires increased precautions. Sometimes even after elimination of prolapse of the uterus, repeated prolapse of the genitals develops. In the palliative treatment of uterine prolapse (using a pessary), irritation and swelling of the vaginal mucosa, ulceration, bedsores, infections, infringement of the cervix in the lumen of the ring, and the formation of rectal and vesicovaginal fistulas often develop.

Prevention of uterine and vaginal prolapse includes proper obstetric care during childbirth, careful suturing of perineal and birth canal tears, careful performance of vaginal operations, and timely surgical treatment of minor genital prolapse. In the postpartum period, to prevent uterine prolapse, it is necessary to fully restore the state of the pelvic floor muscles - the appointment of special gymnastics, laser therapy, electrical stimulation of the pelvic floor muscles. Fitness classes, exercise therapy, rational nutrition, maintaining optimal weight, eliminating constipation, and eliminating hard work are of preventive importance.