Pelvic Organ Prolapse
Pelvic organ prolapse (POP), often called simply prolapse, is a common pelvic floor disorder. POP occurs when one or more of the pelvic organs (uterus and the cervix or the inner vaginal walls), become relaxed and prolapse, meaning they drop down or forward close to or beyond the opening of the vagina.
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, also known as apical prolapse, (vault of the vagina drops), anterior vaginal prolapse (weakness in the front or side wall of the vagina), posterior vaginal prolapse (weakness in back wall of the vagina) and uterocervical prolapse, when the uterus and cervix drop 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 caused by 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.
- Chronic, repetitive heavy lifting.
- Vaginal birth issues.
- Chronic issues that increase pressure on the pelvic organs such as constipation or chronic obstructive pulmonary disease.
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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 moderate to 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:
- Bulge of tissue protruding from the vagina, that may be seen or felt, sometimes described as a ball.
- An aching or pulling feeling in the pelvic area.
- Sensation of heaviness or fullness in the pelvic area.
- Uncomfortable or painful sexual intercourse.
- Trouble having a bowel movement or trouble urinating.
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 urogynecologists 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, anterior vaginal prolapse, uterocervical prolapse and posterior vaginal prolapse) is often dictated by the symptoms. Types of treatments are simple monitoring, conservative management, use of a pessary device or surgical correction.
If no symptoms are present or if symptoms are mild, the urogynecologist may recommend monitoring the situation through regular exams.
The urogynecologist 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. The best way to determine if Kegels are being performed correctly is for an experienced professional to observe the patient doing them. A urogynecologist can assess this exercise.
This intravaginal device is inserted into the vagina and provides support to the pelvic organs. A pessary is usually made of silicon to reduce the chance of infection. 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 or physician 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. Most patients can maintain a pessary themselves but for those who cannot, a health provider can perform this maintenance at a regularly scheduled appointment.
Surgical treatments for pelvic organ prolapse
If symptoms are severe and have not responded to nonsurgical treatments, surgery is the preferred treatment. The urogynecologist 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: reconstructive and obliterative. Reconstructive surgery seeks to restore the pelvic organs to their normal position by restructuring the pelvic floor. Obliterative surgery provides support for the pelvic organs by closing off or narrowing the vagina. Intercourse is no longer possible after obliterative surgery.
Reconstructive surgeries are performed through an incision in the vagina or in the abdomen. Minimally invasive laparoscopic surgery, which can be done with or without robotic assistance, 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 dissolvable stitches to strengthen the anterior wall of the vagina in order to correct anterior vaginal prolapse. Posterior colporrhaphy involves dissolvable stitches in the posterior vaginal wall to support the rectum, correcting posterior vaginal 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. Sacrohysteropexy utilizes a synthetic piece of mesh to support the pelvic organs and may also be an option for suspension, whereby the uterus and cervix remain in place by fixation to the pelvis.
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 surgeon will discuss the risks and how to mitigate them before performing any of these surgeries.
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