Overview

Pelvic organ prolapse is a condition in which pelvic organs abnormally descend or herniate from their normal attachment sites or their normal position in the pelvis to or beyond the vaginal walls. There are varying degrees of prolapse. In the most severe cases, the pelvic organ can prolapse through the genital hiatus. It can be asymptomatic or symptomatic. Very prevalent (~15% of older age women).

Anatomy

Anatomy – Genital Support (De Lancey – 3 level of support)

1. Uterosacral and cardinal ligaments – support the uterus and vaginal vault
2. Pelvic Floor Muscles
   1. Levator Ani
   2. Illiococcygeus
3. Anteversion of the uterus

Organs that support

• Musculature
  • Levator ani
• Ligaments and connective tissue
  • Endopelvic fascia
• Vaginal wall

Risk Factors

• Multiparity – note it can occur in nulliparous women
• Birth weight
• Advancing age
• Post-menopausal status
• Smoking
• Chronic lung disease
• Obesity
• Hysterectomy
• Race and ethnicity
  • More common in people of white ancestry
  • Genetic component
• Prior pelvic surgery

Clinical Manifestation

Bulge or vaginal pressure symptoms This symptom is associated with a prolapse however it does not indicate the stage of prolapse. Anatomically this is defined as a prolapse beyond the hymen

• Vaginal or pelvic pressure
• Back pain and lower abdominal discomfort
• Sensation of a vaginal bulge or something falling out of the vagina
• Protrusion of the vagina can also result in chronic discharge and/or bleeding from ulceration

Urinary symptoms Loss of support of the anterior vaginal wall or the vaginal apex can affect the bladder and/or urethral function.

• Symptoms of stress urinary incontinence

Defecatory symptoms Affects between 24-52% of women with POP

• Constipation
• Incomplete emptying
• Faecal urgency, faecal incontinence, obstructive symptoms (e.g. straining, or the need to apply digital pressure to the vagina or perineum to completely evacuate
• Haemorrhoids, rectal prolapse may also be present

Sexual function Not associated with decreased sexual desire or with dyspareunia

• Some women however avoid sexual activity due to fear of discomfort or embarrassment especially if they develop urinary or fecal incontinence during sexual activity.
• Coital difficulty
• Menstruating women may also find difficulty inserting tampons

Examination

• Pelvic Examination
• Speculum with Valsalva maneuver (cough)
• Bimanual and rectovaginal examinations help identify any coexisting pelvic abnormalities
• +/0 Standing position while she performs the Valsalva maneuver

Classification of Pelvic Organ Prolapse

Different types of Pelvic organ prolapse

• Cystocele – Anterior vaginal wall prolapse – descent of the front wall of the vagina often with the bladder behind
• Rectocoele -Posterior vaginal wall prolapse – descent of the posterior vaginal wall often with rectum protruding (bulges forward) into the vagina
• Uterine prolapse – Descent of the uterus
• Vault prolapse – Descent of the vaginal vault and may occur in women who have had a hysterectomy. There is frequently small bowel behind a vault prolapse in which it is called an enterocele. This name may also be given to prolapse of the upper part of the posterior vaginal wall i.e. with the uterus still in situ.

Grades of uterine prolapse

• 1st degree: Uterine prolapse descents to 1cm above hymen
• 2nd degree: Uterine prolapse descents from 1cm above to 1cm below hymen
• 3rd degree: Prolapse further
• 4th degree: When the uterus is completely outside the vagina (procidentia)

Investigations

Not really needed unless rectal, uterine pathology suspected.

Mechanism of Prolapse

Prevention of prolapse

• No effective strategy for primary or secondary prevention
• Lifestyle and behavioural factors are appropriate
  • Not smoking
  • Maintain healthy body weight
• Unclear long term durability. Short-term benefit can be seen with the following.
  • Elective caesarean delivery
  • Pelvic floor exercises

Treatment

Asymptomatic

• Observation and watchful waiting
• Consider pelvic floor muscle rehabilitation

Symptomatic

• Reversible risk factors
• Pelvic floor exercises
• Intravaginal oestrogen supplementation
• Vaginal packing
• Vaginal pessaries
• Follow-up examinations
• Surgery

Surgery

• Reconstructive surgery
  • Sacrocolpopexy
  • Uterosacral ligament suspension
  • Sacrospinous ligament suspension
• Obliterative surgery
  • Colpocleisis

Complications

Complications of prolapse 

• Vaginal erosion
• Urinary retention

Complications of surgery

• Faecal incontinence
• Urinary incontinence
• Dyspareunia
• Mesh erosion
• Recurrent prolapse

References