26 August 2021 Author : Susana Coutinho Uterus prolapse Uterus prolapse is the descent of the uterus from its normal position . It may or may not be accompanied by the vagina walls or by adjacent organs such as the bladder and bowel. The lowered uterus compresses the vagina, causing discomfort, which increases throughout the day, with a feeling of local heaviness. The degree of the prolapse is variable, the uterus can even come to the exterior through the vaginal opening, without being possible to reduce it manually. A lower-than-normal location of the uterus can make sexual intercourse uncomfortable. Displacement of the bladder or rectum from their normal positions can lead to changes in urinary and bowel function. The prolapse of pelvic organs is mainly due to the weakening of pelvic floor support structures , which keep those organs in their normal position. This can have several causes, which often act together, for example: Trauma associated with the passage of the fetus during childbirth; Exaggerated and repeated abdominal physical exertion; Overweight; Chronic cough; Aging. Surgery is an effective treatment option for prolapsed uterus. It is estimated that the probability of a woman to be operated on for this reason throughout her life is about 11%. When other pelvic organs besides the uterus are involved in the prolapse, the same operative time can include several interventions. Surgical correction of prolapsed uterus Surgical correction of a prolapsed uterus can be done by maintaining the uterus and correcting its position or performing a hysterectomy. Surgery with conservation of the uterus When uterus is kept, the surgery involves suspending the uterus and the apex of the vagina to the pelvic ligaments or to prostheses, to ensure that it returns to its normal position. However, there are several situations in which hysterectomy is a better and advisable option, thus preventing the recurrence of the problem and the need for a new operation. Among these situations are: Uterus with changes in shape or position, eg hypertrophic elongation of the cervix; Uterus with concomitant disease, eg fibroids, endometrial diseases; Difficult access to the supporting ligaments that would allow reconstruction of the vaginal axis. Hysterectomy A hysterectomy is the surgical removal of the uterus . It can be done abdominally – open surgery or laparoscopy – or through the vagina. When a hysterectomy is performed in women of childbearing age, it is no longer possible to become pregnant again. However, there are not: Changes in female hormones; Interference in sexual intercourse. If in the same surgery of hysterectomy the ovaries are also removed, due to some indication, a surgical menopause will happen with alterations in the production of female hormones. Vaginal hysterectomy Vaginal hysterectomy is a common option in the treatment of prolapsed uterus, with several advantages : It is not necessary to cross other structures, as in the abdominal route; Recovery is less painful; Has fewer potential complications than abdominal access. Hysterectomy alone is not usually sufficient to correct the prolapse. Thus, vaginal suspension techniques are used simultaneously to ensure adequate support. Vaginal hysterectomy is performed in a hospital setting under locoregional or general anesthesia and requires a 2-3 day hospital stay. 85% of women with prolapsed uterus treated with vaginal hysterectomy are definitively cured. Relapses are described in up to 15% of cases and these can appear months or years after the initial surgery. This mainly depend on: Severity of the initial prolapse; Adequacy of the surgical technique to the specifics of each woman; Maintenance or not of risk factors for prolapse. Preparation for surgery Preparation for a vaginal hysterectomy involves an assessment of general health , including preoperative diagnostic tests results. In the consultations with the surgeon and the anesthesiologist, details of personal and family health history and usual medication are asked. In some cases, it may be necessary to have vaginal treatments before surgery . In most cases, a light diet within 24-48 hours before surgery, cleaning clysters the day before or on the same day, and genital hair removal are recommended. A minimum 6-hour fasting period for solids and liquids is essential to perform the surgery. Surgery The preparation already carried out in the hospital includes prophylactic antibiotic therapy to prevent infections. Before and after surgery, anticoagulant medication is administered and some other measures to prevent venous thrombosis are used. A urinary catheter is placed, which is maintained after surgery and usually removed the day after the procedure. During the surgery, the uterus is approached by its lower extremity, or cervix, is gently pulled away from the bladder ahead and the rectum and sigmoid colon behind, and then progressively freed with ligation of the ligaments and vessels. At the end, a vaginal tampon can also be placed , which is kept up to 24-48 hours. After surgery, early food intake and walking is promoted. Discharge and post-operative recovery After hospital discharge, convalescence from prolapsed vaginal hysterectomy is usually 6 weeks . During this period women should: Avoid physical efforts, such as carrying heavy objects, practicing sports or physical exercise in the gym; Not have sex. It is possible to have a vaginal discharge , sometimes bloody or brownish, continuous or intermittent, which can last up to 4-6 weeks after surgery. This is due to the presence of sutures in the vagina, which will be reabsorbed during this period. A balanced diet and liquids intake are important to avoid constipation. Sometimes laxatives are prescribed in the post-operative period to avoid defecatory efforts. Tiredness after surgery is normal. That is why it is important to set aside some time to rest for the first few weeks. However, movement is very important, namely to prevent clot formation and venous thrombosis; Participating in household activities and short walks around the house are good options for physical activity during this period. At least one consultation is performed during the recovery period . It usually takes place a month after surgery. In this consultation, an assessment of the recovery is made, and the date for ending convalescence and the return to normal activities determined. Possible complications of vaginal hysterectomy Any surgery has risks, both associated with the surgery itself and with the anesthetic technique. Among the most frequent are: Urinary infection, estimated between 6%-20%; Bleeding during and shortly after the intervention. The risk of blood loss requiring blood transfusion is small, being described between 0%-10% for this surgery; Small bruises near the vaginal vault in about 10% of cases, mostly resolving spontaneously within 10 days, but occasionally requiring drainage. This situation can also progress to a pelvic infection. Other infections in the vagina or elsewhere in the pelvic cavity can arise and usually lead to an unpleasant or foul-smelling discharge, local discomfort and/or fever. It may be difficult to urinate in the first few days after surgery (10%-15%), especially when several procedures are performed in the same surgery, for example interventions for correction of uterus position and/or urinary incontinence. In these cases, it may be necessary to use an intermittent catheter or to extend the urinary catheter for more days. Urinary tract lesions, namely of the bladder, or of the bowel are rare in this type of surgery, being globally described in up to 2% of cases. The occurrence of vaginal fistulas is a very rare event. Clots can form in the blood vessels of the legs or lungs. To avoid this, therapeutic and other measures are taken to reduce this possibility, according to the clinical risk assessment of each woman. Meet the obstetrics-gynecology team from Hospital da Luz network. The content published in the Health Guide is intended for the general public and is provided for informational and educational purposes only. It does not replace individual medical assessment, diagnosis, or personalized clinical advice from a qualified healthcare professional. The content is produced or reviewed by physicians and other healthcare professionals at Hospital da Luz and is based on the knowledge available at the time of publication or the most recent update, as indicated at the beginning of each item.
