Pelvic Organ Prolapse

Contents

1. How common it is, what gives way and in whom
2. From watching to surgery
3. The vocabulary to bring to a visit

Pelvic reconstruction is among the operations in Candace Cooley’s surgical experience, and prolapse, a condition such surgery repairs, is regularly mistaken for something else. Prolapse and incontinence are two different failures of the same region. Prolapse is a failure of support: the muscles and connective tissue beneath the uterus, bladder or rectum weaken or tear, and one or more of those organs drops into the vagina or presses out of it, according to the Office on Women’s Health.¹ Incontinence is a failure of control, the loss of urine or stool. They belong to one family, the pelvic floor disorders, and they often arrive together, which is why they are confused, but one is about where the organs sit and the other about what they let go.¹

The FDA Office of Women’s Health groups prolapse with leakage of urine or stool and with pelvic pain as the usual pelvic floor disorders, together affecting about one woman in four at some point.² A University of Michigan gynecologist told The Washington Post that prolapse behaves much like a hernia, the organs and vaginal walls pushed out through an opening in the pelvic floor muscles, and that it is more uncomfortable than painful.⁶

How common it is, what gives way and in whom

How common prolapse is depends on whether one counts symptoms or findings. Symptoms are reported by about 3 percent of women in the United States, a lecture on prolapse at Loyola University notes, but an examination finds some loss of support in 41 to 50 percent, and most of those women have no symptoms.³ In a national survey announced by the National Institute of Child Health and Human Development, 2.9 percent of women reported prolapse symptoms, and pelvic floor disorders as a group climbed steeply with age.⁴

Figure

Pelvic floor disorders rise with age

• Ages 20 to 399.7
• Ages 40 to 5926.5
• Ages 60 to 7936.8
• 80 and older49.7

percent

The pelvic organs are held up by three kinds of tissue working together: the levator muscles, sheets of fascia, and ligaments, cardinal and uterosacral among them, the Loyola lecture explains. The old picture was of tissue pulled thin over the years; the current one emphasizes rips at particular places, each leaving a gap in support that an examiner can find.³ The name of a prolapse follows the organ. A dropped uterus is uterine prolapse; the bladder bulging into the front wall is a cystocele; the rectum pressing into the back wall is a rectocele; small bowel herniating at the top is an enterocele; a detached urethra is a urethrocele.³

Vaginal childbirth is the commonest risk factor. In 10 to 15 percent of vaginal deliveries, the Post reported, the muscle’s attachment to the pelvic side wall tears, and most women notice nothing until years later, when age weakens what remains.⁶ The Office on Women’s Health lists the main risk factors: vaginal birth, especially several of them, or a baby heavier than eight and a half pounds; long term pressure on the abdomen from obesity, chronic coughing or straining; aging; the loss of estrogen at menopause; and family history. Prolapse can still occur in women who have never given birth or who delivered by cesarean.¹ Heavy lifting and the use of forceps add risk,⁶ and a past hysterectomy or earlier prolapse surgery is linked to higher risk as well.²

The condition is old. References appear in Egyptian hieroglyphics and medieval woodcuts, and remedies through the centuries included fumigating the abdomen with herbs and shaking a woman tied upside down to a ladder.⁶

From watching to surgery

Symptoms follow from the loss of support: seeing or feeling a bulge, pressure or aching in the pelvis that worsens with standing, coughing or as the day goes on, leaking urine, trouble with bowel movements and difficulty inserting tampons.¹ A physical therapist on NPR’s Life Kit added that women often first notice a bulge at the vaginal opening while washing, and that a prolapse can trap urine or stool so emptying feels incomplete.⁷

The examination maps each site of support, and the standard tool, the Pelvic Organ Prolapse Quantification system, measures six points in the vagina against the hymen to assign a stage from 0 to IV.³

Figure

Stages of prolapse on the POP Q exam

1. 01
   Stage 0No prolapse.
2. 02
   Stage IThe leading edge stays more than 1 cm above the hymen.
3. 03
   Stage IIThe leading edge lies within 1 cm above or below the hymen.
4. 04
   Stage IIIThe leading edge passes more than 1 cm beyond the hymen, short of full eversion.
5. 05
   Stage IVComplete eversion of the vagina.

Treatment depends on the type of prolapse, the symptoms, age, other health problems and whether a woman is sexually active.¹ Because findings on examination often do not match symptoms and dangerous complications such as blocked ureters are rare, simply watching is a legitimate choice.³ A pessary, a removable device placed in the vagina to hold the organs up, is often the first treatment tried, and pelvic floor muscle exercises can strengthen support and help with leakage as well.¹ Pessaries come in many shapes and sizes, and certain designs treat leakage as well as prolapse.² For less advanced cases, the Post reported, physical therapy can reduce symptoms; the approach is described under physical rehabilitation of the pelvic floor.⁶ Day to day measures matter too. The Office on Women’s Health suggests keeping a healthy weight, eating enough fiber to avoid constipation and straining, and not smoking, since a chronic cough loads the pelvic floor.¹

Left alone, a prolapse does not always stay small. The Post described prolapses that grow to the size of a grapefruit, become painful when the organs pull on ligaments attached to the sacrum, and, rarely, block the tubes that carry urine from the kidneys. Many women give up running, jumping and lifting because activity worsens the bulge, and some avoid intimacy.⁶ The lecture lists ulceration, bleeding and thickening of the exposed cervix among the signs that push a decision toward treatment.³

Surgery rebuilds support or closes the space, and the Office on Women’s Health describes reconstruction as the choice for sexually active women with serious prolapse of the vagina or uterus. Repairs can use a woman’s own tissue or synthetic mesh, and can be done through the vagina or the abdomen; the FDA has strengthened its safety requirements for mesh placed through the vagina to repair prolapse.¹ An obliterative operation, colpocleisis, closes the vaginal opening and suits women who no longer have or plan vaginal intercourse.¹ Some 320,000 operations a year treat pelvic floor disorders in the United States, about 200,000 of them for prolapse.⁶

Repair can unmask a second problem. Women without leakage before vaginal prolapse surgery can develop it afterward, and a multicenter trial summarized by UroToday tested a preventive midurethral sling placed during the repair. The sling lowered incontinence at 3 and 12 months but brought more bladder perforations, urinary infections, bleeding and trouble emptying.⁵

Figure

Adding a sling during vaginal prolapse surgery

	Midurethral sling	Sham incisions
Incontinence or its treatment at 3 months	23.6%	49.4%
Incontinence at 12 months	27.3%	43.0%
Bladder perforation	6.7%	0%
Urinary tract infection	31.0%	18.3%
Major bleeding complications	3.1%	0%

The vocabulary to bring to a visit

A short list of terms makes the conversation easier to follow. Whether to watch, use a pessary, strengthen the muscles or operate is a choice that belongs to each woman and her own clinician, and these words simply describe the ground.

Pelvic organ prolapse. Descent of the uterus, bladder, rectum or bowel into or out of the vagina because support has weakened.¹

Cystocele, rectocele, enterocele. Prolapse of the bladder, the rectum and the small bowel, named for the organ that moves.³

POP Q stage. The number from 0 to IV that records how far the leading edge reaches relative to the hymen.³

Pessary. A removable support device worn in the vagina, made in many shapes and sizes; some types treat leakage as well.²

Tissue repair and mesh repair. Surgery that rebuilds support with a woman’s own tissue or with synthetic mesh.¹

Colpocleisis. An operation that closes the vaginal canal to hold organs in place.¹

Leakage after repair. Incontinence that appears only once a prolapse is corrected, the reason a sling is sometimes discussed at the same operation, as the entry on stress urinary incontinence explains.⁵