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Pelvic organ prolapse is a condition that may develop in women whose pelvic organs are not properly supported. The support is provided by the female pelvic floor: a hammock-like area made-up of muscles, ligaments and connective tissue. A lack of proper support results in sagging, dropping or bulging of the organs into the vaginal canal and can progress to a protrusion outside of the vagina.

Specific names are given depending upon what anatomic area of the vagina is relaxed or bulging. For example, a cystocele refers to the bladder bulging into vagina. A rectocele refers to the rectum bulging into the vagina. Uterine prolapse occurs when the uterus drops down from its normal position. If the uterus has been removed (hysterectomy) and the top of the vagina is dropping, this is called vaginal vault prolapse. Enterocele is a bulge into the vagina which contains small intestine. There are various degrees of the extent or size of prolapse which are measured during a pelvic exam and staged from 0 – 4 (0=well supported, 4=poorest support/external bulge). The stage is based upon the measurement of how “dropped” the areas of the vagina are compared with normal position.

Artist's rendition: progression of a rectocele

 

Symptoms of Pelvic Organ Prolapse (POP)

Symptoms may include:

• Pelvic or vaginal pressure
• A sensation of fullness in the vagina
• A sensation of sitting on a ball
• Low back discomfort, especially after standing
• Difficultly urinating – slowed stream, trouble starting the stream and/or a sensation of not completely emptying the bladder
• Difficulty defecating – sometimes women need to “splint” or press on the area between the vaginal opening and the anus (the perineum) or place a finger in the vagina to assist with completing a bowel movement
• Difficulty with intercourse – for one or both partners
• Feeling the presence of a ball protruding from the vagina when washing or wiping
• Irritation or ulceration of the protruding vaginal skin from contact with clothing or pads
• Urinary incontinence can sometimes be masked or hidden by prolapse (women may report no leakage with coughing or activity presently but recall that before the bulge they used to leak with activity)
• No symptoms – pelvic organ prolapse will sometimes not cause any symptoms and may first be detected by your healthcare provider during a routine examination.

Causes of Pelvic Organ Prolapse (POP)

Childbirth is commonly thought to be a leading cause of injury to the pelvic floor which may eventually lead to POP (vaginal delivery more so than cesarean delivery, higher number of deliveries more so than lesser). However, women who have never been pregnant may also develop POP. Many other factors can contribute to the occurrence, progression and/or severity of POP and its associated symptoms.

Factors that increase risk of pelvic organ prolapse:

• Increased age
• Race/Ethnicity (Caucasian & Latina higher risk than African American)
• Prior hysterectomy or prolapse surgery
• Heredity / genetics (can run in families)
• Increased joint flexibility / Connective tissue disorders
• Smoking
• Conditions & behaviors which increase pressure placed on the pelvic floor
  • Obesity
  • Chronic coughing (associated with asthma, smoking, COPD, GERD)
  • Chronic heavy lifting
  • High impact activities
  • Straining due to constipation

Treatment of pelvic organ prolapse:

Controlling factors suspect to worsen prolapse and increasing healthy pelvic habits is the best first step. This would include stopping smoking, losing weight, keeping bowel movements soft and easy to pass, avoiding lifting heavy objects and strengthening the pelvic floor muscles. If there are no bothersome symptoms, pelvic organ prolapse can simply be monitored over time at routine yearly examinations.

When symptoms are bothersome, treatment options offered will be done with consideration of several things:

• Age
• General health
• Desire for future pregnancy
• Stage of prolapse & symptom severity
• If the prolapse is a recurrence
• Current/future sexual activity
• Presence of urinary incontinence

Treatment options include:

• Pelvic floor muscle exercises (Kegels) and core-strengthening exercises – will not change the bulge size but may help with symptoms and progression of mild to moderate POP by strengthening these muscles
• Pessaries – flexible devices made of silicone which are placed temporarily in the vagina to hold-up or support the bulging areas. Pessaries must be removed and cleaned regularly either by a healthcare provider or the patient herself.
• Surgery – there are several surgical options for the correction of pelvic organ prolapse. Before you elect to have an operation, your surgeon will discuss which procedure(s) he recommends for you and why. Options for repair are:
  • Vaginal surgery
  • Abdominal surgery
  • Combined abdominal /vaginal
  • Laparoscopic surgery
  • Robotic surgery

Future of pelvic organ prolapse:

It is projected that the number of women with pelvic organ prolapse will increase 46%, from 3.3 million to 4.9 million between the years 2010 and 2050. Research is ongoing and advancing the depth and breadth of knowledge in the area of pelvic floor dysfunction.