Gynecology & Urogynecology & Family Medicine
Uterine prolapse (pelvic organ prolapse)
Uterine prolapse - popularly known as «womb descent» or «organ descent» - is a disorder of pelvic statics characterized by abnormal descent of the uterus into the vaginal canal, or even out of the vulva in advanced forms, resulting from weakening and loosening of the pelvic floor support structures: uterosacral and cardinal ligaments, pelvic fasciae and pelvic floor muscles (levator ani). It is most often part of a larger pelvic organ prolapse (POP) picture, associating to varying degrees a cystocele (descent of the bladder into the anterior vaginal wall), a rectocele (descent of the rectum into the posterior vaginal wall) and an enterocele (descent of the small intestine into the cul-de-sac of Douglas). Uterine prolapse affects around 10 to 15 % of women in their lifetime, with prevalence increasing markedly with age - up to 40 to 50 % of post-menopausal women having had vaginal deliveries. The main risk factors are vaginal delivery (particularly long, instrumented deliveries or deliveries with macrosomic fetuses that strain the pelvic floor), multiparity, menopause (estrogen deficiency reducing the tone of collagen in the pelvic ligaments), obesity (increased chronic intra-abdominal pressure), chronic constipation (repeated pushing efforts), intense physical effort or heavy physical work, and a genetic predisposition linked to the constitutional quality of connective tissue (connectivitis). Management of this condition has evolved considerably with the development of preventive and curative perineal re-education, modernized gynecological pessaries (comfortable silicone devices) and minimally invasive vaginal or laparoscopic surgical techniques.
POP-Q Classification and Clinical Stages
| POP-Q Stadium | Anatomical definition | Clinical translation |
|---|---|---|
| Stage 0 | No descent—all landmarks above the hymen + no prolapse | Normal pelvic exam + asymptomatic + no treatment needed |
| Stage I | The most dependent point of the prolapse is more than 1 cm above the hymen (value > -1 cm). | Minimal prolapse + often asymptomatic + incidental finding on examination + possible pelvic heaviness at the end of the day |
| Stage II | The most declivous point of the prolapse is between 1 cm above and 1 cm below the hymen (value between -1 and +1 cm). | Moderate prolapse + often symptomatic + vaginal bulge sensation + heaviness + frequent urinary symptoms (urgency + dysuria) |
| Stage III | The lowest point is more than 1 cm past the hymen but without complete extrusion (value > +1 cm). | Advanced prolapse + visible and palpable vulvar bulge + disabling symptoms + urinary incontinence or retention + defecation difficulties + pelvic pain |
| Stage IV | Total or near-total exteriorization of the vaginal wall + complete uterine prolapse (cervix and uterine body protruding outside the vulva) | Severe prolapse + permanent or intermittent protrusion + decubitus ulcers on the protruding cervix + possible urinary retention + significant pain + major impact on quality of life + formal surgical indication if the patient is operable |
Clinical presentation
- Feeling of heaviness or a «ball» in the pelvic area Most frequent and characteristic symptom: pelvic heaviness or pressure, worsened when standing, during exertion, and at the end of the day, relieved when lying down (spontaneous reduction of the prolapse). Some patients describe a sensation of «something coming out» when standing. The bulge may be visible at the vulva in stages III-IV.
- Urinary symptoms (related to associated cystocele): Urinary urgency + pollakiuria + dysuria (difficulty initiating urination) + incomplete urinary retention + stress urinary incontinence (coughing + sneezing + laughing) + or urinary incontinence masked by prolapse (manual reduction of prolapse sometimes unmasks incontinence) → prolapse reduction test (pessary test) before surgery to assess underlying incontinence
- Digestive symptoms (related to rectocele): Dyschezia (difficulty passing stool) + need for digital prolapse reduction to defecate (digital pressure on the posterior vaginal wall to aid defecation) + constipation + sensation of incomplete evacuation
- Sexual symptoms: Dyspareunia + decreased sexual satisfaction + discomfort during intercourse + some patients completely avoid sexual intercourse due to shame or discomfort + possible improvement after surgical correction
- Pressure ulcers in stages III-IV with permanent protrusion → friction of the protruded cervix on underwear → ulcerations + contact bleeding + risk of superinfection + ulcerations regress after manual reduction or treatment with local estrogens (Premarin® vaginal cream + Vagifem® ovules) for 4 to 6 weeks before surgery to improve tissue trophicity
Conservative treatment
- Perineal rehabilitation — basic treatment: exercices de contraction-relâchement du plancher pelvien (exercices de Kegel) + supervisés par un physiothérapeute spécialisé en santé pelvienne + biofeedback + électrostimulation neuromusculaire + amélioration des symptômes dans 40–60 % des stades I–II + efficace en prévention primaire post-partum + recommandée avant toute décision chirurgicale dans les formes légères à modérées + le Programme québécois de kinésithérapie périnéale rembourse partiellement ces soins
- Gynecological pessary: medical silicone device inserted into the vagina to mechanically support prolapsed pelvic organs + different types according to anatomy and stage: ring pessary (stages I–III + preservation of sexual activity) + cube or donut pessary (stages III–IV) + Gellhorn pessary (advanced prolapse + non-sexually active patients) + insertion by doctor or gynecologist + patient can often remove and reinsert it herself (ring pessary) + weekly cleaning + gynecological check-up every 3–6 months + use of local estrogen (cream or vaginal suppository) to reduce mucosal erosions + satisfaction rate: 50–80% long term + ideal alternative for patients refusing surgery + elderly patients + surgical contraindications
- Local estrogens Estrogenic vaginal cream (Premarin® + estradiol cream) or vaginal suppositories (Vagifem® 10 µg) + improves vaginal mucosa and pelvic ligament tissue + reduces urinary symptoms (urgency + recurrent urinary tract infections in menopausal women) + not significantly absorbed systemically in low local doses → safe even in patients with a history of breast cancer according to recent studies + essential adjuvant treatment before surgery for prolapse with atrophic mucosa
- Dietary and hygiene measures: Weight loss if obese (reduction of intra-abdominal pressure) + treatment of chronic constipation (fiber + hydration + osmotic laxatives) + avoid prolonged straining + adaptation of physical activities (high-impact sports like running or CrossFit worsen prolapse → swimming + cycling + yoga as alternatives)
Surgical treatment
- Surgical indications: Stage III-IV symptomatic and refractory to conservative treatment, or Stage II-III with major impact on quality of life, or complication (urinary retention, ulcerations), or pessary refusal or intolerance, or patient's preference, or risk of recurrence of 10-30 % at 10 years depending on the technique
- Vaginal hysterectomy with colporrhaphy Vaginal hysterectomy + anterior vaginal wall repair (anterior colporrhaphy = cystocele correction) and posterior vaginal wall repair (posterior colporrhaphy = rectocele correction) + parametrial suspension + classic reference technique + good efficacy + satisfaction rate 70–85% % + recurrence rate 10–20% % at 10 years + vaginal approach only (without laparoscopy)
- Laparoscopic Promontofixation (Sacrocolpopexy): Laparoscopic fixation of the vagina or cervix (if hysteropexy - uterus conserved) to the anterior sacrum using a synthetic or biological prosthesis + reference technique for severe apical prolapse + superior anatomical results to vaginal approach + recurrence rate < 5–10 % at 5 years + preserves sexual function + preferable in young sexually active women
- Hysteropexy (uterus preservation): Fixation of the uterus in place rather than its removal + options: laparoscopic sacrohysteropexy + or Manchester technique (cervical amputation + cardinal ligament fixation) + preferable in women wishing to keep their uterus + comparable results to hysterectomy for stages II-III
- Colpocleisis (LeFort operation): Partial colpocleisis for very elderly patients with severe comorbidities, no longer sexually active. Simple, rapid technique with low morbidity and a very high satisfaction rate in this selected population.
ℹ️
The gynecological pessary is often under-proposed and under-utilized—a large majority of patients can benefit from significant symptomatic relief with a pessary, avoiding or postponing surgery. Its insertion is simple, reversible, and carries no surgical risk. Patients with an intact uterus and stage II–III prolapse are particularly good candidates. The first pessary consultation takes 20 to 30 minutes, and the device can often be adjusted during one or two follow-up visits for optimal results.
Situations requiring rapid medical consultation
Consult a doctor or gynecologist quickly if a known uterine prolapse is accompanied by an inability to empty the bladder (acute urinary retention) – an emergency requiring urinary catheterization – or if bleeding ulcerations appear on the cervix or exteriorized vaginal lining. Similarly, if a prolapse is found to be irreducible (inability to manually reposition the prolapse) → urgent gynecological consultation for evaluation and reduction under analgesia if necessary.
For the evaluation of uterine prolapse or pelvic organ prolapse, fitting a pessary, referral to pelvic floor physiotherapy, or gynecological surgery, Clinique Omicron offers medical consultations at its service points in Quebec and via telemedicine. To make an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's physicians and nurse practitioners (NPs) clinically assess pelvic organ prolapse (POP-Q staging), initiate prescriptions for local estrogen and supervised pelvic floor rehabilitation, fit and follow up with gynecological pessaries, and refer patients to urogynecology or gynecological surgery for advanced stages requiring surgical intervention. Consultations are available at several service points in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The content of this page is provided for informational purposes only and does not substitute for advice from a physician, gynecologist, or urogynecologist. The treatment decision for uterine prolapse is individualized according to the stage, symptoms, comorbidities, patient's wishes, and reproductive plans.
Omicron Clinic
Need to consult a doctor?
Treatment within 24-48 hours. In-clinic or telemedicine, anywhere in Quebec.
Insurance receipts. 7j/7. No family doctor required.