Pelvic Organ Prolapse
Pelvic organ prolapse (POP) is a hernia of the pelvic organs to or through the vaginal opening. Approximately 200,000 operations are performed yearly in the United States for POP. Although not life threatening, POP is life altering and results in significant quality of life changes in women.
The pelvic organs (bladder, uterus and rectum) are supported by a complex “hammock” that includes the pelvic muscles, ligaments, 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, mild cases of POP have no symptoms and do not require medical intervention, while more severe cases are generally bothersome to women. Treatment options for POP are limited and include the use of pessaries,surgery or watchful waiting. Disappointing surgical results as well as high recurrence rates after treatment unfortunately have led many women to avoid seeking treatment. Risk factors for the development of POP include difficult vaginal deliveries, family history of POP, obesity, advancing age, prior hysterectomy, and conditions such as chronic constipation or habitual coughing.
Commonly, women with severe POP report feeling or seeing a “ball” or protrusion from the vagina. Women with mild POP may also describe 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. During a routine vaginal exam, the degree of prolapse can be determined. 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 women 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.
Prolapse or support problems can affect one or multiple organs of the pelvis. Weakness of the frontside vaginal wall near the bladder results in a cystocele, often called a “dropped bladder” (Diagram 2). Weakness of the vaginal ceiling results in uterine prolapse, known as an enterocele (Diagram 3). Defects of the backside vaginal wall near the rectum results in a rectocele (Diagram 4).
Diagram 2: Cystocele (prolapsed bladder)
Diagram 3: Uterine prolapse
Diagram 4: Rectocele
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. Pessaries represent the only non-surgical option for managing symptomatic prolapse and may be considered for even severe cases. Pessaries are medical-grade plastic 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 and relieves prolapse symptoms by providing support of the displaced organ(s). Topical estrogen cream is considered helpful in preventing and even treating vaginal ulcers that may develop with pessary use. In addition to topical estrogen, Trimo-San vaginal jelly can be used to lubricate the vagina before using a pessary. Pessaries should be removed and cleaned regularly, depending on amount of vaginal discharge, type of pessary, and patient preference. While vaginal discharge may develop with pessary use, it rarely is associated with an infection and therefore antibiotics are not typically needed. 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 health care provider, e.g. every three months.
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.
Reconstructive surgery is a mainstay of treatment for POP. Approximately 11% of women will have surgery for POP and/or urinary incontinence 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, often related pelvic floor problem.
Prolapse repairs can be done through a vaginal approach, abdominal incision or through a laparoscope (when a scope is placed through the belly button). More recently, robot-assisted procedures are being done for prolapse. Early data on minimally invasive approaches, including the robot and laparoscope, indicate reduced recovery time, shorter hospital stays, and less blood loss for the patient. Because few surgeons are fully trained in the robotic technique, data collection is continuing.
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, open abdominal repairs using graft materials are thought to have higher success rates at the cost of increased morbidity. 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 graft materials (made of synthetic and biologic materials) in attempts to improve long-term success rates. However, little research has been done to prove that this improves results without increasing complications. Research is currently being done to determine if the use of vaginal graft materials in POP surgical repairs is more effective and longer lasting than use of a woman’s own tissue for repair. Since the use of synthetic mesh is relatively new, the FDA is inviting commentary to aid in its oversight of safety considerations. Click here to read the FDA's public health notification on the possible complications associated with using mesh in prolapse repair surgery, and to learn how to report adverse events to the FDA. You may also listen to a podcast by Dr. Marie Fidela Paraiso, urogynecologist at the Cleveland Clinic, on the subject.
For women who never plan on having sexual intercourse again, there are relatively simple surgeries that have nearly a 100% success rate. In these techniques the vagina is shortened so that it can no longer prolapse. After these surgeries, vaginal intercourse is impossible. These techniques are ideally suited for the elderly patient with severe prolapse and multiple medical problems that would otherwise place her at increased risk with an invasive, reconstructive approach.
In a recent study NAFC seeked to identify how pelvic organ prolapase impacts the lives of women. The purpose was to understand the barriers and frustrations that women encounter in seeking diagnosis and intervention.
As the population grows older, the number of women who develop POP will increase. Preventive strategies have yet to be identified and are needed. Some risk factors for POP cannot be changed (such as your family history), but others, including constipation, can. While evidence suggests that women having three or more vaginal deliveries are at two to three times greater risk of POP than others, the risks of cesarean versus vaginal delivery as a prevention strategy remain unsupported by research.