gynecology and obstetrics
Uterine and Apical Prolapse
Treatment of Uterine and Apical Prolapse
For mild symptomatic prolapse, pessaries Surgical repair of supporting structures if necessary, usually with hysterectomy Asymptomatic prolapsedoes not require treatment, but patients should be followed clinically for progression. Symptomatic prolapsecan be treated with a pessary if the perineum can structurally support a pessary; surgical repair is an option for women who do not wish to use a pessary or the perineum cannot support a pessary. Surgery for uterovaginal prolapse can be done through the vagina or through an incision in the abdomen using various techniques. Factors determining choice of techniques include surgeon experience and patient desires. Techniques may include one or a combination of the following: Hysterectomy Surgical repair of the pelvic support structures (colporrhaphy) Suspension of the top of the vagina (suturing of the upper vagina to a stable structure nearby) Colpocleisis (closure of the vagina after removal of the uterus or with the uterus in place [Le Fort procedure]) Procedures are done using a transvaginal or abdominal route. Regardless of the surgical route, symptoms often recur, especially along the anterior vaginal wall. Surgery is delayed until all ulcers, if present, have healed. Vaginal prolapse is treated similarly to uterine prolapse. The vagina may be stitched close (colpocleisis) if women are not good candidates for prolonged surgery (eg, if they have serious comorbidities). Advantages of vaginal closure include short duration of surgery, low risk of perioperative morbidity, and very low risk of prolapse recurrence. However, after vaginal closure, women are no longer able to have vaginal intercourse. Urinary incontinence requires concurrent treatment. 