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Pelvic organ prolapse

The Australian Centre for Female Pelvic and Vaginal Rejuvenation
The Australian Centre for Female Pelvic and Vaginal Rejuvenation

What is pelvic organ prolapse?

The pelvic organs are supported by different combinations of muscles, ligaments and fascia (a form of connective tissue). They form a ‘hammock.’ Pelvic organ prolapse occurs when abnormal descent or herniation of the pelvic organs occurs from their normal attachment sites or their normal position in the pelvis.

The hammock principle

It is a common problem, affecting up to 50% of parous women. Uterovaginal prolapse was found to be responsible for around 20% of women on waiting lists for major gynaecological surgery in the UK.

Normal pelvic anatomy

Pelvic floor muscles supporting the pelvic organs

Types of prolapse

prolapse can occur in any part of the vagina. They can involve the front (anterior) wall of the vagina, the back (posterior) wall of the vagina, the top of the vagina (vaginal vault &/or uterus) or the entrance (introitus) to the vagina.

Patients with prolapse can have defects in one, two or all three compartments. Not all will be symptomatic.

Types of prolapse

Anterior compartment

Prolapse of the front wall of the vagina

Cystocele

Bladder falls into the front wall of the vagina.

Urethrocele

Urethra drops and bulges into the vagina.

Cysto-urethrocele

Bladder and urethra fall into the vagina.

Posterior compartment

Prolapse of the back wall of the vagina

Rectocele

Rectum bulges into the vagina.

Enterocele

Small bowel slips into a space called the Pouch of Douglas, bulging into the vagina.

Apex

Prolapse of the uterus (or cervix)

Uterus

Uterus drops into the vagina. The cervix can also be elongated and in some cases can be diagnosed incorrectly as uterine body prolapse (note that the cervix is anatomically a part of the uterus).

Apex

Prolapse of the vaginal vault

Vaginal vault

Top part of vagina (after previous hysterectomy) drops into vagina.

Large, central cystocele

The cervix just beyond the introitus

Complete (utero-vaginal) proccidentia

Cysto-urethrocele

Vaginal wall relaxation

Complete (vagina) proccidentia with ulceration

Large rectocele and enterocele

Patulous introitus

Damage to the perineal body or  the deeper aspects of the levator muscles  can cause the perineum to collapse inwards and appear depressed.

Moderate rectocele

Left perineal body detachment

Depression of the perineum

Symptoms of pelvic organ prolapse

  • Sensation of a lump in the vagina.
  • Dragging sensation in the lower abdomen and pelvis.
  • Lower back pain.
  • Urinary dysfunction (including incontinence, recurrent urinary tract infections and voiding dysfunction).
  • Spotting or bleeding from the vagina.
  • Sexual dysfunction (including pain on intercourse and reduced sensation).
  • Vaginal flatus (‘wind’).
  • Anorectal dysfunction (including faecal & flatus incontinence, faecal urgency, incomplete evacuation, straining to defecate and constipation).
  • Feeling embarrassed and suffering from low self-esteem related to perception of body image.

Risk factors for pelvic organ prolapse

  • Number of pregnancies and children.
  • Number of vaginal deliveries.
  • Delivery of large babies.
  • Prolonged 2nd stage of labour.
  • Increasing age.
  • Increasing body mass index (obesity).

Inherited risk for prolapse

  • Chronic obstructive pulmonary (lung) disease.
  • Chronic constipation.
  • Strenuous activity, weight bearing and heavy lifting.

i.e.:

  • Marfan Syndrome
  • Ehlers-Danlos Syndrome

Pregnant woman

Childbirth is the most common contributor to pelvic organ prolapse. During the pregnancy the pelvic floor is weakened not only from the weight of the baby and the other uterine contents (placenta and amniotic fluid) but also by circulating hormones such as Progesterone and Relaxin that are required to enable the baby to pass through the birth canal. During birth the muscles and fascia are further stretched and sometimes torn as the baby is born.

Crowning of the baby’s head

Assessment of prolapses

Physical examination:

  • Speculum
  • Bimanual (internal)

Assessment of prolapse needs to be made mindful of the day-to-day situations that aggravate it. For example examining a woman after a bout of exercise or when she has been on her feet for a long period of time.

The parameters of clinical examination would need to be determined:

  • Position for examination: Sitting/Standing/Lying on side/Squatting
  •  State of the bladder: Empty/Full
  • State of the rectum:  Empty/Full
  • Dynamic state of the pelvis: Relaxed (no straining)/Active (straining)
  • Mode of straining: Cough/Valsalva (attempting to breath out with mouth and nose closed)

The list goes on. All of these factors can affect the expression of a prolapse and the degree to which each factor impacts may be very different for individual women.

Women with pelvic organ prolapse experience and describe complaints that do not necessarily correlate with the degree of prolapse noted on clinical examination.

Quantification of prolapse

Currently there are four commonly used classification systems used by gynaecologists to describe pelvic organ prolapse:

  1. Small, medium and large (mild, moderate and severe).
  2. First, second, third and fourth degree (grade one, two, three and four).
  3. Baden-Walker system.
  4. Pelvic Organ Prolapse Quantification system (POPQ).

Schematic of descent into vagina

The first 2 classification systems are very subjective and describe (without any reference to landmarks or anatomy) an impression of the size of the defect. Both the Baden-Walker and POPQ systems use as their reference points the hymen. The POPQ system was introduced in 1996 and has become the standard classification system, at least for the purpose of the publication of academic papers.

  • The recommendation for using the POP-Q system is that the woman is examined in a standing position and straining the pelvic floor (a Valsalva manoeuvre).
  • Gynaecologists most commonly examine women in one of two positions; lying on their back with their knees drawn up and apart or lying on their left side with the right knee bent up and the left leg straight (Sim’s position).

Options for managing pelvic organ prolapse

  • Many women with prolapse do not need treatment as the problem does not seriously interfere with their normal activities.
  • Lifestyle changes such as weight loss and pelvic floor exercises are usually recommended in mild cases.
  • If the symptoms require treatment, a prolapse may be treated effectively using a vaginal pessary. This helps to hold the prolapsed organ(s) in place.
  • Surgery may also be an option for some women. This usually involves giving support to the prolapsed organ(s).
Conservative treatment
  • Pelvic floor exercises
  • Vaginal cones
  • Electromagnetic muscle stimulation
  • Vaginal support devices
No further action

Some women wish to be reassured that the prolapse is not a cancer and opt not to have any further treatment.

Surgery

11% of women in the western world will have surgery for pelvic organ prolapse during their lifetime. Of these, about 33%, will require more than one surgical repair.

Factors to be considered if thinking about having surgery:
  • Age
  • Sexual activity
  • Sexual function (present and desired)
  • Desire for future fertility
  • Pre or post menopausal status
  • Specific desire of individual
  • Desire for preservation or conservation of uterus

 

  • Associated pathology (including but not limited to menstrual dysfunction and urinary incontinence)
  • Previous gynaecological, colorectal, urological and abdomino-pelvic surgery
  • Past medical history
  • Specific findings on physical examination
  • Findings of ancillary tests

 

One of the most commonly quoted papers (Olsen et al. Obstet Gynecol. 1997 Apr;89(4):501-6), noted:
The age-specific incidence increased with advancing age. The lifetime risk of undergoing a single operation for prolapse or incontinence by age 80 was 11.1%. Most patients were older, postmenopausal, parous, and overweight. Nearly half were current or former smokers and one-fifth had chronic lung disease. Reoperation was common (29.2% of cases), and the time intervals between repeat procedures decreased with each successive repair.

It has been shown that women seeking treatment for advanced prolapse have decreased body image and quality of life scores. These are often improved by surgery.

Both male and female physicians frequently underestimate the impact of prolapse symptoms upon the quality of life of their patients. Make sure your doctor understands your particular situation.

Many parous women may have some degree of prolapse when examined; however, many prolapses are not clinically bothersome without specific pelvic symptoms and may not require an intervention.

Risks associated with prolapse surgery

General risks of surgery

Anaesthetic risks

Cardiovascular:

  • Heart attack
  • Blood clots
  • Stroke

Wound infection requiring antibiotic therapy

Bleeding that may necessitate blood transfusion or a return to theatre (1%)

Specific risks of prolapse surgery

Urinary tract infection

Discomfort or pain with intercourse

Damage to the rectum or small intestine

Stress incontinence

A gas embolism during laparoscopic surgery

Complications related to the use of mesh

Constipation

Damage to the bladder or urethra

Damage to the ureter

Recurrence of prolapse either at site of surgery or a new site

Failure of the procedure

Ongoing symptoms despite repair of the prolapse

Laser Vaginal Rejuvenation Institute of Adelaide
Laser Vaginal Rejuvenation Institute of Adelaide