Pelvic organ prolapse

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 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.

• 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: pelvic organs are only partially outside the vaginal opening.
  • Total prolapse: pelvic organs are everted and located outside of the vaginal opening.
• Specific sites
  • Vaginal wall prolapse
    • 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
  • Apical compartment prolapse: herniated uterus, cervix, or vaginal vault
  • Uterine procidentia: protrusion of all vaginal walls or cervix beyond the vaginal introitus

• POP is a common disorder in older women.

Epidemiological data refers to the US, unless otherwise specified.

Risk factors ^[1]

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:

• Multiple vaginal deliveries and/or traumatic births (greatest risk factor)
• Low estrogen levels; (e.g., during menopause)
• Increased intraabdominal pressure; (e.g., obesity, cough related to chronic lung disease and/or smoking, ascites, pelvic tumors, constipation)
• Previous pelvic surgery (e.g., hysterectomy)
• Congenital connective tissue disorders
• Diabetes mellitus

• Feeling of pressure on or discomfort around the perineum (“sensation of vaginal fullness”) ^[2]
• Lower back and pelvic pain (may become worse with prolonged standing or walking)
• Rectal fullness, constipation, incomplete rectal emptying
• Prolapse of the anterior (most common) or the posterior vaginal wall
  • Occurs at rest and with increased abdominal pressure
  • Possibly with excessive vaginal discharge on inspection, bimanual examination, and speculum examination of the patient in lithotomy position
• Weakened pelvic floor muscle and anal sphincter tone

Patients with POP may present with concurrent complications.

• Usually a clinical diagnosis relying on the Pelvic Organ Prolapse Quantitation system (POP-Q) ^[2][3]
  • 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.

Elongation of the cervix

• An elongated cervix can be mistaken for a prolapse.
• Evaluated during pelvic examination

Urethral diverticulum ^[4]

• Definition: a distinct outpouching of the urethral mucosa most often located posterolaterally in the mid and distal two-thirds of the urethra
• Epidemiology
  • Rare
  • Most commonly occurs in women (20–60 years of age)
• Etiology
  • Acquired (most common)
    • Recurrent infection of the periurethral glands
    • Pelvic trauma (particularly involving the vagina, bladder, or urethra)
    • Gynecological surgery, periurethral procedures
    • Vaginal delivery
  • Congenital
• Clinical features
  • Dysuria
  • Dyspareunia
  • Urinary incontinence (particularly, postvoid dribbling of urine)
  • Tender anterior vaginal wall mass during pelvic examination
• Diagnostics
  • MRI
  • Transvaginal ultrasound if MRI is not available/feasible
  • Urinalysis to evaluate for other conditions (e.g., urinary tract infection or malignancy)
• Differential diagnosis
  • Skene duct cyst
    • A retention cyst that results from obstruction, accumulation of fluid, and cystic dilation of the ducts that drain the paraurethral glands.
    • Manifests with dysuria, dyspareunia, and urinary overflow incontinence.
    • Pelvic examination typically shows masses located just lateral to the external urethral meatus.
• Treatment
  • Conservative management
    • Indicated for individuals with minor symptoms
    • Manual compression of the suburethral mass after voiding
  • Surgery
    • Indicated for individuals with persistent symptoms, urinary calculi in the diverticulum, or suspicion of malignancy
    • Transvaginal diverticulectomy: is a preferred procedure

Pelvic floor dysfunction ^[5]

• Definition: inability to relax and coordinate pelvic floor muscles correctly in order to urinate and/or have bowel movements
• Risk factors: See “Etiology” above.
• Clinical features
  • Urinary incontinence, urgency, and/or dysuria
  • Fecal incontinence
  • Dyssynergic defecation
  • Dyspareunia
  • Lower back or pelvic pain
  • Feeling of pressure on the pelvic region or rectum
  • Pelvic muscle spasms
• Diagnostics
  • Clinical features and physical examination
  • Pelvic ultrasound
  • Urodynamic studies
  • Anorectal manometry
• Treatment
  • Pelvic floor muscle training (e.g., Kegel exercises) and physical therapy
  • Biofeedback and electrical stimulation: probes or electrodes are placed externally or inserted into the vagina or rectum to stimulate the pelvic floor muscles
  • Stool softeners and muscle relaxants

The differential diagnoses listed here are not exhaustive.

Conservative treatment ^[2]

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
  • A silicone or latex device that is inserted into the vagina
  • Pessary insertion is not a long-term treatment!
• 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 ^[6]

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

• Obliterative surgery: colpocleisis in which 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: 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

• Pressure ulcers with hemorrhage
• Ascending infections
• Urinary disorders ^[7]
  • Stress incontinence
  • "Masked" urinary incontinence
  • Obstructive uropathy
• Defecation disorders (e.g., constipation or fecal incontinence if the anal sphincter is weakened)
• Sexual dysfunction
• Surgical complications (e.g., recurrence)

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