• Clinical science

Pelvic organ prolapse

Abstract

Pelvic organ prolapse (POP or female genital prolapse) is the protrusion of bladder, rectum, intestines, uterus, cervix, or vaginal apex into the vaginal vault due to decreased pelvic floor support. It is a commonly seen in women of advanced age. Other risk factors include multiparity (particularly vaginal births), prior pelvic surgery, connective tissue disorders, and increased intra-abdominal pressure secondary to obesity or chronic constipation. Patients present with a sensation of vaginal pressure, discomfort, and/or pain. The protruded pelvic organ is visualized and assessed during inspection. Low-grade prolapse can be managed conservatively with pelvic floor (Kegel) exercises or a vaginal pessary to support the pelvic floor. Pelvic floor repair surgery is indicated for women with symptomatic prolapse who do not respond to or decline conservative management. Complications include urinary or fecal retention or incontinence, abdominal/pelvic pain, and avoidance of sexual activity because of embarrassment or discomfort.

Overview

  • Anatomical overview: The pelvic floor is supported by a continuous endopelvic fascia, which consists of:
    • Uterosacral ligament complex (suspends the uterus and vaginal apex from the sacrum and lateral pelvis)
    • Paravaginal attachments
    • Perineal body, perineal membrane, and the perineal muscles
  • Definition: herniation into or descent of pelvic organs to or beyond the vaginal walls
    • Partial/subtotal prolapse: The pelvic organs are only partially outside the vaginal opening.
    • Total prolapse: The pelvic organs are everted and located outside of the vaginal opening.
  • Specific sites
    • Anterior vaginal wall prolapse: herniated anterior vaginal wall; , which is often associated with a cystocele (descent of the bladder) or urethrocele (descent of the urethra); can be due to weakness of the pubocervical fascia
    • Posterior vaginal wall prolapse: : herniated posterior vaginal wall; , which is associated with a rectocele; (descent of the rectum) or enterocele (herniated section of the intestines); can be due to weakness of the rectovaginal fascia
    • Uterine prolapse: descent of the uterus
    • Vaginal vault prolapse: descent of the apex of the vagina
    • Uterine procidentia: protrusion of all vaginal walls or cervix beyond the vaginal introitus

References:[1]

Epidemiology

  • POP is a common disorder in older women.

References:[1]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Risk factors

POP is due to an insufficiency of the pelvic floor muscles and the ligamentous supportive structure of the uterus and vagina , which may be caused by:

References:[1][2]

Clinical features

  • Feeling of pressure on or discomfort around the perineum (“sensation of vaginal fullness”)
  • Lower back and pelvic pain (may become worse with prolonged standing or walking)
  • Rectal fullness, constipation, incomplete rectal emptying
  • Prolapse of the anterior (in cystocele/urethrocele) or the posterior (in enterocele/rectocele) vaginal wall, possibly with excessive vaginal discharge on inspection, bimanual examination, and speculum examination of the patient in lithotomy position; occurs at rest and with increased abdominal pressure
  • Weakened pelvic floor muscle and anal sphincter tone (ask the patient to contract the pelvic floor muscles during digital examination)

Patients with POP may present with concurrent complications!

References:[1][2]

Diagnostics

  • Usually a clinical diagnosis relying on the Pelvic Organ Prolapse Quantitation system (POP-Q)
    • Stage 0: no prolapse
    • Stage 1: : The most distal portion of prolapse is more than 1 cm above the level of the hymen.
    • Stage 2: : The most distal portion of prolapse is 1 cm or less proximal or distal to the hymenal plane.
    • Stage 3: : The most distal portion of prolapse is more than 1 cm from the hymenal plane but no more than 2 cm less than the vaginal length.
    • Stage 4: The vagina is completely everted or uterine procidentia has occurred.
  • Vaginal or KUB ultrasound may be considered to exclude paravaginal complications (see “Complications” below).

References:[3][4]

Differential diagnoses

  • Elongation of the cervix

The differential diagnoses listed here are not exhaustive.

Treatment

Conservative treatment

First-line treatment for all cases of POP. May be definitive treatment for patients with manageable symptoms (low-grade POP) who would like to avoid complications of surgery or patients at high risk of surgical complications.

  • Insertion of a vaginal pessary (to support the pelvic organs)
  • Reduction of modifiable risk factors; (e.g., avoid smoking to prevent a chronic cough, weight loss; , prevent constipation)
  • Kegel exercises: pelvic floor muscle training (also as a preventive measure)

Surgery

Indicated for symptomatic prolapse if conservative treatment fails or the patient declines it.

  • Obliterative surgery: The vagina is closed off or narrowed to provide more support for pelvic organs.
  • Reconstructive surgery (abdominal or vaginal approach): to restore the original position of the descended pelvic organs
    • Sacrocolpopexy: (with vaginal vault suspension and hysterectomy): fixation of the vaginal apex to the sacrum for the repair of apical or vaginal vault prolapse, with suspension and hysterectomy
    • Suspension techniques: The prolapsed organ is fixated or suspended using native tissues such as the endopelvic fascia, iliococcygeus muscle, uterosacral ligament, or sacrospinous ligaments.
    • Colporrhaphy: reinforcement of the anterior or posterior vaginal wall for the repair of cystocele or rectocele
    • Sacrohysteropexy: fixation of the cervix to the sacrum for the repair of uterine prolapse

References:[2][5]

Complications

References:[6]

We list the most important complications. The selection is not exhaustive.