Pelvic organ prolapse
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
A 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
Prolapse of the front wall of the vagina
Bladder falls into the front wall of the vagina.
Urethra drops and bulges into the vagina.
Bladder and urethra fall into the vagina.
Prolapse of the back wall of the vagina
Rectum bulges into the vagina.
Small bowel slips into a space called the Pouch of Douglas, bulging into the vagina.
Prolapse of the uterus (or cervix)
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).
Prolapse of the 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
Vaginal wall relaxation
Complete (vagina) proccidentia with ulceration
Large rectocele and enterocele
Damage to the perineal body or the deeper aspects of the levator muscles can cause the perineum to collapse inwards and appear depressed.
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.
- Marfan Syndrome
- Ehlers-Danlos Syndrome
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
- 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:
- Small, medium and large (mild, moderate and severe).
- First, second, third and fourth degree (grade one, two, three and four).
- Baden-Walker system.
- 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).
- Pelvic floor exercises
- Vaginal cones
- Electromagnetic muscle stimulation
- Vaginal support devices
Some women wish to be reassured that the prolapse is not a cancer and opt not to have any further treatment.
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.
- 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
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
- Heart attack
- Blood clots
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
A gas embolism during laparoscopic surgery
Complications related to the use of mesh
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