definition prolaps

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Definition/Description Uterine prolapse is the condition of the uterus collapsing, falling down, or downward displacement of the uterus with relation to the vagina. [1]  It is also defined as the bulging of the uterus into the vagina. [2]  [3]  [4]  When in proper alignment, the uterus and the adjacent structures are suspended in the proper position by the uterosacral, round, broad, and cardinal ligaments. The musculature of the pelvic floor forms a sling-like structure that supports the uterus, vagina, urinary bladder, and rectum. [2]  Uterine prolapse is a result of pelvic floor r elaxation or structural overstretching of the muscles of the pelvic wall and ligamentous structures.

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    Definition/Description

    Uterine prolapse is the condition of the uterus collapsing, falling down, or downward displacement

    of the uterus with relation to the vagina.[1]It is also defined as the bulging of the uterus into the

    vagina.[2][3]

    [4]

    When in proper alignment, the uterus and the adjacent structures are suspended in the proper

    position by the uterosacral, round, broad, and cardinal ligaments. The musculature of the pelvic

    floor forms a sling-like structure that supports the uterus, vagina, urinary bladder, and

    rectum.[2]Uterine prolapse is a result of pelvic floor relaxation or structural overstretching of the

    muscles of the pelvic wall and ligamentous structures.

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    Uterine prolapse is characterized under a more general classification called pelvic organ

    prolapse which encompasses descent of the anterior, middle and posterior structures

    into the vagina.[5]

    Those organs that bulge anterior into the vagina are the urinary bladder which is called acystocele, the urethra, which is called a urethrocele or a combination, which is a

    cystourethrocele.[2],[5]

    The uterus and the vaginal vault, which is the apex of the vagina, make up the organs thatconstitute the middle portion descent into the vagina. The vaginal vault often prolapses as

    a result of a hysterectomy.[5]

    The rectal bulge is called a rectocele and a bulge of part of the intestine and peritoneum iscalled an enterocele, these make up the posterior portion of pelvic organ prolapse.[2],[5]

    The information from this point forward will focus on uterine prolapse.

    Uterine prolapse is classified using a four part grading system:

    Grade 1: Descent of the uterus to above the hymen

    Grade 2: Descent of the uterus to the hymen

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    Grade 3: Descent of the uterus beyond the hymen

    Grade 4: Total prolapse.[5]

    [6]

    Prevalence

    Each source presents with a different prevalence depending on the researcher and the population

    used. One study stated that the prevalence of pelvic organ prolapse, a clinical classification for all

    of the pelvic structures prolapse into the vagina, was 50% for women who have give birth, though

    most women are asymptomatic.[5]Another article cited that 50% of the female population in the

    United States are affected by pelvic order prolapse with a prevalence rate that can vary from 30%

    to 93%, varying among different populations.[7]A questionnaire based study stated that 46.8% of

    the responses were positive for symptoms of pelvic organ prolapse and of the response group,

    46.9% were vaginally examined with 21% having clinically relevant pelvic organ prolapse.[8]

    Characteristics/Clinical PresentationThe primary symptoms of a uterine prolapse are backache, perineal pain, and a sense of

    "heaviness" in the vaginal area.[2]Pain associated with uterine prolapse can be located centrally

    or suprapubic, and can be described as "dragging" in the groin. This pain is due to stretching of

    the ligamentous supports and secondarily to abrasion of the prolapsed tissues.[1]If the prolapse

    has progressed into a grade three or third degree prolapse, the person may feel as though they

    have a lump at the vaginal opening and have irritation and abrasion of the exposed mucous

    membrane of the cervix and vagina. This is possible both during sexual intercourse and from

    wiping with toileting procedures. The person may report that the symptoms are relieved by lying

    down and exacerbated with prolonged standing, walking, coughing or straining. An associated and

    often common complication of uterine prolapse is urinary incontinence.[2] Other descriptions used

    are the feeling of sitting on a small ball and a report of repeated bladder infections.[9]

    Summary from Differential Diagnosis for Physical Therapists:

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    Observation is often the first means of diagnosis.[2]Physical examination is the primary means for

    diagnosis. A bimanual test is performed with a speculum while the person is at rest and when the

    person is straining. If prolapse is not apparent with the first method, the person repeats the test

    while standing with one foot on a chair. The person is then graded using a first through third

    degree categorization. A first degree prolapse is characterized by descent of the uterus to above

    the hymen. A second degree prolapse is to the level of the hymen and a third degree prolapse is

    below the level of the hymen and protrudes through the vaginal opening.[2]

    Urine culture is orderedif needed. If still unsure about the diagnosis, a pelvic ultrasonography or cystography can be

    ordered.[5]

    Causes

    Women most at risk for this condition are those who have had multiple pregnancies and deliveries

    in combination with obesity. Associated risk factors are trauma to the pudendal or sacral nerves

    when giving birth. The disorder has been attributed to prolonged labor, bearing down before full

    dilation, and forceful delivery of the placenta. Decreased muscle tone due to aging, excessive

    strain during bowel movement and complications of pelvic surgery have also been associated with

    prolapse of the uterus and adjacent organs.[2]Associated risk also exists with pelvic tumors and

    neurologic condition like spina bifida and diabetic neuropathy which interferes with innervation of

    pelvic musculature.[2]Genetics are suspected in this condition due to multiple familial relations and

    generations with this and related conditions.[13]A recent article has found that Cesarean section

    may lower the risk for pelvic organ prolapse.[14]

    Summary of Causes:

    Multiple pregnancies and deliveries

    Obesity

    Trauma to pudendal or sacral nerves

    Aging related muscle changes

    Excessive strain during bowel movements

    Pelvic tumors

    Genetic predisposition

    Systemic Involvement

    The digestive and urinary system can be impacted by uterine prolapse if the uterus obstructs the

    bladder/urethra and the rectum, decreasing the ability to void.[15]The reproductive system can

    also be impacted by painful intercourse, decreasing the ability for reproduction.[1]

    Medical Management (current best evidence)Corrective Surgery

    Corrective surgery was a once popular first step for uterine prolapse but has fallen second choice

    to rehabilitation. When surgery is indicated, it is a management tool for second, third, and fourth-

    degree uterine prolapse.[2]Pelvic organ prolapse surgery has a success rate of 65% to 90% and

    has a repeated rate of operation at 30%. Patients who have more than one compartment involved

    may need a combination of surgeries and surgery can often predispose patients to prolapse in

    another compartment. Surgery can be either open or laparoscopic of the abdomen or can be in the

    vagina using fasciae, mesh, tape or sutures to suspend the organs. Another surgical procedure

    that is used in attempt to conserve the uterus is a sacrohysteropexy which is a Y-shaped graft that

    attaches the uterus to the sacrum.[5]One case study that examined the effectiveness in

    laparoscopic sacrohysteropexy, stated that this procedure maintains durable anatomicrestoration, normal vaginal axis and sexual function. It also requires less time and less adhesion

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    formation due to the laparoscopic approach versus an abdominal route.[16]Vaginal hysterectomy,

    vesicourethral suspension, and abdominal hysterectomy are other possible

    approaches.[2]Important components for consideration of a surgical approach are:

    Degree of prolapse

    Desire for future pregnancies

    Other medical conditions

    The woman's desire to retain vaginal function

    The woman's age and general health[9][17]

    Pessary

    A pessary is a shaped device made to support the uterus in the vagina. This is often a non-surgical

    approach used for both uterine prolapse and urinary incontinence. There is a supportive type for

    milder prolapse and a space-occupying type for more serious prolapse. The goal of the pessary is

    to find the largest fit that is comfortable. They are to be removed regularly for cleaning by the

    individual with correct education or by a health care professional.[5]

    There are rings, rings with arubber support, cubes, donut shapes and inflatable balls. Depending on the degree of prolapse will

    determine the type that is chosen.[13]Patients who are not eligible for use of a pessary are those

    who cannot perform maintenance care of the pessary, those with vaginal ulcerations or lesions,

    severe atrophy of the vagina and women who develop recurrent vaginitis.[18]Signs of improper fit

    are: those who have pain when wearing the pessary, vaginal ulceration and infection, and the

    inability to have a bowel movement or urinate.[13]

    [19]

    No Treatment

    Surgical treatment is not appropriate when the woman has recently had a baby. Tissue damaged

    during childbirth that has caused an associated prolapse, often begins to improve when

    undergoing tissue healing. A symptomatic prolapse in the first few weeks after delivery,

    especially in breastfeeding mothers have lower estrogen levels, does not necessarily predispose

    the mother to long term issues. Improvement tends to occur after discontinuation of nursing and

    the return of normal hormone levels. Other women and/or physicians do not elect for medical

    treatment for Stage 1 and Stage 2 prolapse and take a wait and see approach.[13]

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    Physical Therapy Management (current best evidence)

    Pelvic floor strengthening exercise is currently the front line treatment before surgery and also

    following surgery, these include but are not limited to Kegel exercises.[2][5]Other methods currently

    used are pelvic floor musculature re-education, postural education, biofeedback and electrical

    stimulation.[2]

    Pelvic Floor Training

    Pelvic floor muscles are seventy percent slow-twitch muscle fibers, which assist in muscle

    endurance with generation of slow and sustained contractions. These muscles are designed to

    have a less intense contraction, whereas the other thirty percent, which are fast twitch, are

    designed for quick and forceful contraction. An example of fast twitch muscles are the muscles

    that close the urethra during increased intra-abdominal pressure.[20]Pelvic floor training is

    progressive resistive exercises for the pelvic floor that are often titled Kegel exercises. These

    exercises improve urethral resistance and pelvic visceral support by increasing the voluntary

    periurethral muscles. Pelvic floor exercises enhance the voluntary closing mechanisms. A thorough

    assessment of pelvic floor function is necessary to determine the muscular strength and endurance

    by manual muscle test.[21]

    Kegel exercises are often explained as contracting the muscles that stopthe flow of urine. A sustained pelvic contraction for a minimum of two seconds is likely to ensure a

    better response to physical therapy. A five point rating scale is used to describe the contractile

    strength during pelvic musculature examination.

    Five-Point Rating Scale[22]

    Grade Description

    0 No contraction

    1 Flicker, only with muscles stretched

    2 Weak squeeze, 2 second hold

    3Fair squeeze with definite "lift" (in which thecontraction can be felt to move in an upwarddirection)

    4Good squeeze, good hold with lift (thecontraction must be able to be repeated a fewtimes)

    5 Strong squeeze, good lift, repeatable

    One important observation with success of Kegel exercise is the identification of the correct

    musculature contraction by a specialized Physical Therapist. Approximately 19% to 31% of women

    who believe they perform Kegels actually perform them correctly. The woman is instructed tocontract her muscles around the examiners fingers while the examiner determines if the patient is

    using auxiliary muscles like the abdomen, gluteals, or thighs. Bearing down is a common mistake

    when asked to perform a pelvic muscle contraction. Once the women has achieved holding the

    outer layer of the pelvic floor (bulbocavernosus and ischiocavernosis) in conjunction with

    higher level muscles like the levator ani, she should attempt to hold both for ten seconds.[22]An

    article by Lianne Herbruck listed a chart of instructions that summate the correct Kegel exercise

    procedure for pelvic floor muscle training.

    Proper Performance of Kegel Exercises for Pelvic Floor

    Muscle Training[20]

    Kegel exercises are performed to strengthen the

    muscles of the pelvic floor to help increase support

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    of the bladder and the urethra. They also can beused postpartum to facilitate circulation to theperineum, which promotes faster healing andincreases pelvic floor muscle tone.

    Have the woman contract the muscles in theperineum/pelvic floor as if she is trying to preventpassage of intestinal gas. (The old adage of"stopping the flow of urine" can actually encourageretention and cause dysfunction of the micturationreflex).

    She should feel the muscles draw upward andinward.

    She should avoid straining or bearing-down motionswhile performing the contractions. (This can be

    avoided by exhaling gently with an open mouth asshe contracts the muscles.)

    Contractions should be intense, but should notinvolve abdomen, thighs, or buttocks.

    The woman should be able to hold this contractionfor 5 to 10 seconds, but may need to work up tothat.

    The woman should rest for 10 seconds betweencontractions.

    Kegels should be performed at least 10 times, 3times a day, or from 30 to 80 times a day.

    Current research prescribes a frequency of 30 contraction per day with an emphasis on increasing

    the strength and intensity of the contraction. A greater emphasis is placed on devoting a particular

    time to exercise and gradually increasing the amount and intensity of the exercise.[22]Though these

    exercises can improve function, they cannot reverse a Grade 3 or 4 uterine prolapse.[23]These

    exercises are often indicated as treatment for stress urinary incontinence, pelvic organ prolapse,

    pelvic pain and defecatory dysfunction.[22]

    Vaginal Cones

    This exercise is used as a adjunct to contraction exercises of the pelvic floor. The patient insertsweighted cones into the vagina and is instructed to maintain the position of the weighted cone.

    This method provides proprioceptive feedback to desired pelvic sustained contraction.[21]This is

    thought to help improve the tone through active and sustained muscle contraction.[20]

    Colpexin Sphere

    The Colpexin Sphere is an intravaginal device that provides support to the pelvic floor musculature

    and assists in elevation for more effective pelvic floor musculature exercises. "The Colpexin Sphere

    is a smooth, round sphere made of medical grade polycarbonate plastic with an attached braided

    nylon string for easy removal. It provides dual benefits for the management of pelvic organ

    prolapse and improvement of pelvic floor muscle weakness. The Colpexin Sphere is available only

    by prescription."[24]This is especially helpful for those who have urinary incontinence in association

    with uterine prolapse. This device is appropriate for candidates who prefer a conservative

    approach to pelvic floor prolapse management and urinary incontinence.[20][24]

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    Biofeedback

    Biofeedback is used to detect and amplify internal physiological events and conditions using a

    monitoring instrument. This training helps to develop conscious control over these body processes.

    The objectives are to assist patients in gaining greater awareness and voluntary control over

    muscular control and contraction. This allows for a refined control of pelvic floor musculature for

    functional training. This technique uses a color video screen connected to a computerized unit

    which monitors different channels using intravaginal probe or surface electrodes depending on the

    muscles being selected.[21]The identification of the levator ani is important with contraction during

    the Kegel exercises. If they are weak or absent, physical therapy is indicated.[20]

    Behavioral modification

    This technique is used to bring attention to the possible interactions between the patient'ssymptoms and their environment and provide techniques for behavioral modification. Such

    techniques consist of conditioning, fluid intake regulation, and use of devices. Bladder training is

    used for patients with associated incontinence for bladder prompted training, bladder drills,

    bladder habit training, and bladder retraining. In bladder retraining the patient is to keep a record

    of voiding activity over seven days and gradually increase increments between urination toward a

    normal three hour interval. The patient attempts to resist the urge to urinate by squeezing the

    pelvic floor and sphincter muscles until the urge resolves.[21]

    Electrical Stimulation

    Electrical stimulation is used to inhibit the micturition reflex and contract pelvic floor muscles.

    Using a vaginal or anal probe, the electrical stimulation produces a contraction of the levator ani

    muscle. Electrical stimulation is also used based on the theory that low-level electrical currentsmight re-innervate the pelvic floor and change the ratio of slow-to-fast-twitch muscle

    fibers.[20]Electrostimulation is used in treatment of stress incontinence, enhancing the periurethral

    sphincter and urge incontinence, inhibiting the overactive detruser muscle. There are no side-

    effects except some discomfort but it is contraindicated for pregnancy, vaginal infection, retention

    and demand pacemaker.[21]

    Education

    Education is an important aspect of treatment, especially education on positions of irritation and

    management of pain. Education plays an important role during exercise and discussion of sexual

    intercourse with gravity assisted positions. Supine with a pillow or wedge support under the pelvis

    can be useful position for rest, pelvic floor exercise performance and during

    intercourse.[1]Education is also important to help the patient understand why maintaining an ideal

    body weight limits the pressure the abdominal content places on the pelvic floor. Patients also be

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