Pelvic Organ Prolapse

Overview

How is the diagnosis of POP made?

Female PelvisThe pelvic organs (bladder, uterus and rectum) are supported by a complex “structure” that includes the pelvic “hammock.” This hammock includes the pelvic muscles, fibrous or ligamentous support structures, and their attachment to the bony anatomy of the pelvis.

Pelvic organ prolapse (POP) is a condition unique to females in which the genitourinary (pelvic) internal organs descend within the pelvis, distort the vaginal wall and, in some patients, bulge outside the vagina. Therefore, POP may be considered a type of “hernia” in which the pelvic organs dip into the vagina but remain entirely covered by the vaginal wall. In fact, researchers have demonstrated an association between prolapse and a history of abdominal hernia in women, suggesting a possible connection with abnormal collagen, or the quality of connective tissue(1). POP is also known as vaginal prolapse. POP may involve any combination of the organs located within the female pelvis including the bladder, urethra, cervix and uterus, bowel (intestines) and rectum. POP may be represented by such a mild descent of one segment of the vagina that no symptoms are felt, or to the extreme of the vagina turning completely inside out including prolapse of all organs of the pelvis.

POP and its consequences have been written about since 2000 B.C. The malady “falling of the womb” was one of the first gynecologic conditions to be recognized.

Minor degrees of poor pelvic organ support affect up to 50% of all women who have had a vaginal delivery, while 20% have symptoms that require them to seek care. Approximately 11% of women will have surgery for POP prior to 80 years of age (approximately 300,000 procedures in the United States per year) and nearly 30% of these will need another surgery due to failure or recurrence of prolapse or treatment of subsequent dysfunction(4).

There are many risk factors for pelvic organ prolapse that include difficult vaginal deliveries, family history of POP, obesity, advancing age and prior hysterectomy.

Symptoms

Many women with urinary incontinence wonder if (or have been told that) their bladder has “fallen.” What does this mean? A “fallen” bladder is a simple way of saying that the support of the bladder is no longer normal. Another word for this is “cystocele” (sis’to-seal). Cystocele is one of the many words health care teams say when they are describing pelvic organ prolapse. The pelvic organs (uterus, bladder, bowels) can move out of position because the walls and supports that should keep them in place have given way. This is very common in women who have delivered a child vaginally.

The degree or severity of prolapse is often but not invariably related to symptoms. The presence or absence of symptoms may depend on factors such as the type of prolapse and its effects on the pelvic region and gastrointestinal tract.

POP is often but not always accompanied by symptoms of urinary dysfunction. Urinary symptoms in patients with POP include urinary incontinence, obstructive symptoms including hesitancy, straining and decreased force of stream, urgency and frequency of urination and urinary retention. Other symptoms unrelated to POP’s effects on the urinary tract may include most commonly a vaginal bulge or mass, pelvic pain, back and hip pain, pelvic discomfort, pain during sexual intercourse, bowel dysfunction and related symptoms including constipation, diarrhea and painful, unsuccessful attempts to empty the bladder or rectum.

In sum, the symptoms of prolapse typically include feeling like you are sitting on a ball, feeling something that is outside the normal opening of the vagina and pressure low in the pelvis. Some related symptoms, such as constipation, or difficulty having bowel movements, are not necessarily related to prolapse.

It is important to understand that prolapse by itself doesn’t CAUSE urinary incontinence. However, many women have both conditions – that is, prolapse as well as urinary incontinence. This is important to understand, because “lifting” the bladder by having a prolapse surgery rarely solves the problem of urinary incontinence. Depending on the type of urinary incontinence you have, a procedure that is specially designed to reduce urinary incontinence can be done at the same time as a prolapse repair surgery.

Some women with prolapse do not have urinary incontinence. However, after repair of the prolapse, urinary incontinence can develop. Recent studies have demonstrated that in women without symptoms of stress incontinence who have an abdominal prolapse repair (called sacrocolpopexy), an additional anti-incontinence procedure (Burch colposuspension) reduces the risk of bothersome stress incontinence symptoms.

There are many words that are used to describe prolapse. The “o’celes” are Latin names for the organs that are out of place. Cystocele describes a support problem in the front wall of the vagina (the wall that separates the bladder and vagina). Rectocele describes a support problem in the back wall of the vagina (the wall that separates the bladder and vagina). Another “o’cele” is enterocele, which describes a weakness in the vaginal wall that allows part of the bowel to move out of place. If the front wall of the vaginal has descended involving the urethra only, this is known as an urethrocele. A support defect at the perineum (the area between the vagina and anus) results in a perineocele. The uterus (and cervix) can also be prolapse and out of place. When this happens, simple removal of the uterus (hysterectomy) is not enough to repair the support loss. The supports at the top of the vagina need to be repaired as well. The medical term for this is uterovaginal prolapse. There are several surgical procedures that can be selected for this purpose.

If you are bothered by prolapse, it is best for your doctor to examine you when you are standing because that is when the prolapse will show itself. Treatments for prolapse include a vaginal support ring, called a pessary, or surgery. If left untreated, prolapse can be associated with vaginal sores, ulceration and bleeding. Rarely, the urinary tract can become blocked if the prolapse remains severe and untreated. Be sure to ask your doctor for a pelvic examination if you think you have prolapse.

Prevalence & Risk Factors

How widespread is POP and what are the risk factors?

POP is quite common. It has been estimated that up to 50% of parous women (i.e. females who have delivered at least one live birth baby) have some degree of genital prolapse, of which 10-20% are symptomatic(2). Approximately 20% of all women awaiting major gynecologic surgery have some degree of prolapse. The incidence of POP increases with age. Approximately half of all women over the age of 50 complain of symptoms associated with prolapse(4).

In a review of almost 150,000 female patients, researchers concluded that the lifetime risk of undergoing a single operation for the surgical repair of POP was about 10%(5). Interestingly, the rate of repeat surgery in this study, which implies failure of the initial surgery but could also suggest further deterioration in support, was nearly one third, or 29%. Regardless, the surgery for POP is considered more complicated, with a higher failure rate, and more difficult for women to undergo than surgery for incontinence.

POP has been associated with many factors. Studies have implicated pregnancy, aging, hormonal status, obesity and weight gain, chronic pulmonary disease and smoking, genetic factors, congenital anatomic factors, connective tissue abnormalities, as well as congenital and acquired neurological abnormalities. However, the strongest relationship exists with childbirth and its effects on the musculofascial structures of the pelvis. In support of this concept, POP is exceedingly rare in patients who have never been pregnant. Pregnancy may promote POP in several ways(6): changes in connective tissue during pregnancy, pressure and weight of the uterus on the pelvic floor, weight gain of the mother, trauma to the pelvic floor and connective tissue during vaginal delivery, abdominal straining during labor, and ensuing nerve damage(7,8).

Age appears to be a contributing factor, as it would appear that partial loss of the nerve supply to the pelvic floor is part of the normal aging process. This may be accelerated by pregnancy and childbirth.

Hormonal factors can be a consideration, as there is known reduction in tissue collagen content following menopause. In fact, researchers have documented no release of estrogen, progesterone, or androgen in the pelvic floor muscles of women undergoing pelvic surgery(9).

Heavy lifting has found to be a significant risk factor10. Consequently, such sports as weight lifting, high impact aerobics and long distance running are consider to place women at higher risks of urogenital prolapse.

Prior pelvic surgery appears to have a possible effect on the incidence of developing prolapse. In other words, repair for one problem, such as stress urinary incontinence, may lead to a weakening of ligaments in another part of the pelvic region. Although the association between prolapse and prior hysterectomy is not as clear, there has been research that demonstrated a significant association of prolapse with a prior history of hysterectomy or prolapse surgery(11).

How is the diagnosis of POP made?

POP cannot be diagnosed by patient history alone, as an accurate diagnosis of POP requires, at a minimum, physical examination. Although a thorough history of symptoms is helpful, POP symptoms are generally non-specific for the type and degree of POP found on physical examination(12),(13). Occasionally, the full extent of the prolapse does not show until the patient is upright and examined in the standing position, allowing gravity to take its full effect.

It is important to emphasize that POP commonly involves multiple vaginal segments or compartments. POP rarely occurs as an isolated defect of one vaginal compartment, which often further limits the diagnostic accuracy of the physical examination alone. There often exists complex anatomic relationships between different types of prolapse in the same patient. In fact, clinicians have evolved different grading systems over the years because of the difficulty in agreeing on an objective, reproducible system of grading. Because of variability not only among women but even from one examination to the next in the same woman, it is sometimes difficult to compare successive examinations over time. Not only may extensive diagnostic tests be needed, in some instances, the full recognition of repair to be done may not be easily known until a patient is in surgery.

Treatment Options

Non-Surgical Therapy

Mild pelvic organ prolapse often will respond to non-surgical approaches. If the leading edge of the prolapsed organ has not reached the opening to the vagina, improvement is expected in better than 20-50% with non-surgical therapy.

Although not proven, pelvic floor exercises done on a consistent basis may also help treat prolapse. Exercises cannot reattach vaginal supports and thereby reverse the prolapse, but contracting strong pelvic floor muscles when lifting or bearing down may prevent pelvic organ prolapse from becoming worse or help relieve pressure symptoms and may prevent further descending of the organ. Because the pelvic floor is composed of both slow and fast twitch muscle fibers, it is important to do both lengthy and short contractions when exercising these muscles. The slow twitch fibers provide muscle tone over a long period of time, thus supporting the primary organs housed in the pelvic cavity. The fast twitch fibers react to sudden increases in pressure and thus primarily protect against urine leakage.

Behavioral changes for treatment of pelvic organ prolapse include weight loss, avoiding heavy lifting, correcting a chronic cough, or preventing constipation that contributes to straining to have a bowel movement. More research is needed to determine how well these interventions work.

Avoiding activities that involve straining is key. This should not mean becoming less active. Swimming is excellent exercise for those who have access to a pool, and riding a bicycle, or exercise bicycle, can provide aerobic exercise without the downward forces of gravity that occur when running. Similarly, these activities are much better than weight lifting that creates increased abdominal pressure. Furthermore, avoiding constipation that can cause you to strain during bowel movements will help keep the prolapse from getting worse. The key here is to have adequate fiber in your diet, either by eating a high-fiber diet or by taking over-the-counter supplements. This should result is soft, easy-to-pass bowel movements; and if the stool is still hard, more fiber is needed. If these symptoms do not improve, seeking the advice of your doctor should help.

When prolapse is consistently at the opening of the vagina or beyond, then supporting the prolapse is very important to prevent further deterioration of bladder and rectal function, as well as to prevent ulcer formation (bleeding and irritation) on the prolapse.

Treatment options are few and poorly studied. At present, vaginal pessaries are an inexpensive alternative to surgery for women with symptomatic prolapse.

Prevention Strategies

Pelvic muscle exercises are another way to help keep the organs in place. It is important, when considering this treatment to build muscle strength. Simply doing mild contractions many times a day won't do this. It is better to really work on building stronger muscles. Exercise once a day, but focus on really working the muscles. Start by making sure you are contracting the right muscles. When you tighten these muscles (as you would to stop your urine stream) the tissues around your vagina and anus should move up toward your head. Try this lying down and you may want to gently put your hand in this area to feel if everything moves up. If what you are doing pushes things down toward your feet, it's not correct. Once you can do the contraction correctly, make the strongest contraction and try to hold it for 10 seconds. You will probably find that the muscles start to give-way after a few seconds. Rest for one minute and then repeat this. Ten repetitions should therefore take about ten minutes. Don't be surprised if the muscles are mildly sore the next day (as your arms would be if you were doing push-ups and were not in shape). This will go away as the muscles strengthen. Remember it takes about six weeks for the muscles to get stronger, so be patient and persistent.

There's also a lot of discussion about the role of Cesarean section in preventing these types of problems. At the present time, this doesn't seem very logical. Only one in ten women develop problems with incontinence and prolapse as a result of birth. Therefore nine of ten women would have a c-section when they were never destined to develop prolapse. At present, it seems best to have a vaginal delivery and, in the event that prolapse does occur, there is good treatment for it. Of course, there are many other reasons that elective c-section is being discussed and you will be reading more about this topic soon.

Pessaries

Pessaries are artificial devices made of medical-grade polyethylene plastics or silicone, that are placed into the vagina to hold pelvic organs in place. They can be used to treat both pelvic organ prolapse and urinary incontinence. Finding a pessary that is right for you is a trial and error process, like finding a pair of shoes that are comfortable. Over 13 different kinds of pessaries are available with multiple sizes of each type. A properly fitted pessary should be comfortable and remain in place with bearing down and allow you to void. Fitting is typically done by trial and error by a specially trained nurse specialist or physician. Once sized properly, the pessary should allow a finger to fit between the device and the vaginal wall to allow easy removal, similar to a diaphragm used for contraceptive purposes. When fitted correctly, you should not be able to tell that the pessary is there!

Pessaries do require upkeep and have to be removed and cleaned on a regular basis. Most women can learn how to take care of their pessaries themselves. They should be changed every six months. Although the exact time interval that women can wait between cleanings is unknown, most women remove their pessaries weekly. Some women will have their pessary cleaned by a medical provider on a monthly basis. Menopausal women may need to use hormone cream to keep vaginal tissue healthy enough to wear a pessary. Complications from pessary use are rare and include vaginal discharge, constipation, difficulty voiding or vaginal bleeding. Some women may be prescribed a low dose topical estrogen to prevent vaginal ulceration and chaffing. In fact, some clinicians recommend treating the vaginal area for several weeks prior to the fitting appointment in order to enhance vaginal lubrication, to decrease atrophy and minimize discomfort at the time of initial insertion. Patients may use a pessary while awaiting surgery, until childbearing is complete, or lifelong.

Surgical Therapy

Considering surgery for pelvic organ prolapse? It is important to understand that while surgeries for pelvic organ prolapse help many women, there is no such thing as a surgery that is 100% effective for 100% of women over an entire lifetime. In recommending a surgery for you, your surgeon is weighing the pros and cons of different options, based on what he or she knows about you, your history, your anatomy, your desire for sexual function and other factors. Some surgeries have been done for many years and so surgeons have a good understanding of the long term effectiveness and complication rates, while others are brand new and so lack such information, but may have other advantages. Here are some questions you should ask your doctor:

  • What are the different surgical options that would help me?
  • Which one do you recommend?
  • Why do you recommend this particular surgery, rather than another one?
  • How many of this particular surgery have you personally performed?
  • How long ago did you begin doing this particular surgery?
  • What kinds of complications are possible and how often do these happen?
  • Will surgery affect my bladder control?
  • What are my chances of needing another surgery or procedure to treat problems related to this surgery?
  • How well does this surgery work in the long-term (two or more years later)?

-Dr.Ingrid Nygaard

One in nine women has surgery for prolapse in their lifetime. Of those who have surgery, one in three will have a second surgery. In addition to poor long-term success rates, surgery can cause other problems with urinating, emptying your bowels or sex. In fact, several studies have described a mysterious, unexplainable onset of stress urinary incontinence of 23-50% after various surgical means of correcting POP (¹),(²). Very recently, a study was completed and published in which performing a Burch colposuspension procedure to prevent stress incontinence at the same time as an abdominal procedure to treat symptomatic pelvic organ prolapse revealed advantages in a lower post-operative incidence of stress incontinence, i.e., only 24% compared to 44% in women undergoing only prolapse repair?.

Because of the variation in types and severity of prolapse as well as considerations of pre-emptive strategies, research is lacking in comparisons of types of surgical procedures for POP. Doctors have thus far been unable to prove what the single best possible treatment for prolapse is. Reconstructive surgery for POP is an option. Prolapse repairs can be done transvaginally, abdominally or through a laparoscope (when a scope is placed through the belly button). Each approach has ardent supporters among surgeons. Correcting all support defects is paramount in the surgical approach to POP. However, given the nearly 30% recurrence rate with surgical approaches, pelvic surgeons are constantly looking for new ways to approach this problem. Many surgeons are using grafts (made of synthetic and biologic materials) in attempts to improve long-term success rates.

Research is currently being done to determine if the use of grafts in POP surgical repairs is more effective than traditional repair procedures. Retaining sexual function is an important topic for women to discuss with their surgeon prior to surgery, as it is important not to compromise vaginal capacity, elasticity or sensation in the choice of procedures. In the case of synthetic materials, women should question their surgeons about experience with rates of infection, erosion, and painful intercourse post-operatively and compare such risks with those outcomes most closely associated with traditional procedures, including longer recovery and recuperation times.

Finally, in women who never plan on having sexual intercourse again, there are simple trans-vaginal, obliterative techniques that have success rates of over 97%. In these techniques the vagina is sewn shut; therefore intercourse is impossible post operatively. These techniques are ideally suited for the elderly patient who no longer wishes to be sexually active with multiple medical problems that would otherwise place her at increased risk with a reconstructive approach.

Contributing Authors & Citations:

  • Linda Brubaker, MD Professor and Fellowship Director Department of OB/GYN and Urology Loyola University Medical Center Maywood, IL
  • Rebecca G. Rogers, MD Director, Division of Urogynecology Department of Obstetrics and Gynecology University of New Mexico Health Sciences Center Albuquerque, NM
  • John O. L. DeLancey, MD Norman F. Miller Professor of Gynecology Director, Pelvic Floor Research Group Director, Fellowship in Female Pelvic Medicine and Reconstructive Surgery University of Michigan
  • Ann Arbor, MI Eric S. Rovner, MD Associate Professor of Urology Department of Urology Medical University of South Carolina Charleston, SC

Reference List

  1. Rinne KM, Kirkinen PP. What predisposes young women to genital prolapse? Eur J Obstet Gynecol Reprod Biol 1999, 84: 23-5
  2. Beck RP, Nordstrom L: A 25 year experience with 519 anterior colporrhaphy procedures. Obstetr.Gynecol 78:1011-1018, 1991
  3. Cardozo L: Prolapse, in Cardozo L, Staskin D (eds): Urogynecology. vol1st. New York, Churchill-Livingstone, 1997, pp 321-350
  4. Olsen AL, Smith, Bergstrom, et al: Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstetrics and Gynecology 89:501-506, 1997
  5. Swift, SE: The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol 2000, 183: 277-85
  6. Pigne A, Bourcier AP, Scotti: Risk factors for pelvic organ prolapse, in Appell RA, Bourcier AP, LaTorre F (eds): Pelvic floor dysfunction: Investigations and conservative treatment. Rome, Italy, Casa Editrice Scientifica Internazionale, 1999, pp 27-34
  7. Aanestad O, Flink R: Urinary stress incontinence. A urodynamic and quantitative electromyographic study of the perineal muscles. Acta Obstetricia et Gynecologica Scandinavica 78:245-253, 1999
  8. Hale DS, Benson JT, Brubaker L, et al: Histologic analysis of needle biopsy of urethral sphincter from women with normal and stress incontinence with comparison of electromyographic findings. American Journal of Obstetrics & Gynecology 180:342-348, 1999
  9. Copas, P, Bukovsky A, Asbury B, Elder RF, Caudle MR. Estrogen, progesterone and androgen receptor expression in levator ani muscle and fascia. J Womens Health Gend Based Med 2001, 10: 785-95
  10. Jorgensen S, Hein HO, Gyntelberg F. Heavy lifting at work and risk of genital prolapse and herniated lumbar disc in assistance nurses. Occup Med 1994, 44: 47-9.
  11. Vasavada SP, Comiter CV, Raz S: Cytoscopic light test to aid in the differentiation of high-grade pelvic organ prolapse. Urology. 54:1085-1087, 1999
  12. Comiter CV, Vasavada SP, Barbaric ZL, et al: Grading pelvic prolapse and pelvic floor relaxation using dynamic magnetic resonance imaging. Urology 54:454-457, 1999
  13. Chaikin, DC, Groutz A, Blaivas JG. Predicting the need for antiincontinence surgery in continence women undergoing repair of severe urogenital prolapse. J Urol 2000, 163: 531-4
  14. Gallentine ML, Cespedes RD. Occult stress urinary incontinence and the effect of vaginal vault prolapse on abdominal leak point pressures. Urology 2001, 57: 40-4
  15. Brubaker L et. al. Combined continence operation with prolapse surgery improves urinary control. N Engl J Med 2006; 354: 1557-1566, 1627-1629
 
    
Updated: Mar.06.2008