Pelvic Organ Prolapse

Pelvic organ prolapse refers to the descent of pelvic organs into the vagina. Prolapse is the result of weakness and lengthening of the ligaments and muscles surrounding the uterusrectum and bladder

 

Uterine Prolapse

Uterine prolapse is where the uterus itself descends into the vagina.

 

Vault Prolapse

Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina. 

 

Rectocele

Rectoceles are caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina. Rectoceles are particularly associated with constipation. Women can develop faecal loading in the part of the rectum that has prolapsed into the vagina. Loading of faeces results in significant constipationurinary retention (due to compression on the urethra) and a palpable lump in the vagina. Women may use their fingers to press the lump backwards, correcting the anatomical position of the rectum, and allowing them to open their bowels. 

 

Cystocele

Cystoceles are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. Prolapse of the urethra is also possible (urethrocele). Prolapse of both the bladder and the urethra is called a cystourethrocele.

 

Risk Factors

Pelvic organ prolapse is the result of weak and stretched muscles and ligaments. The factors that can contribute to this include:

  • Multiple vaginal deliveries
  • Instrumental, prolonged or traumatic delivery
  • Advanced age and postmenopause status
  • Obesity
  • Chronic respiratory disease causing coughing
  • Chronic constipation causing straining

 

Presentation

Typical presenting symptoms are:

  • A feeling of “something coming down” in the vagina
  • A dragging or heavy sensation in the pelvis 
  • Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
  • Bowel symptoms, such as constipation, incontinence and urgency
  • Sexual dysfunction, such as pain, altered sensation and reduced enjoyment

Women may have identified a lump or mass in the vagina, and often will already be pushing it back up themselves. They may notice the prolapse will become worse on straining or bearing down. 

 

Examination

Ideally, the patient should empty their bladder and bowel before examination of a prolapse. When examining for pelvic organ prolapse, various positions may be attempted, including the dorsal and left lateral position. 

A Sim’s speculum is a U-shaped, single-bladed speculum that can be used to support the anterior or posterior vaginal wall while the other vaginal walls are examined. It is held on the anterior wall to examine for a rectocele, and the posterior wall for a cystocele. 

The women can be asked to cough or “bear down” to assess the full descent of the prolapse. 

 

Grades of Uterine Prolapse

The severity of a uterine prolapse can be graded using the pelvic organ prolapse quantification (POP-Q) system:

  • Grade 0: Normal
  • Grade 1: The lowest part is more than 1cm above the introitus
  • Grade 2: The lowest part is within 1cm of the introitus (above or below)
  • Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
  • Grade 4: Full descent with eversion of the vagina

A prolapse extending beyond the introitus can be referred to as uterine procidentia.

 

Management

There are three options for management:

  1. Conservative management
  2. Vaginal pessary
  3. Surgery

 

Conservative management is appropriate for women that are able to cope with mild symptoms, do not tolerate pessaries or are not suitable for surgery. Conservative management involves:

  • Physiotherapy (pelvic floor exercises)
  • Weight loss
  • Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
  • Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
  • Vaginal oestrogen cream

 

Vaginal pessaries are inserted into the vagina to provide extra support to the pelvic organs. They can create a significant improvement in symptoms and can easily be removed and replaced if they cause any problems. There are many types of pessary: 

  • Ring pessaries are a ring shape, and sit around the cervix holding the uterus up
  • Shelf and Gellhorn pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards
  • Cube pessaries are a cube shape
  • Donut pessaries consist of a thick ring, similar to a doughnut
  • Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina.

Women often have to try a few types of pessary before finding the correct comfort and symptom relief. Pessaries should be removed and cleaned or changed periodically (e.g. every four months). They can cause vaginal irritation and erosion over time. Oestrogen cream helps protect the vaginal walls from irritation. 

 

Surgery is the definitive option for treating a pelvic organ prolapse. It is essential to consider the risks and benefits of any operation for each individual, taking into account any co-morbidities. There are many methods for surgical correction of a prolapse, including hysterectomy. Surgery can be very successful in correcting the problem. Possible complications of pelvic organ prolapse surgery include:

  • Pain, bleeding, infection, DVT and risk of anaesthetic
  • Damage to the bladder or bowel
  • Recurrence of the prolapse
  • Altered experience of sex

 

Mesh repairs have been the subject of a lot of controversy over recent years. Mesh repairs involve inserting a plastic mesh to support the pelvic organs. After review, NICE recommend that mesh procedures should be avoided entirely. Potential complications associated with mesh repairs are:

  • Chronic pain
  • Altered sensation
  • Dyspareunia (painful sex) for the women or her partner
  • Abnormal bleeding
  • Urinary or bowel problems

Women presenting with possible complications of mesh repair should be referred to a specialist for assessment and management.

 

Last updated June 2020
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