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Retroverted Uterus (Tilted or Tipped Uterus)

By Liji Thomas, MD

Retroversion of the uterus is also called a tipped or tilted uterus. This condition most commonly occurs as a normal variant of uterine position in up to 30% of women. In a majority of women, the uterus is tilted forwards, to lie over the urinary bladder in front of it. Thus it faces towards the abdominal wall.

A retroverted uterus however is directed towards the back, falling backward towards the rectum. A retroverted uterus usually becomes symptomatic only when associated with disorders of the pelvic organs such as endometriosis.

A tipped or retroverted uterus is not associated with infertility or with a higher risk of abortion, or with pain, in the vast majority of cases. Indeed, the only consistent association has been with painful intercourse, especially in certain positions. The pain is due to the pressure exerted by the penile thrusts on the ovaries and the uterine tubes, which are also carried backwards with the uterus.

If pregnancy occurs in a retroverted uterus, the growing uterus usually lifts out of the pelvis, so that it straightens up. In a very few cases, the uterus has tipped backward so far that it is doubled over in the hollow of the sacrum. This leads to pain and problems with urination in the third or fourth month of gestation, as the enlarging uterus starts to become too big for the confined space (called an ‘incarcerated uterus’). The greatest difficulties are experienced in the third or fourth month of gestation. The uterine position usually corrects itself, very rarely requiring treatment.

Causes

A tipped uterus is normal in up to a third of women. In some women it is held in this position because of adhesions forming to connect the uterus with the rectum behind it. These adhesions or bands of scar tissue are a result of inflammation.

They may follow:

  • pelvic infection
  • pelvic surgery
  • pelvic inflammatory disease (PID)
  • endometriosis
  • the presence of fibroids on the back of the uterus which pull it backwards
  • pregnancy-related loosening of the uterine ligaments which persists after delivery, allowing the uterus to fall back. While normal involution prevents this from occurring, failure of involution can result in retroversion.

Diagnosis and treatment

The presence of a retroverted uterus is usually diagnosed by a pelvic examination. Occasionally, the tipped uterus may be mistaken for a fibroid or other mass in the pelvis. A rectovaginal examination or an ultrasound will quickly show the right diagnosis.

The retroverted uterus is mostly just an incidental finding in most women, as when a woman goes in to have a Pap smear done. Treatment is therefore not necessary unless there are any symptoms. If the woman does have any problems like difficulty with urination or passing stools, or pain during intercourse, treatment should be aimed at identifying and treating the underlying causes like adhesions or fibroids. In pregnancy, an incarcerated uterus is freed by first emptying the bladder followed by pelvic rocking, a maneuver which usually succeeds.

In a non-pregnant woman, if there are no contributing factors, the doctor may physically lift the tilted uterus forwards. If it remains in position, no further manipulation is necessary. Pelvic floor strengthening exercises may help to keep it tilted forward. Another option is the use of vaginal pessaries to change the uterine tilt. Surgical treatment is sometimes performed to place the uterus into a forward tilt and retain it in place, using a few sutures. Hysterectomy is performed only in selected cases.

References

Last Updated: Apr 19, 2015

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