Pelvic organ prolapse

Last updated
Pelvic organ prolapse
Other namesFemale genital prolapse
Uterine prolapse - standing.jpg
A 40 year old woman with uterine prolapse, which is visible only in standing position, with the cervix protruding through the vulva.
Specialty Gynecology
Frequency316 million women (9.3% as of 2010) [1]

Pelvic organ prolapse (POP) is characterized by descent of pelvic organs from their normal positions into the vagina. In women, the condition usually occurs when the pelvic floor collapses after gynecological cancer treatment, childbirth or heavy lifting. [2] Injury incurred to fascia membranes and other connective structures can result in cystocele, rectocele or both. Treatment can involve dietary and lifestyle changes, physical therapy, or surgery. [3]

Contents

Types

A cystocele protruding through the vagina in a 73 year old woman. Cystocele.jpg
A cystocele protruding through the vagina in a 73 year old woman.
Large rectocele. The diagnosis and treatment of diseases of women (1907) (14597977337).jpg
Large rectocele.
Uterine prolapse in a 71 year old woman, with the cervix visible in the vaginal orifice. Uterine prolapse.jpg
Uterine prolapse in a 71 year old woman, with the cervix visible in the vaginal orifice.

Grading

Pelvic organ prolapses are graded either via the Baden–Walker System, Shaw's System, or the Pelvic Organ Prolapse Quantification (POP-Q) System. [6]

Shaw's System

Anterior wall

Posterior wall

Uterine prolapse

Baden–Walker

Baden–Walker System [7] for the Evaluation of Pelvic Organ Prolapse on Physical Examination
GradePosterior urethral descent, lowest part other sites
0normal position for each respective site
1descent halfway to the hymen
2descent to the hymen
3descent halfway past the hymen
4maximum possible descent for each site

POP-Q

Pelvic Organ Prolapse Quantification System (POP-Q)
StageDescription
0No prolapse anterior and posterior points are all −3 cm, and C or D is between −TVL and −(TVL−2) cm.
1The criteria for stage 0 are not met, and the most distal prolapse is more than 1 cm above the level of the hymen (less than −1 cm).
2The most distal prolapse is between 1 cm above and 1 cm below the hymen (at least one point is −1, 0, or +1).
3The most distal prolapse is more than 1 cm below the hymen but no further than 2 cm less than TVL.
4Represents complete procidentia or vault eversion; the most distal prolapse protrudes to at least (TVL−2) cm.

Management

Vaginal prolapses are treated according to the severity of symptoms.

Non-surgical

With conservative measures, such as changes in diet and fitness, Kegel exercises, and pelvic floor physical therapy. [8]

A pessary, a rubber or silicone rubber device fitted to the patient is also a non-surgical option, it is inserted into the vagina and may be retained for up to several months. Vaginal pessaries can immediately relieve prolapse and prolapse-related symptoms. [9] Pessaries are a good choice of treatment for women who wish to maintain fertility, are poor surgical candidates, or who may not be able to attend physical therapy. [10] Pessaries require a provider to fit the device, but most can be removed, cleaned, and replaced by the woman herself; however, others have this done for them by a clinician biannually. A trial compared the two approaches and found that, compared with clinic-based care, self-management was associated with a similar quality of life, fewer complications, and was more cost-effective. [11] [12] Pessaries should be offered as a non-surgical alternative for women considering surgery.

Surgery

Surgery (for example native tissue repair, biological graft repair, absorbable and non-absorbable mesh repair, colpopexy, or colpocleisis) is used to treat symptoms such as bowel or urinary problems, pain, or a prolapse sensation. When operating a pelvic organ prolapse, introducing a mid-urethral sling during or after surgery seems to reduce stress urinary incontinence. [13] Transvaginal repair seems to be more effective than transanal repair in posterior wall prolapse, but adverse effects cannot be excluded. [14] According to the FDA, serious complications are "not rare." [15]

Evidence does not support the use of transvaginal surgical mesh compared with native tissue repair for anterior compartment prolapse owing to increased morbidity. [16] For posterior vaginal repair, the use of mesh or graft material does not seem to provide any benefits. [14]

Compared to native tissue repair, transvaginal permanent mesh likely reduces both the perception of vaginal prolapse sensation, and the risk of recurrent prolapse and of having repeat surgery for prolapse. However, transvaginal mesh (TVM) has a greater risk of bladder injury and of needing repeat surgery for stress urinary incontinence or mesh exposure. [17] Also, the use of a TVM in treating vaginal prolapses is associated with side effects including pain, infection, and organ perforation.

Safety and efficacy of many newer meshes is unknown. [16] Thousands of class action lawsuits have been filed and settled against several manufacturers of TVM devices. [18]

For surgical treatment of apical vaginal prolapse, going through the abdomen (sacral colpopexy) may have better outcomes than a surgical approach that goes through the vagina. [5]

Epidemiology

Genital prolapse occurs in about 316 million women worldwide as of 2010 (9.3% of all females). [1]

Research

To study POP, various animal models are employed: non-human primates, sheep, [19] [20] pigs, rats, and others. [21] [22]

See also

Related Research Articles

In medicine, prolapse is a condition in which organs fall down or slip out of place. It is used for organs protruding through the vagina, rectum, or for the misalignment of the valves of the heart. A spinal disc herniation is also sometimes called "disc prolapse". Prolapse means "to fall out of place", from the Latin prolabi meaning "to fall out".

<span class="mw-page-title-main">Hysterectomy</span> Surgical removal of the uterus

Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. The term “partial” or “total” hysterectomy are lay-terms that incorrectly describe the addition or omission of oophorectomy at the time of hysterectomy. These procedures are usually performed by a gynecologist. Removal of the uterus renders the patient unable to bear children and has surgical risks as well as long-term effects, so the surgery is normally recommended only when other treatment options are not available or have failed. It is the second most commonly performed gynecological surgical procedure, after cesarean section, in the United States. Nearly 68 percent were performed for conditions such as endometriosis, irregular bleeding, and uterine fibroids. It is expected that the frequency of hysterectomies for non-malignant indications will continue to fall given the development of alternative treatment options.

A pessary is a prosthetic device inserted into the vagina for structural and pharmaceutical purposes. It is most commonly used to treat stress urinary incontinence to stop urinary leakage and to treat pelvic organ prolapse to maintain the location of organs in the pelvic region. It can also be used to administer medications locally in the vagina or as a method of contraception.

<span class="mw-page-title-main">Pelvic floor</span> Anatomical structure

The pelvic floor or pelvic diaphragm is an anatomical location in the human body, which has an important role in urinary and anal continence, sexual function and support of the pelvic organs. The pelvic floor includes muscles, both skeletal and smooth, ligaments and fascia. and separates between the pelvic cavity from above, and the perineum from below. It is formed by the levator ani muscle and coccygeus muscle, and associated connective tissue.

<span class="mw-page-title-main">Rectocele</span> Bulging of the rectum into the vaginal wall

In gynecology, a rectocele or posterior vaginal wall prolapse results when the rectum bulges (herniates) into the vagina. Two common causes of this defect are childbirth and hysterectomy. Rectocele also tends to occur with other forms of pelvic organ prolapse, such as enterocele, sigmoidocele and cystocele.

Vaginoplasty is any surgical procedure that results in the construction or reconstruction of the vagina. It is a type of genitoplasty. Pelvic organ prolapse is often treated with one or more surgeries to repair the vagina. Sometimes a vaginoplasty is needed following the treatment or removal of malignant growths or abscesses to restore a normal vaginal structure and function. Surgery to the vagina is done to correct congenital defects to the vagina, urethra and rectum. It may correct protrusion of the urinary bladder into the vagina (cystocele) and protrusion of the rectum (rectocele) into the vagina. Often, a vaginoplasty is performed to repair the vagina and its attached structures due to trauma or injury.

<span class="mw-page-title-main">Pelvic floor dysfunction</span> Medical condition

Pelvic floor dysfunction is a term used for a variety of disorders that occur when pelvic floor muscles and ligaments are impaired. The condition affects up to 50 percent of women who have given birth. Although this condition predominantly affects women, up to 16 percent of men are affected as well. Symptoms can include pelvic pain, pressure, pain during sex, urinary incontinence (UI), overactive bladder, bowel incontinence, incomplete emptying of feces, constipation, myofascial pelvic pain and pelvic organ prolapse. When pelvic organ prolapse occurs, there may be visible organ protrusion or a lump felt in the vagina or anus. Research carried out in the UK has shown that symptoms can restrict everyday life for women. However, many people found it difficult to talk about it and to seek care, as they experienced embarrassment and stigma.

<span class="mw-page-title-main">Cystocele</span> Medical condition

The cystocele, also known as a prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms. Others may have trouble starting urination, urinary incontinence, or frequent urination. Complications may include recurrent urinary tract infections and urinary retention. Cystocele and a prolapsed urethra often occur together and is called a cystourethrocele. Cystocele can negatively affect quality of life.

<span class="mw-page-title-main">Stress incontinence</span> Form of urinary incontinence from an inadequate closure of the bladder

Stress incontinence, also known as stress urinary incontinence (SUI) or effort incontinence is a form of urinary incontinence. It is due to inadequate closure of the bladder outlet by the urethral sphincter.

<span class="mw-page-title-main">Uterine prolapse</span> Medical condition

Uterine prolapse is a form of pelvic organ prolapse in which the uterus and a portion of the upper vagina protrude into the vaginal canal and, in severe cases, through the opening of the vagina. It is most often caused by injury or damage to structures that hold the uterus in place within the pelvic cavity. Symptoms may include vaginal fullness, pain with sexual intercourse, difficulty urinating, and urinary incontinence. Risk factors include older age, pregnancy, vaginal childbirth, obesity, chronic constipation, and chronic cough. Prevalence, based on physical exam alone, is estimated to be approximately 14%.

A urethrocele is the prolapse of the female urethra into the vagina. Weakening of the tissues that hold the urethra in place may cause it to protrude into the vagina. Urethroceles often occur with cystoceles. In this case, the term used is cystourethrocele.

Colporrhaphy is a surgical procedure in women that repairs a defect in the wall of the vagina. It is the surgical intervention for both cystocele and rectocele.

Urogynecology or urogynaecology is a surgical sub-specialty of urology and gynecology.

Obstructed defecation syndrome is a major cause of functional constipation, of which it is considered a subtype. It is characterized by difficult and/or incomplete emptying of the rectum with or without an actual reduction in the number of bowel movements per week. Normal definitions of functional constipation include infrequent bowel movements and hard stools. In contrast, ODS may occur with frequent bowel movements and even with soft stools, and the colonic transit time may be normal, but delayed in the rectum and sigmoid colon.

<span class="mw-page-title-main">Surgical mesh</span> Material used in surgery

Surgical mesh is a medical implant made of loosely woven mesh, which is used in surgery as either a permanent or temporary structural support for organs and other tissues. Surgical mesh can be made from both inorganic and biological materials and is used in a variety of surgeries, although hernia repair is the most common application. It can also be used for reconstructive work, such as in pelvic organ prolapse or to repair physical defects created by extensive resections or traumatic tissue loss.

The Pelvic Organ Prolapse Quantifications System (POP-Q) is a system for assessing the degree of prolapse of pelvic organs to help standardize diagnosing, comparing, documenting, and sharing of clinical findings. This assessment is the most frequently used among research publications related to pelvic organ prolapse.

A urogenital fistula is an abnormal tract that exists between the urinary tract and bladder, ureters, or urethra. A urogenital fistula can occur between any of the organs and structures of the pelvic region. A fistula allows urine to continually exit through and out the urogenital tract. This can result in significant disability, interference with sexual activity, and other physical health issues, the effects of which may in turn have a negative impact on mental or emotional state, including an increase in social isolation. Urogenital fistulas vary in etiology. Fistulas are usually caused by injury or surgery, but they can also result from malignancy, infection, prolonged and obstructed labor and deliver in childbirth, hysterectomy, radiation therapy or inflammation. Of the fistulas that develop from difficult childbirth, 97 percent occur in developing countries. Congenital urogenital fistulas are rare; only ten cases have been documented. Abnormal passageways can also exist between the vagina and the organs of the gastrointestinal system, and these may also be termed fistulas.

Vaginal rugae are structures of the vagina that are transverse ridges formed out of the supporting tissues and vaginal epithelium in females. Some conditions can cause the disappearance of vaginal rugae and are usually associated with childbirth and prolapse of pelvic structures. The rugae contribute to the resiliency and elasticity of the vagina and its ability to distend and return to its previous state. These structures not only allow expansions and an increase in surface area of the vaginal epithelium, they provide the space necessary for the vaginal microbiota. The shape and structure of the rugae are supported and maintained by the lamina propria of the vagina and the anterior and posterior rugae.

<span class="mw-page-title-main">Vaginal cysts</span> Benign growths of the vaginal epithelium

Vaginal cysts are uncommon benign cysts that develop in the vaginal wall. The type of epithelial tissue lining a cyst is used to classify these growths. They can be congenital. They can present in childhood and adulthood. The most common type is the squamous inclusion cyst. It develops within vaginal tissue present at the site of an episiotomy or other vaginal surgical sites. In most instances they do not cause symptoms and present with few or no complications. A vaginal cyst can develop on the surface of the vaginal epithelium or in deeper layers. Often, they are found by the woman herself and as an incidental finding during a routine pelvic examination. Vaginal cysts can mimic other structures that protrude from the vagina such as a rectocele and cystocele. Some cysts can be distinguished visually but most will need a biopsy to determine the type. Vaginal cysts can vary in size and can grow as large as 7 cm. Other cysts can be present on the vaginal wall though mostly these can be differentiated. Vaginal cysts can often be palpated (felt) by a clinician. Vaginal cysts are one type of vaginal mass, others include cancers and tumors. The prevalence of vaginal cysts is uncertain since many go unreported but it is estimated that 1 out of 200 women have a vaginal cyst. Vaginal cysts may initially be discovered during pregnancy and childbirth. These are then treated to provide an unobstructed delivery of the infant. Growths that originate from the urethra and other tissue can present as cysts of the vagina.

Transvaginal mesh, also known as vaginal mesh implant, is a net-like surgical tool that is used to treat pelvic organ prolapse (POP) and stress urinary incontinence (SUI) among female patients. The surgical mesh is placed transvaginally to reconstruct weakened pelvic muscle walls and to support the urethra or bladder.

References

  1. 1 2 Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. (December 2012). "Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010". Lancet. 380 (9859): 2163–2196. doi:10.1016/S0140-6736(12)61729-2. PMC   6350784 . PMID   23245607.
  2. ↑ Ramaseshan AS, Felton J, Roque D, Rao G, Shipper AG, Sanses TV (April 2018). "Pelvic floor disorders in women with gynecologic malignancies: a systematic review". International Urogynecology Journal. 29 (4): 459–476. doi:10.1007/s00192-017-3467-4. PMC   7329191 . PMID   28929201.
  3. ↑ "Pelvic organ prolapse". womenshealth.gov. 2017-05-03. Retrieved 2017-12-29.
  4. ↑ Donita D (2015-02-10). Health & physical assessment in nursing. Barbarito, Colleen (3rd ed.). Boston. p. 665. ISBN   978-0-13-387640-6. OCLC   894626609.{{cite book}}: CS1 maint: location missing publisher (link)
  5. 1 2 Maher C, Yeung E, Haya N, Christmann-Schmid C, Mowat A, Chen Z, Baessler K (2023-07-26). "Surgery for women with apical vaginal prolapse". The Cochrane Database of Systematic Reviews. 2023 (7): CD012376. doi:10.1002/14651858.CD012376.pub2. ISSN   1469-493X. PMC  10370901. PMID   37493538.
  6. ↑ ACOG Committee on Practice Bulletins—Gynecology (September 2007). "ACOG Practice Bulletin No. 85: Pelvic organ prolapse". Obstetrics and Gynecology. 110 (3): 717–729. doi: 10.1097/01.AOG.0000263925.97887.72 . PMID   17766624.
  7. ↑ Beckley I, Harris N (2013-03-26). "Pelvic organ prolapse: a urology perspective". Journal of Clinical Urology. 6 (2): 68–76. doi:10.1177/2051415812472675. S2CID   75886698.
  8. ↑ "Kegel Exercises | NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 2017-12-02.
  9. ↑ Boyd S, Propst K, O'Sullivan D, Tulikangas P (March 2019). "25: Pessary use and severity of pelvic organ prolapse over time: a retrospective study". American Journal of Obstetrics and Gynecology. 220 (3): S723. doi: 10.1016/j.ajog.2019.01.055 . ISSN   0002-9378. S2CID   86740242.
  10. ↑ Tulikangas P, et al. (Committee on Practice Bulletins—Gynecology and the American Urogynecologic Society) (April 2017). "Practice Bulletin No. 176: Pelvic Organ Prolapse". Obstetrics and Gynecology. 129 (4): e56–e72. doi:10.1097/aog.0000000000002016. PMID   28333818. S2CID   46882949.
  11. ↑ Hagen S, Kearney R, Goodman K, Best C, Elders A, Melone L, Dwyer L, Dembinsky M, Graham M, Agur W, Breeman S, Culverhouse J, Forrest A, Forrest M, Guerrero K (December 2023). "Clinical effectiveness of vaginal pessary self-management vs clinic-based care for pelvic organ prolapse (TOPSY): a randomised controlled superiority trial". eClinicalMedicine. 66: 102326. doi:10.1016/j.eclinm.2023.102326. ISSN   2589-5370. PMC   10701109 . PMID   38078194.
  12. ↑ "Pelvic organ prolapse: self-management of pessaries can be a good option". NIHR Evidence. 11 April 2024. doi:10.3310/nihrevidence_62718.
  13. ↑ Baessler K, Christmann-Schmid C, Maher C, Haya N, Crawford TJ, Brown J (19 August 2018). "Surgery for women with pelvic organ prolapse with or without stress urinary incontinence". Cochrane Database Syst Rev. 2018 (8): CD013108. doi:10.1002/14651858.CD013108. PMC   6513383 . PMID   30121956.
  14. 1 2 Mowat A, Maher D, Baessler K, Christmann-Schmid C, Haya N, Maher C (5 March 2018). "Surgery for women with posterior compartment prolapse". Cochrane Database Syst Rev. 2018 (3): CD012975. doi:10.1002/14651858.CD012975. PMC   6494287 . PMID   29502352.
  15. ↑ "UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse: FDA Safety Communication". U.S. Food and Drug Administration. 13 July 2011. Retrieved 23 June 2015.
  16. 1 2 Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Brown J (November 2016). "Surgery for women with anterior compartment prolapse". The Cochrane Database of Systematic Reviews. 2017 (11): CD004014. doi:10.1002/14651858.CD004014.pub6. PMC   6464975 . PMID   27901278.
  17. ↑ Yeung E, Baessler K, Christmann-Schmid C, Haya N, Chen Z, Wallace SA, Mowat A, Maher C (2024-03-13). "Transvaginal mesh or grafts or native tissue repair for vaginal prolapse". The Cochrane Database of Systematic Reviews. 2024 (3): CD012079. doi:10.1002/14651858.CD012079.pub2. ISSN   1469-493X. PMC  10936147. PMID   38477494.
  18. ↑ Michelle Llamas, BCPA (2022-11-11). "Transvaginal Mesh Lawsuits". drugwatch. Retrieved 2023-01-16.
  19. ↑ Patnaik SS, Brazile B, Dandolu V, Damaser M, van der Vaart CH, Liao J. "Sheep as an animal model for pelvic organ prolapse and urogynecological research" (PDF). ASB 2015 Annual Conference 2015. Archived from the original (PDF) on 2019-03-27. Retrieved 2019-03-26.
  20. ↑ Patnaik SS (2015). Investigation of sheep reproductive tract as an animal model for pelvic organ prolapse and urogyencological research. Mississippi State University.
  21. ↑ Couri BM, Lenis AT, Borazjani A, Paraiso MF, Damaser MS (May 2012). "Animal models of female pelvic organ prolapse: lessons learned". Expert Review of Obstetrics & Gynecology. 7 (3): 249–260. doi:10.1586/eog.12.24. PMC   3374602 . PMID   22707980.
  22. ↑ Patnaik SS (2016). Chapter Six - Pelvic Floor Biomechanics From Animal Models. Academic Press. pp. 131–148. doi:10.1016/B978-0-12-803228-2.00006-4.
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