The uterus is held in the pelvis by the pelvic floor muscles (especially the levator ani), the endopelvic fascia, and the cardinal and uterosacral ligaments. When these supports are congenitally different, stretched, or torn, the uterus can lie in an unusual position or descend into the vagina.

Normal and displaced uterine positions

Two angles describe uterine position. Version is the angle of the whole uterus relative to the vagina. Flexion is the angle between the uterine body (corpus) and the cervix.

The direction of the angle between the uterine body and the cervix distinguishes anteflexion from retroflexion.

• Primary (congenital, mobile) retrodisplacement — a normal variant with no disease; the uterus moves freely.
• Secondary (acquired, often fixed) retrodisplacement — caused by disease that pulls or tethers the uterus backward: adhesions from endometriosis or pelvic inflammatory disease, pelvic tumors (e.g., fibroids), or stretched supports after childbirth.

A fixed retroverted uterus may cause dysmenorrhea, deep dyspareunia, and low back pain; treatment is aimed at the cause (e.g., endometriosis), not the position itself.

Congenital uterine anomalies arise from incomplete fusion or resorption of the Müllerian ducts. The septate uterus (a fibromuscular septum dividing a normally shaped uterine cavity) is the most common and is linked to recurrent pregnancy loss and malpresentation. Others: bicornuate, didelphys, unicornuate, arcuate.

Pelvic organ prolapse (POP) is the descent of one or more of the anterior vaginal wall, posterior vaginal wall, uterus/cervix, or vaginal vault (after hysterectomy) into or beyond the vagina.

Risk factors: vaginal childbirth (especially multiple, large babies, operative delivery, prolonged second stage) — the strongest factor; aging and menopause (loss of estrogen weakens connective tissue); chronic raised intra-abdominal pressure (obesity, chronic cough, constipation and straining, heavy lifting); connective tissue disorders; prior pelvic surgery.

Subjective

• Sensation of pelvic pressure or heaviness, "something falling out," or a vaginal bulge — often worse after prolonged standing or at the end of the day and relieved by lying down
• Low back discomfort, dragging sensation
• Urinary symptoms: frequency, urgency, incomplete emptying, slow stream, need to push the bulge back (splinting) to void, recurrent UTIs; stress leakage (may appear only after the prolapse is reduced)
• Bowel symptoms: incomplete evacuation, need to press on the posterior vagina or perineum to defecate
• Sexual discomfort, reduced body image; older women may be embarrassed and under-report symptoms

Objective

• Visible or palpable bulge with straining (Valsalva) or standing
• Exposed cervix or vaginal wall may be dry, thickened, or ulcerated and bleeding
• Atrophic vaginal mucosa in postmenopausal clients
• Elevated post-void residual (PVR) urine; palpable bladder

Staging — POP-Q system (current standard)

Older texts use first, second, and third degree; the POP-Q is now preferred because it is reproducible.

• Pelvic examination at rest and with straining, supine and standing; split speculum to assess each compartment
• Urinalysis and urine culture — UTI is common with incomplete emptying
• Post-void residual by bladder scanner or catheter
• Urodynamic testing in selected clients before surgery (to detect occult stress incontinence)
• Renal ultrasound in severe prolapse — ureteral kinking can cause hydronephrosis
• Imaging for congenital anomalies: hysterosalpingography (HSG), 3D ultrasound, or MRI; a septate uterus appears as a cavity divided by a septum with a normal outer fundal contour

Uterine displacement

• Asymptomatic retroversion needs no treatment. Treat the underlying cause of fixed retroversion (e.g., endometriosis, adhesions).
• Septate uterus with recurrent loss: hysteroscopic septum resection.

Pelvic organ prolapse — treatment depends on symptoms, not stage alone. Observation is appropriate for asymptomatic prolapse.

1. Conservative
   • Supervised pelvic floor muscle training (PFMT) — reduces symptoms in mild to moderate prolapse
   • Weight loss, treating chronic cough and constipation, avoiding heavy lifting
2. Vaginal pessary — a silicone device (ring, Gellhorn, cube, donut) that supports the pelvic organs; first-line nonsurgical option for most stages
   • Fitted by a clinician; client should be able to void and move comfortably with it in place
   • Screen for active vaginal or pelvic infection before fitting and treat first
   • Low-dose vaginal estrogen is often prescribed for postmenopausal clients to reduce mucosal erosion; systemic absorption is low, but clients with a history of estrogen-sensitive cancer need individual counseling
3. Surgery
   • Reconstructive: anterior colporrhaphy (cystocele), posterior colporrhaphy (rectocele), apical suspension (uterosacral or sacrospinous ligament fixation), abdominal or laparoscopic sacrocolpopexy, vaginal hysterectomy, or hysteropexy (suspending the uterus back in its normal anatomic position while keeping it)
   • Obliterative: colpocleisis (closing the vagina) — low-risk option for frail clients who do not plan vaginal intercourse
   • Transvaginal mesh for prolapse repair is no longer marketed in the US (see Country Notes); mesh placed abdominally (sacrocolpopexy) is still used

Preoperative

• Assess for UTI and treat before surgery; review anticoagulants and other medications
• Fasting per anesthesia guidelines (current practice allows clear liquids until about 2 hours before anesthesia unless ordered otherwise, rather than routine "NPO after midnight")
• Bowel preparation only if ordered

Postoperative and ongoing care (priority order)

1. Postoperative airway, bleeding, and circulation
   • Monitor vital signs, vaginal bleeding (pad count), and vaginal packing per protocol; report saturation of a pad in 1 hour or signs of hypovolemia
   • Watch for hematoma: increasing pelvic or rectal pressure and pain
2. Urinary elimination
   • Maintain catheter patency; perform a voiding trial and check PVR after removal — urinary retention is common after prolapse and incontinence repair
   • Monitor intake and output; assess for UTI
3. Prevent venous thromboembolism and ileus
   • Early ambulation as soon as stable, especially after laparoscopic surgery — it promotes return of bowel function, relieves shoulder pain from retained CO₂, and reduces VTE and pulmonary complications
   • Mechanical or pharmacologic prophylaxis per protocol
4. Prevent straining — stool softeners, fluids, fiber; treat cough
5. Pain management — multimodal analgesia
6. Pessary care
   • Inspect the vaginal mucosa at follow-up for erosion, bleeding, or odor
   • Removal and cleaning schedule depends on the device and the client's ability (self-care or clinic visits at regular intervals)
7. Psychosocial and therapeutic communication
   • Older women may view prolapse as a normal part of aging or feel ashamed. Use privacy, open-ended questions, and active listening about how symptoms affect daily life, sexuality, and social activities

• Pelvic floor (Kegel) exercises: identify the muscles used to stop gas or urine (do not practice by repeatedly stopping the urine stream); squeeze and hold for about 3–10 seconds, relax equally long, repeat about 10 times, several sets daily; results take at least 8–12 weeks
• Maintain a healthy weight; prevent constipation (fluids, fiber, do not strain); stop smoking (chronic cough)
• Use correct lifting technique; limit heavy lifting and prolonged standing when symptomatic; lying down relieves pressure
• Pessary users: know the cleaning and removal routine; keep all follow-up visits; report foul discharge, bleeding, pain, difficulty voiding or defecating, or the device falling out
• After prolapse surgery (typical instructions — follow the surgeon's plan):
  • No heavy lifting (often more than about 4.5 kg / 10 lb) or strenuous exercise for about 6 weeks
  • Nothing in the vagina (intercourse, tampons, douching) until cleared, usually about 6 weeks
  • Showers are allowed; avoid tub baths, hot tubs, and swimming until the surgeon approves
  • Report fever, heavy bleeding, foul discharge, inability to void, or increasing pain
• Prolapse does not improve on its own and may progress; explain treatment choices so the client can decide

• Anteversion/anteflexion is the normal uterine position; retroflexion = body bent backward on the cervix
• Primary retrodisplacement = normal variant; secondary = caused by disease (adhesions from endometriosis or PID, tumors)
• Retrodisplacement may cause dysmenorrhea, dyspareunia, backache
• Septate uterus — most common Müllerian anomaly, linked to pregnancy loss; treated with hysteroscopic resection
• Prolapse: pressure, heaviness, "something coming out," worse on standing, better lying down
• Vaginal childbirth is the main risk factor; also menopause, obesity, chronic cough, constipation, heavy lifting
• POP-Q stage IV = complete eversion
• Nonsurgical care: PFMT (Kegel) and pessary; screen for infection before pessary fitting
• Prolapse commonly causes urinary symptoms — assess voiding, PVR, and UTI first
• Postoperative: early ambulation, voiding trial, no heavy lifting or vaginal insertion for about 6 weeks