Pelvic Organ Prolapse
POP most commonly affects older women and is experienced by an estimated 41 percent of postmenopausal women over 60 who have not had a hysterectomy. As lifespans increase, the incidence of POP increases.
Primary types of POP are related to the organ that has prolapsed. These include vaginal prolapse (vault of the vagina drops), bladder prolapse (weakness in the front or side wall of the vagina), rectal prolapse (weakness in back wall of the vagina) and urethral prolapse, when the urethra drops into the vagina. More than one pelvic organ can prolapse.
Most cases of POP are mild, in which the organ drops down only slightly and is not felt or visible.
POP is generally not dangerous, but it can be very inconvenient and affect one’s lifestyle and comfort. Treatments range from merely monitoring the prolapse to surgery.
Causes of pelvic organ prolapse
Pelvic organ prolapse is due to a lack of underlying support for the organs due to weakness in the muscles, ligaments and connective tissue that attach to the bones of the pelvis. The weakening of this “hammock” of support, as it is often called, may occur due to a number of factors. These include:
- Family history of POP
- Hispanic heritage
- Prior hysterectomy or other pelvic surgery
- Considerable heavy lifting
- Vaginal birth issues
- Chronic issues that increase pressure on the pelvic organs such as constipation or asthma.
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Symptoms of pelvic organ prolapse
Most cases of pelvic organ prolapse are mild and result in no symptoms. Such asymptomatic pelvic organ prolapse is when the organ has prolapsed but does not protrude in the vagina. The woman does not feel any different and does not experience any of the accompanying symptoms described below.
When symptoms are severe, the woman will feel and see the prolapsed organ bulging into her vagina, sometimes outside of it. In all cases of POP, the following symptoms may be experienced:
- An aching or pulling feeling in the pelvic area
- Sensation of heaviness or fullness in the pelvic area
- Uncomfortable or painful sexual intercourse
- Lower back pain
- Trouble having a bowel movement or trouble urinating
- Bulge of tissue protruding from the vagina, sometimes described as a ball.
These symptoms may be present at all times. They may also appear and disappear, sometimes depending on exertion or standing for long periods. POP often occurs in conjunction with other issues of the pelvic floor, so urologists often suspect POP when symptoms of other issues are present.
Pelvic organ prolapse is diagnosed by a pelvic floor examination.
Nonsurgical treatments for pelvic organ prolapse
Treatment for POP (vaginal prolapse, bladder prolapse, urethral prolapse and rectal prolapse) is often dictated by the symptoms. Types of treatments are simple monitoring, conservative management, use of a pessary device and surgical correction.
If no symptoms are present or if symptoms are mild, the urologist may recommend monitoring the situation through regular exams.
The urologist may pursue conservative management of mild to moderate cases of pelvic organ prolapse. This approach can reduce symptoms, strengthen the weakness causing the prolapse to keep it from becoming worse, and help avoid or delay surgical correction.
Conservative treatment may also include lifestyle changes that can minimize the pressures on the pelvic floor. These can include weight loss for obese patients, dietary changes to reduce constipation and efforts to stop smoking that is causing coughing that stresses the pelvic floor.
Another aspect of conservative management can be doing pelvic floor exercises to strengthen the muscles that are resulting in the prolapse. These exercises are called Kegels and can be performed easily by learning the proper way to contract the pelvic floor muscles. Doing Kegels can reduce symptoms and prevent the prolapse from becoming worse.
This device, usually made of silicon to reduce the chance of infection, is inserted into the vagina, providing support for pelvic organs. Pessaries vary in size and shape depending on the patient and the stage of POP. They are generally either ring-like devices that support the organs or are of a different shape to fill a space.
The patient removes, cleans and replaces the pessary. Local application of estrogen may also be used with the device. Pessaries are used when surgery is not an option for physical reasons or because the patient does not want to undergo surgery.
Surgical treatments for pelvic organ prolapse
If symptoms are severe and have not responded to nonsurgical treatments, surgery is the preferred treatment. The urologist will discuss surgical options with the patient according to her specific prolapse condition. Factors to consider include age, overall health and childbearing plans, as surgery is often postponed until after childbearing years because childbirth may cause the prolapse to return.
Surgeries for pelvic organ prolapse fall into two categories: Obliterative and reconstructive. Obliterative surgery provides support for the pelvic organs by closing off or narrowing the vagina. Intercourse is no longer possible after obliterative surgery.
Reconstructive surgery seeks to restore the pelvic organs to their normal position by restructuring the pelvic floor. These surgeries are performed through an incision in the vagina or in the abdomen. Laparoscopic minimally invasive surgery can often be used. The types of reconstructive surgery follow.
Fixation or suspension surgery
This uses the patient’s own tissue to support the pelvic organs. The surgery is done either through sacrospinous fixation or uterosacral ligament suspension. Procedures performed through the vagina rather than through the abdomen require less recovery time. During fixation and suspension, another procedure may be performed to reduce the risk of urinary incontinence.
Colporrhaphy, anterior and posterior
Anterior colporrhaphy utilizes stiches to strengthen the anterior wall of the vagina in order to correct bladder prolapse. Posterior colporrhaphy involves stiches in the posterior vaginal wall to support the rectum, correcting rectal prolapse.
Both surgeries are generally performed through the vagina, reducing recovery time. When these corrections are performed via the abdomen, they are called sacrocolpopexy and sacrohysteropexy. These procedures can reduce pain from sexual intercourse after the prolapse correction.
Vaginal mesh placement
Synthetic mesh placed in the vagina to support pelvic organs has been shown to produce complications in a significant number of patients. Therefore, vaginal mesh placement is not used often. It is reserved for those patients who cannot have abdominal surgery due to increased risks, whose own tissue is too weak to be used to support the pelvic organs, or who have had previous reconstructive surgery that has not worked.
Considerations & risks of pelvic organ prolapse surgery
Recovery time depends on the type of surgery, but most women can expect to take a few weeks off from work and normal activities. For a few weeks after surgery women should avoid sexual intercourse, lifting, straining and vigorous exercise.
Risks from surgery to repair pelvic organ prolapse are similar to risks of all surgeries. These include infection, blood loss, tissue or organ damage, pain and reaction to anesthesia. Urinary incontinence may also occur following these types of surgeries, as well as pain during intercourse.
The urologists will discuss the risks and how to mitigate them before performing any of these surgeries.