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Prolapse of pelvic organs (POP)

Pelvic organ prolapse (POP) is a hernia of the pelvic organs to or through the vaginal opening. Although not life threatening, POP is life altering and results in significant quality of life changes in women.

What is POP?

The pelvic organs (bladder, uterus and rectum) are supported by a complex “hammock” that includes the pelvic muscles, fibrous or ligamentous support structures, and their attachment to the bony anatomy of the pelvis. Damage to these support systems results in descent of the pelvic organs. POP is not a new problem; POP and its consequences have been written about since 2000 B.C. While minor degrees of POP affect up to 50% of women who have had a vaginal delivery, only 20% have symptomatic POP that prompts women to seek care. In general, POP that does not extend beyond the vaginal opening is asymptomatic and does not require care, while POP that extends beyond the vaginal opening is generally bothersome to women. Treatment options for POP are limited and include the use of pessaries, surgery or watchful waiting. Suboptimal surgical results as well as high recurrence rates after treatment have prompted many providers to view prolapse as a chronic disease. Risk factors for the development of POP include difficult vaginal deliveries, family history of POP, obesity, advancing age, prior hysterectomy, and conditions which chronically increase intra-abdominal pressure, such as asthma or constipation.

Symptoms

Commonly, patients with severe POP report feeling or seeing a “ball” or protrusion from the vagina. Other prolapse symptoms are often vague and nonspecific. Patients with mild POP can report feelings of heaviness or pressure that may be present all the time or only after a long day of being on their feet or after heavy physical exercise. POP commonly occurs with other pelvic floor disorders including bladder and bowel problems such as urinary or anal incontinence, constipation and overactive bladder. Symptoms for one pelvic floor problem should prompt questioning for all other disorders as patients often have more than one pelvic floor problem. Fortunately, mild POP rarely affects sexual function although more severe POP may lead to decreased rates of sexual activity.

What are the signs of prolapse?

There are a few signs that you may have a prolapse. These signs depend on the type of prolapse and how much pelvic organ support has been lost. Early on, you may not know you have a prolapse as there will be no symptoms, but your doctor or nurse might be able to see your prolapse when you have your routine Pap smear test.

When a prolapse is further down, you may notice things such as:

• A heavy feeling or dragging in the vagina

• something ‘coming down' or a lump in the vagina

• A lump bulging out of your vagina, which you see or feel when you are in the shower or having a bath

• Sexual problems of pain or less feeling

• Your bladder might not empty as it should, or your urine stream might be weak

• Urinary tract infections might be reoccurring, or

• It might be hard for you to empty your bowel.

These signs can be worse at the end of the day and may feel better after lying down. If the prolapse bulges right outside your body, you may feel sore and bleed as the prolapse rubs on your underwear.

What causes a prolapse?

Childbirth is the main cause of a prolapse.  On the way down the vagina, the baby can stretch and tear the supporting tissues and pelvic floor muscles. The more vaginal births you have, the more likely you are to have a prolapse.  

Other things that press down on the pelvic organs and the pelvic floor muscles that can lead to prolapse are:

• Chronic coughing (such as smoker's cough or poorly controlled asthma)

• Heavy lifting (washing baskets, supermarket bags or children), and

• Constipation - chronic straining to empty the bowel can cause prolapse.

How is pelvic organ prolapse diagnosed?

Diagnosing the exact cause of pelvic organ prolapse is critical to successful treatment.

Proper diagnosis starts with a detailed medical history and a thorough physical exam, including both pelvic and rectal exam. Pelvic organ prolapse can usually be diagnosed by observation of the vaginal walls and cervix. You may be asked to strain or cough during the exam. Bladder function may also be tested.

Types of prolapse

Pelvic organs may bulge through the front wall of the vagina (called a cystocele), through the back vaginal wall (called a rectocele or an enterocele) or the uterus may drop down into the vagina (uterine prolapse). More than one organ may bulge into the vagina.

There are several types of pelvic organ prolapse, including:

• Uterine prolapse – Uterus drops down into the vagina

• Vaginal vault prolapse – Top of the vagina (vaginal vault) drops down

• Cystocele – Bladder drops down into the front (anterior wall) of the vagina; also called dropped bladder

• Urethrocele – Urethra drops down and bulges into the vagina

• Enterocele – Small intestine drops and pushes into the wall of the vagina

• Rectocele – Rectum drops down and bulges into the vagina (also known as posterior wall prolapse)

Who is likely to have a prolapse?

Prolapse tends to run in families. It is more likely after menopause or if you are overweight.  But it can happen in young women right after having a baby.

About half of all women who have had a child have some level of prolapse, but only one in five women need to seek medical help.

Sites of POP

Prolapse or support problems can affect one or multiple organs of the pelvis. Weakness of the front side vaginal wall near the bladder results in a cystocele, often called a “dropped bladder”. Weakness of the vaginal ceiling results in uterine prolapse, known as an enterocele. Defects of the backside vaginal wall near the rectum results in a rectocele.

Treatment Options

Non-Surgical Therapy

Mild pelvic organ prolapse that is asymptomatic does not require treatment. Some prolapse will improve on its own with watchful waiting, although it is not possible to identify whose POP will improve with time. Although there are limited non-surgical management options for POP, there is emerging information that pelvic floor exercises, or Kegels, may have some limited effectiveness in addressing symptoms of POP.  Other non-surgical options for treatment of symptomatic POP include pessaries. 

Pessaries are silicon devices that come in a variety of shapes and sizes and are placed in the vagina to provide support to the pelvic organs. Since women come in all shapes and sizes, pessaries need to be fitted to the individual. There are many different types of pessaries and multiple sizes of each type. Fitting is by trial and error. A successful pessary is one that is comfortable, is retained with Valsalva and treats POP symptoms adequately. Pessaries do require upkeep and need to be removed and cleaned on a regular basis. Most women can learn to care for their pessaries themselves, however, women who cannot care for their pessaries need to have the pessary removed and cleaned on a regular basis by their provider.   For many, local vaginal estrogen is prescribed for use in conjunction with a pessary for comfort, lubrication to reduce the risk of irritation or ulceration, and a lower incidence of urinary tract infections.

Although there are limited non-surgical management options for POP, there is emerging information that pelvic floor exercises, or Kegels, may have some limited effectiveness in addressing symptoms of POP. For assistance in performing the exercises correctly and consistently, consider ordering the Women’s Pelvic Floor Muscle Exercises Instruction Kit from NAFC. It includes a manual with descriptions and detailed drawings, a motivational video and instructional audio recording. Instruction by a physical therapist or other expert may be necessary, as well as the help of biofeedback in locating the muscles to contract.

Surgical Therapy

Reconstructive surgery for POP is an option. Prolapse procedures are done to provide support for the pelvic organs. Ultimately, the purpose of the surgery is correct the anatomy as well as provide better bowel, bladder and vaginal function. 

Prolapse repairs can be done transvaginally, abdominally, laparoscopically and/or robotically (when a scope is placed through the belly button). 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.

Approximately 11% of women will have surgery for POP prior to 80 years of age. Unfortunately, nearly 30% of these women will need another surgery due to failure or recurrence of prolapse or treatment of another pelvic floor problem.

What is the best surgery for the treatment of POP? Since women are individuals, the best treatment is a decision that needs to be made between a woman and her surgeon. In general, abdominal repairs are thought to have higher success rates at the cost of increased morbidity when performed through a large incision. Because of less than optimal success rates with traditional repairs, pelvic surgeons are constantly looking for new surgeries to approach this problem. Many surgeons are using vaginal grafts (made of synthetic and biologic materials) in attempts to improve long-term success rates; however, limited research has been done to prove that these methods improve results without increasing complications. While use of permanent mesh that is placed vaginally may improve vaginal support, many women have good results with repairs that are performed using their own tissues. In addition, the use of permanent mesh is associated with complications, some of which may require additional surgeries to correct. The most common complications associated with the use of permanent mesh to repair POP are urinary tract infections (4%), exposure of the mesh into the vagina (3%), and pelvic or genital pain (2.5%); other problems include erosion of the mesh, or perforation, into organs such as the bladder or urethra, urinary retention, and, possibly, mesh shrinkage. Research is currently being done to determine if the benefits of using mesh grafts in POP surgical repairs for greater durability sufficiently outweigh the risks of undesirable adverse consequences. Limited research to date indicates that women who are older, smoke, are diabetic, or have had a hysterectomy are at higher risk for these more common complications.

For women who never plan on having sexual intercourse again, there are simple trans-vaginal surgeries that have nearly a 100% success rate. In these techniques the vagina is sewn shut and shortened so that it no longer prolapses. After these surgeries, vaginal intercourse is impossible post-operatively. These techniques are ideally suited for the elderly patient with multiple medical problems that would otherwise place her at increased risk with a reconstructive approach.

Anterior colporrhaphy: An anterior colporrhaphy repairs the wall between the vagina and the bladder. A pliable piece of material called a “graft” can be placed between the vagina and bladder to strengthen the repair. There are many types of grafts available.

Posterior colporrhaphy: A posterior colporrhaphy repairs the wall between the vagina and the rectum. As with the anterior colporrhaphy, graft material can be used to strengthen this type of repair. This procedure is performed vaginally. Doctors generally use the pelvic floor muscles adjacent from the rectum as the “graft” material. This reduces graft complications.

Perineorrhaphy: A perineorrhaphy is the surgical repair of a weakened perineum (the area between the vaginal opening and anus). This procedure is sometimes done at the same time as a posterior repair.

Vaginal vault suspension/Uterine resuspension: A vaginal vault suspension is the surgical repair of a vaginal vault prolapsed by attaching the top of the vagina to ligaments in the pelvis with permanent sutures or graft material. This procedure can be performed vaginally or abdominally.

Hysterectomy: A hysterectomy is the surgical removal of the uterus. This is the surgery done to reduce future risk of gynecologic cancers. There is no documented benefit to prolapse repair by including a hysterectomy. A hysterectomy can be done through a vaginal or abdominal incision.

Robotic Sacropopexy or Sacrohysteropexy: In specific situations, the vaginal vault can be suspended to the back bone of the pelvis. Doctors have done this procedure laparoscopically and robotically. A permanent graft is sutured to the vaginal walls and/or uterus and then permanently connected to the sacrum.

What can be done to prevent prolapse?

It is much better to prevent prolapse than try to fix it! If any women in your close family have had a prolapse, you are more at risk.

As prolapse is due to weak pelvic tissues and pelvic floor muscles, all women should keep their pelvic floor muscles strong - no matter what their age.

Pelvic floor muscles, just like any other muscles, can be made stronger with the right exercises. It is important to have your pelvic floor muscle training checked by an expert such as a pelvic floor physiotherapist or a continence nurse advisor. 

If you have been told you have a prolapse, these experts are the best people to help plan a pelvic floor muscle training program to suit your needs.