Pelvic Organ Prolapse

• Pelvic organ prolapse


  Weakening or loss of support to the pelvic organs
• Normal structural support of the pelvic organs

  • Complex interaction between the muscles of the pelvic floor and connective tissue attachments to the bony pelvis
  • Network of muscles, fascia, nerves, and ligaments provides support on which the pelvic organs rest
• Damage to any one of the supporting structures


  Can potentially result in weakening or loss of support to the pelvic organs
• Damage to the anterior vaginal wall pubocervical fascia


  • Can result in herniation of the bladder (cystocele) and/or urethra (urethrocele) into the vaginal lumen
• Injuries to the endopelvic fascia of the rectovaginal septum in the posterior vaginal wall


  • Can result in herniation of the rectum (rectocele) into the vaginal lumen
• Injury or stretching of the uterosacral and cardinal ligaments

  • Can result in descensus, or prolapse, of the uterus (uterine prolapse)
• After hysterectomy


  • Women may experience prolapse of the small intestine (enterocele) or the apex of the vagina (vaginal vault prolapse) secondary to loss of support structures upon removal of the uterus and cervix
• Symptoms of pelvic organ prolapse

  • Pelvic pressure and discomfort
  • Dyspareunia
  • Difficulty evacuating the bowels and bladder
  • Low back discomfort
• Pelvic support is most commonly compromised by

  • Pregnancy and subsequent delivery
  • Chronic increases in intra-abdominal pressure from obesity, chronic cough, or chronic heavy lifting
  • Connective tissue disorders
  • Atrophic changes due to aging or estrogen deficiency
• Pelvic relaxation is especially apparent in the postmenopausal population
• Atrophy


  Compromised elasticity, diminished vascular support, and laxity in structural elements
• Tissues become less resilient to forces of gravity and increased intra-abdominal pressure, and accumulative stresses on the pelvic support system take effect
• The reported prevalence of pelvic organ prolapse in population-based surveys ranges from 2.9% to 9%
• Population-based surgical intervention studies report a 11% to 19% lifetime risk for undergoing surgery for symptomatic prolapse
• Previous studies have asserted that lower rates of prolapse are seen in African American women compared to Caucasian women, but this has not been consistently demonstrated in the literature
• Risk factors for pelvic organ prolapse

  • Advancing age
  • Menopause
  • Parity
  • Obstructed labor and traumatic delivery
  • Conditions that result in chronically elevated intra-abdominal pressure (obesity, chronic cough, COPD, chronic constipation, repeat heavy lifting, large pelvic tumors)
  • Surgical history of hysterectomy
• Symptoms that may be manifested in pelvic organ prolapse

  • Vaginal/sexual symptoms (pelvic pressure and/or heaviness, palpable or visible vaginal bulging, backache)
  • Urinary symptoms (urinary frequency, urinary urgency, incomplete/interrupted voiding, difficulty starting urinary stream, urinary incontinence)
  • Bowel symptoms (obstructed defecation, constipation, painful defecation, incomplete defecation, "splinting")
• Pelvic relaxation is best observed

  • By separating the labia and viewing the vagina while the patient strains or coughs
  • Using a split-speculum examination to visualize the anterior vaginal wall, posterior vaginal wall, and apex individually
• Baden-Walker Halfway Scoring System


  Quantifies pelvic organ prolapse using a four-point system with the hymen as a fixed point of reference
• Pelvic Organ Prolapse Quantitative (POP-Q) scale


  Objective, site-specific system for describing, quantifying, and staging pelvic support in women
• The diagnosis of pelvic organ prolapse depends primarily on an accurate history and thorough physical examination
• Other diagnostic tools that may be useful include urine cultures, cystoscopy, urethroscopy, urodynamic studies, anoscopy, sigmoidoscopy, and defecography
• Differential diagnosis for cystocele and urethrocele

  • Urethral diverticula
  • Gartner cysts
  • Skene gland cysts
  • Tumors of the urethra and bladder
• Differential diagnosis for rectocele


  • Obstructive lesions of the colon and rectum (lipomas, fibromas, sarcomas)
• Differential diagnosis for uterine prolapse

  • Cervical elongation
  • Prolapsed cervical polyp
  • Prolapsed uterine fibroid
  • Prolapsed cervical and endometrial tumors
  • Lower uterine segment fibroids
• Differential diagnosis for cystocele and urethrocele

  • Urethral diverticula
  • Gartner cysts
  • Skene gland cysts
  • Tumors of the urethra and bladder
• Differential diagnosis when a rectocele is suspected

  • Obstructive lesions of the colon and rectum (lipomas, fibromas, sarcomas)
  • Cervical elongation
  • Prolapsed cervical polyp
  • Prolapsed uterine fibroid
  • Prolapsed cervical and endometrial tumors
  • Lower uterine segment fibroids
• Pelvic organ prolapse (POP-Q)

  • Six sites (points Aa, Ba, C, D, Bp, Ap), genital hiatus (gh), perineal body (pb), and total vaginal length (tvl) are used to quantify the degree of pelvic organ prolapse
• Prolapse


  Benign condition, further evaluation and treatment is guided by the patient's goals for improvement in her quality of life
• Conservative modalities for prolapse

  1. Kegel exercises to strengthen pelvic floor musculature

  2. Use of pessaries to manage prolapse and associated symptoms

  3. Low-dose vaginal estrogen in postmenopausal women
• Kegel exercises


  Tightening and releasing of the levator ani muscles repeatedly to strengthen the muscles and improve pelvic support
• Pessaries


  Mechanical support devices that replace the lost structural integrity of the pelvis and diffuse the forces of descent over a wider area
• Certain physical characteristics like longer vagina, smaller introitus, and lower weight are associated with more successful pessary placement</b>
• Pessary use requires a highly motivated patient who is willing to accept an intravaginal device and the small risks of pain, ulcerations, bleeding, leukorrhea, and infection
• Surgical treatment options for pelvic organ prolapse

  • Anterior colporrhaphy for cystocele
  • Posterior colporrhaphy for rectocele
  • Vaginal enterocele repair
  • Hysterectomy (abdominal or vaginal) and McCall culdoplasty for uterine prolapse
  • Sacrospinous ligament fixation for vaginal vault prolapse
  • Abdominal sacral colpopexy for vaginal vault prolapse
• Colpocleisis is a vaginal obliterative procedure that closes off the vaginal canal as a means of treating symptomatic pelvic organ prolapse in women who are poor surgical candidates and no longer plan vaginal intercourse
• Colpocleisis is less invasive with a shorter operative time, fewer complications and recurrences and a high patient satisfaction rate