- Definition. Descent of one or more pelvic organs (uterine cervix, vaginal apex [after hysterectomy], anterior vagina, posterior vagina, or cul-de-sac peritoneum) through the pelvic floor into the vagina.
- Incidence. Half of parous women have prolapse on examination; 10% of women will undergo surgery for prolapse or urinary incontinence in their lifetime. Prolapse is the most common indication for hysterectomy in women after age 55.
- Pelvic support. The vagina and uterus have three levels of support in the pelvis: (1) the uterus, cervix, and upper vagina are supported by cardinal and uterosacral ligaments; (2) the arcus tendinus fascia (white line) and the levator ani fascia support the midvagina; and (3) the perineal muscles and membrane support the distal vagina. The levator ani complex of muscles (see Chapter 2) provides the major support for the pelvic organs.
- Etiology:
1 Vaginal parity. Pregnancy, labor, and vaginal delivery may result in various degrees of damage to pelvic support structures, including the ligaments, fascia, muscles, and their nerve supply.
2 Race. Prolapse occurs more frequently among white women than Asian and black ones. Inherited differences in pelvic architecture and the quality of supporting muscles/connective tissue are thought to be responsible.
3 Estrogen deficiency. Pelvic tissues are estrogen sensitive. Prolapse often becomes symptomatic during the menopausal years as collagen fibers deteriorate.
4 Chronic conditions that cause repeated increases in intra-abdominal pressure (obesity, “smokers’ cough,” heavy lifting, constipation) can contribute to significant pelvic relaxation.
5 Connective tissue disease. Chronic steroid use, Ehlers–Danlos syndrome, and other related conditions can disrupt normal, collagen-based, pelvic tissue support.
Diagnosis
- History. Each woman’s condition should be assessed to ascertain the nature, severity, and progression of her symptoms in addition to coexisting medical conditions, prior obstetric events and past/present medications.
- Symptoms.
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