Pelvic prolapse: diagnosing and treating uterine and vaginal vault prolapse.

Uterine prolapse is often associated with a concomitant rectocele, cystocele, and/or an enterocele. Moderate degrees of prolapse are often associated with a feeling of pelvic heaviness or fullness or low back pain. The symptoms usually worsen with exertion and ease with bed rest. In severe prolapse, the cervix may descend outside the vaginal introitus, and patients may complain that a "mass" is protruding from the vagina. Bleeding from mucosal ulcerations or from the cervical os may occur due to rubbing of the prolapsed tissue against the patient's clothing. The commonly associated problems of cystoceles and rectoceles may lead the patient to complain of difficulty voiding, recurrent urinary infections, and/or "splinting" to defecate. Mild cases of uterine prolapse do not require therapy unless the patient is symptomatic; in most cases of second- or third-degree prolapse, however, patients may be quite uncomfortable and desire therapy. Nonsurgical options, such as a pessary, are usually tried first if the patient desires conservative therapy. Operative repair for uterine prolapse is usually approached vaginally if the uterus is small. An abdominal approach may be preferred if the uterus is large or if the woman has had multiple previous pelvic procedures or has extensive endometriosis or other processes that may obliterate the cul-de-sac. In either approach, the uterosacral and cardinal ligaments must be carefully ligated and tied together, and the cul-de-sac must be obliterated to reduce the risk of subsequent enterocele and to properly suspend the vaginal vault.