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.
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)