Management of Nulliparous Uterine Prolapse

Uterine prolapse in a nulliparous woman (never given birth) presents a specific challenge, especially when infertility is also being investigated. The management aims to correct the prolapse while considering the potential desire for future fertility.

Evaluating Management Options

• Ring pessary: A conservative, non-surgical option providing temporary support. It manages symptoms but doesn't correct the underlying anatomical defect. It might be considered for mild cases or patients unfit for surgery.
• Fothergill repair (Manchester repair): This surgery corrects anterior and apical prolapse but often involves shortening the cardinal and uterosacral ligaments and may include cervical amputation. This can negatively impact future fertility and childbirth.
• Sling operation: Various surgical techniques use synthetic or biological material (or native tissue) to create a supportive sling, elevating and suspending the uterus and vaginal vault. Procedures like sacrocolpopexy or pubovaginal slings can offer robust support. For nulliparous women, especially those concerned about fertility, sling operations that preserve the uterus and cervix are often preferred over procedures involving amputation.
• Cervical amputation: This procedure removes the cervix and is typically part of a larger repair like the Fothergill repair, not a primary standalone treatment for uterine prolapse itself.

Most Appropriate Choice

For a nulliparous woman with uterine prolapse, particularly when infertility is a factor, preserving reproductive organs is often a priority. While a pessary offers conservative management, surgical correction may be needed. Among the surgical options, a sling operation provides significant pelvic support and can be performed in ways that maintain the integrity of the uterus and cervix, making it more suitable than procedures like the Fothergill repair which involves cervical amputation and potential fertility impairment.

Therefore, the most appropriate management among the choices is a sling operation.