Pelvic organ prolapse (POP) is the descent of the pelvic organs. This may be completely asymptomatic and noted simply as a protrusion of the vagina, or there may be a host of symptoms related to the loss of vaginal support.
The incidence of POP is widely varied, anywhere from 25% to greater than 90%, depending on the definition used and the population studied. Regardless of the exact number, it is clear that a significant number of women have some degree of POP. In once review, the lifetime risk for undergoing a single operation for prolapse or incontinence was by the age of 80 was 11.1%.
Prolapse may be present in isolated compartments of vagina or be multicompartmental. Prolapse is often described by its location.
- Anterior vaginal wall prolapse: is descent of the top of the vagina. It is often referred to as a cystocele or “the bladder dropping” as the bladder is located anterior to or on top of the vagina.
Posterior vaginal wall prolapse: is the loss of support of the back wall of the vagina and is often referred to as a rectocele as the rectum is located posterior to the vagina.
Apical vaginal wall prolapse: is descent of the proximal or innermost portion of the vagina. This may occur in women who have had a hysterectomy and may be referred to as an enterocele, as bowel may behind the protrusion. It may also occur in women who still have a uterus and is called uterovaginal prolapse.
Risks factors for developing POP include aging, pregnancy, parity, previous pelvic surgery, genetic factors, obesity, and conditions which lead to increased intrabdominal pressure such as constipation and chronic respiratory problems.
Signs and Symptoms
POP is typically brought to the attention of the physician by the patient or is determined at the time of a pelvic examination. The signs and symptoms that may be associated with POP are varied:
- Vaginal bulge: a protuberance from the vagina which may be subtle or quite obvious when it goes beyond the opening of the vagina. This may worsen as the day progresses or be more evident with certain activities such as walking or lifting.
- Feeling of pelvic pressure/fullness: which may worsen as the day progresses.
- Low back pain
- Dyspareunia: is pain or discomfort with sexual intercourse.
- Urinary and/or bowel problems: may result in incontinence, retention, or incomplete evacuation of urine or stool.
- History and physical examination: used to review symptoms and their impact on quality of life. Risk factors, medical history, and surgical history are also reviewed.
- Pelvic examination: may be performed in the lithotomy or standing positions
- Cough/Valsalva stress test: is performed at the time of a pelvic examination. The patient may be asked to strain or cough to look for any signs of urinary incontinence.
- Post void residual: is a measurement of the urine, performed with an ultrasound machine or with catheterization to measure the volume of urine left in the bladder after a patient urinates.
- Urinalysis: is a urine test to check for any signs of blood in the urine or possible infection.
- Validated questionnaire: are questionnaires which have undergone rigorous testing which gives the physician a more objective idea of how your problems may be impacting various areas of your life or your overall quality of life.
- Urodyanmic study: is a bladder study which gives the physician important information about how your bladder is storing and emptying urine.
Although POP may be managed conservatively, the mainstay of treatment is surgical. The goals or surgery are the following: the relief of symptoms related to POP; improvement of urinary, bowel, and sexual function; restoration of normal anatomy; long lasting/ durable result. The exact treatment plan will depend on the patient workup results, severity of patient symptoms, and discussion with the treating physician.
- Nonsurgical treatment may include minimizing associated risk factor if possible, pelvic floor exercises, and the use of a pessary. A pessary is an intravaginal device that helps to maintain vaginal support. Pessary use does require a motivated patient. Side effects from pessary use include vaginal infection, vaginal ulceration, new onset urinary symptoms, and discomfort. Estrogen replacement therapy is often used along with the pessary.
- Reconstructive surgical procedures aim to restore the normal functional vaginal anatomy. These are generally the preferred treatment options for most women. They can be performed through different routes including transvaginal, transabdominal, laparoscopic, and robotic assisted approaches. Each approach has various advantages and disadvantages, and many of these procedures are minimally invasive which helps to decrease hospitalization and recovery times. The surgery may also include the use of different graft materials which may help increase the durability of POP surgery; however, this is still controversial.
- Obliterative surgical procedures reduce the vaginal prolapse, but create a nonfunctional vagina. These surgeries are reserved for patients who are not and do not plan on being sexually active and are not optimal surgical candidates for longer, more invasive reconstructive procedures. A colpocleisis is an obliterative procedure which is performed transvaginally and can be done in the presence or absence of a cervix and uterus.