Vaginal Hysterectomy, Uterosacral Ligament Suspension, and Excision of Redundant Vaginal Tissue

Abstract

Uterine prolapse refers to the uterus descending into the vaginal canal because of weakened pelvic floor muscles and overstretched ligaments. It can occur at any age, but most often affects post-menopausal women. Common causes of uterine prolapse include childbirth, surgery, menopause, aging, extreme physical activity, and heavy lifting. There is also a genetic component. Uterine prolapse can be categorized as incomplete or complete: Incomplete uterine prolapse refers to a partial displacement of the uterus into the vagina without protrusion to the exterior; complete prolapse refers to the uterus protruding from the vaginal opening. The severity of uterine prolapse is graded by how far the uterus descends: Grade I refers to the uterus descending to the upper vagina; Grade II refers to the uterus descending to the introits; Grade III refers to the cervix descending outside of the introitus; in Grade IV, the cervix and uterus have both descended outside the introitus. Symptoms depend on the severity of the prolapse; however, most women have a feeling of fullness or heaviness in the pelvic area that often worsens when coughing, standing, or lifting. Other symptoms include lower back pain, urinary incontinence or retention, bulging in the vagina, and problems with sexual intercourse. Uterine prolapse is generally diagnosed during a pelvic examination. Treatment depends on the severity of the prolapse. Self-care measures include Kegel exercises, avoidance of heavy lifting, managing chronic cough, and treatment of constipation. These can reduce the risk of uterine prolapse and prevent it from worsening. Nevertheless, in severe cases, a vaginal pessary, reduction of the uterus to its normal position, or hysterectomy may be needed. Here, we present a patient with a severe case of uterine prolapse. A vaginal hysterectomy with uterosacral ligament suspension and excision of redundant vaginal tissue was performed.

Case Overview

Background

Uterine prolapse is the downward descent of the uterus into or beyond the vagina secondary to global pelvic floor weakening and dysfunction.^1, 2 Postmenopausal women are at the highest risk, although it can occur at any age. Development of uterine prolapse is multifactorial, but risk factors include vaginal childbirth, multiparity, prior hysterectomy, and conditions that result in increased intra-abdominal pressure, such as high body mass index, chronic cough, constipation, and heavy lifting.^2, 3 It is difficult to quantify the frequency of uterine prolapse due to variable definitions and criteria. It is reported that loss of vaginal or uterine support is seen in up to 30–76% of women presenting for a routine gynecological exam, but only a small fraction of these women report symptoms.^1, 4 Women in the United States have a 13% lifetime risk of requiring surgery for pelvic organ prolapse.¹ 

The classification system for uterine prolapse is based on the level of distension of the uterus and ranges from grade I–IV^5">5:

• Grade I refers to the uterus descending to the upper vagina.
• Grade II refers to the uterus descending to the introits.
• Grade III refers to the cervix descending outside of the introitus.
• Grade IV refers to the cervix and uterus both having descended outside the introitus.
  

Focused History of the Patient

This patient is a middle-aged, indigent, multiparous, Filipino female with a symptomatic procedencia/total uterine-vaginal vault prolapse and stress urinary incontinence. 

Physical Exam

In this case, total uterine-vaginal vault prolapse is visualized on a general inspection of the external genitalia. This degree of anatomic defect is rarely seen today in advanced countries; thus, a pelvic examination in the dorsal lithotomy position is generally required for diagnosis and to determine the severity of the uterine prolapse.

Imaging

Imaging typically does not play a role in the evaluation of mild uterine prolapse as diagnosis and grading are usually achieved based on history and physical exam alone. In cases of recurrent, complicated, multicompartment uterine prolapse where performing a complete physical exam may be challenging, both magnetic resonance imaging and translabial ultrasound have been reported as valuable imaging modalities.^6, 7 

Natural History

Further research is needed on the natural progression of uterine prolapse. Based on the limited reports available, prolapse will typically both progress and relapse. In postmenopausal women, prolapse tends to progress more than relapse.⁸

Options for Treatment

Conservative treatment is effective for many women and includes Kegel exercises and the avoidance of increasing intra-abdominal pressure by minimizing chronic cough, heavy lifting, and constipation. These actions can both reduce the risk of developing uterine prolapse and prevent existing prolapse from further progressing. A vaginal pessary is a non-surgical intervention that may be used in women with symptomatic prolapse refractory to conservative methods or for women who prefer not to undergo surgery. Although robust studies assessing the effectiveness of pessaries are limited, the American College of Obstetricians and Gynecologists (ACOG) and the American Urogynecologic Society (AUGS) both endorse the use of pessaries in the treatment of uterine prolapse.¹ Surgical treatment is reserved for patients who are bothered by their prolapse and who have failed or declined conservative treatment options.¹ 

Surgical repair typically falls into two categories: obliterative and reconstructive. Obliterative surgery will narrow or close off the vagina to support the prolapsed uterus. Vaginal sexual intercourse will no longer be possible after this procedure. Conversely, reconstructive surgery aims to restore the natural anatomy of the pelvic organs. Worldwide, vaginal hysterectomy is the most commonly performed surgical method to correct uterine prolapse and is largely considered the technique of choice by practitioners.⁹ Other techniques exist to correct uterovaginal prolapse including uterine-preserving hysteropexy with mesh reinforcement and the Manchester operation, which involves excision of the cervix and suture of the cervical stump to the cardinal ligament.^10, 11 None of these techniques have been reported to yield superior outcomes when compared.^10, 12

Rationale for Treatment

Once conservative approaches are no longer able to adequately manage a patient’s symptoms, surgery should be considered to correct the anatomical deformity and remove pressure from the pelvic floor. 

Special Considerations

A surgical approach should only be decided on after discussing the expectation of future fertility and sexual function with the patient.  

Discussion

This case presents a vaginal hysterectomy with uterosacral ligament suspension and excision of redundant vaginal tissue to treat a severe, grade IV uterine prolapse on a middle-aged, multiparous Filipino female. Recovery time is highly variable and is dependent upon the severity of the disease. For a few weeks following surgery, rest and avoidance of both sexual intercourse and movements that will increase intra-abdominal pressure, such as vigorous exercise and straining, is typically necessary for healing.¹³ 

Complications associated with this procedure include hemorrhage, hematoma, nerve damage, dyspareunia, and prolapse recurrence.5 The uterine prolapse recurrence rate following surgery is difficult to quantify due to significant variability in disease severity and the potential for anatomical failure that remains asymptomatic.^14-16 Various factors, such as age, body weight, and prolapse severity have all been reported to influence the likelihood of recurrence.¹⁵

The best technique for the repair of severe uterine prolapse remains unclear and is largely dependent upon patient preference, disease severity, and surgeon expertise. In this case, the most widely used vaginal hysterectomy with uterosacral ligament suspension using a native tissue repair in place of a mesh repair. Mesh repairs have not been used as frequently since the release of a joint statement issued by AUGS and ACOG that stated that the use of transvaginal mesh should not be first-line therapy due to an increased risk of recurrence and complications.¹⁷ Conversely, for patients who do not desire future vaginal intercourse, colpocleisis shows the highest cure rate and the lowest morbidity of any surgical approach.¹³ Due to the wide range of surgical and nonsurgical approaches to alleviate uterine prolapse, further research is necessary to characterize the optimal use for each strategy.  

Equipment

No special equipment used.

Disclosures

Nothing to disclose. 

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online. 

Acknowledgments

The authors would like to thank the Operating Room staff for their help in making this video.