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Pelvic Organ Prolapse

Pelvic organ prolapse is a medical condition that occurs when the normal support of the vagina is lost, resulting in “sagging” or dropping of the bladder, urethra, cervix and rectum. As the prolapse of the vagina and uterus progresses, women can feel bulging tissue protruding through the opening of the vagina. 

Causes and Risk Factors

The strength of our bones, muscles and connective tissue are influenced by our genes and our race. Some women are born with weaker tissues and are therefore at risk to develop prolapse. Caucasian women are more likely than African American women to develop pelvic organ prolapse.  Loss of pelvic support can occur when any part of the pelvic floor is injured during vaginal delivery. Some other conditions that promote prolapse include: constipation and chronic straining, smoking, chronic coughing and heavy lifting. Obesity, like smoking, is one of the few modifiable risk factors. Women who are obese have a 40 to 75% increased risk of pelvic organ prolapse.  Aging, menopause, debilitating nerve and muscle diseases contribute to the deterioration of pelvic floor strength and the development of prolapse.

Symptoms

Some loss of support is a very common finding upon physical exam in women, many of whom do not have bothersome symptoms. Those women who are uncomfortable often describe the very first signs as subtle - such as an inability to keep a tampon inside the vagina, dampness in underwear or discomfort due to dryness during intercourse. 

As the prolapse gets worse, some women complain of:

  • A bulging, pressure or heavy sensation in the vagina that worsens by the end of the day or during bowel movements 
  • The feeling that they are “sitting on a ball” 
  • Needing to push stool out of the rectum by placing their fingers into the vagina during bowel movement 
  • Difficulty starting to urinate, a weak or spraying stream of urine 
  • Urinary frequency or the sensation that they are not emptying their bladder well 
  • The need to lift up the bulging vagina or uterus to start urination 
  • Urine leakage with intercourse

Types of pelvic organ prolapse

Different types of pelvic organ prolapse affect different parts of the vagina (see illustrations):

Cystocele and urethrocele. A cystocele occurs when the bladder protrudes into the front wall of the vagina. A similar defect, known as a urethrocele, develops when the urethra presses into the front vaginal wall.

Rectocele.
Part of the rectum bulges into the back wall of the vagina, sometimes causing difficulty with defecation.

Uterine prolapse.
The uterus drops down into the vagina. In women who have undergone a hysterectomy, a similar condition known as vaginal vault prolapse can occur: the top of the vagina protrudes into the lower vagina.


Pelvic organ prolapse conditions
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Depending on where weak spots occur, the bladder, urethra, rectum, or uterus may protrude into the vagina.

What causes pelvic organ prolapse?

Pelvic support comes from pelvic floor muscles, connecting tissue (fascia), and thickened pieces of fascia that serve as ligaments. When pelvic floor muscles are weakened, the fascia and ligaments have to bear the brunt of the weight. Eventually, they may stretch and fail, allowing pelvic organs to drop and press into the vaginal wall.

Women who have had multiple vaginal births are at greatest risk for pelvic organ prolapse, particularly after menopause. Other risk factors include surgery to the pelvic floor, connective tissue disorders, and obesity.

What are the symptoms?

Women with mild prolapse discovered during a routine pelvic exam may have no symptoms at all. But others experience considerable discomfort and a range of symptoms, including:

Pressure and pain.
The most common complaints are a feeling of pelvic pressure, or bearing down, leg fatigue, and low back pain.

Urinary symptoms.
Cystocele, urethrocele, and uterine prolapse can cause stress incontinence and difficulty in starting to urinate.

Bowel symptoms.
A rectocele may cause problems with defecation by forming a pocket just above the anal sphincter. Stool can become trapped, causing pain, pressure, and constipation.

Sexual problems.
A prolapse can cause irritated vaginal tissues or pain during intercourse, as well as psychological stress.

If you think you have a pelvic prolapse condition, see your primary care provider or gynecologist. A traditional pelvic examination is the only way to diagnose it.

Treating prolapse.

Women with no or very mild symptoms don’t need treatment, although they should avoid anything that might worsen the prolapse. Losing weight if necessary, avoiding lifting heavy objects, and quitting smoking all prevent prolapses from progressing. Prolapse doesn’t necessarily worsen over time, so there’s no need to seek aggressive treatments, unless your symptoms are really bothersome.

If you’re experiencing major discomfort or inconvenience, surgery is the only definitive way to relieve symptoms and improve your quality of life (see “Surgical treatment,” below). But if your symptoms are mild or you want to delay or avoid surgery, less invasive treatments can help:

Kegel exercises.
The physiotherapist will teach you these. A woman with prolapse but no symptoms may be urged to practice Kegel exercises to reduce the chance that her condition will progress. Kegel exercises are a series of contractions that strengthen the pelvic floor. You squeeze two sets of pelvic floor muscles at the same time: those you would use to prevent yourself from passing gas and those you would tighten to stop urinating. Avoid contracting your stomach muscles.

Try to do 30–40 pelvic contractions each day; you may want to divide them into three or four groups of 10 each, spread throughout the day. Squeeze and hold the contraction for 3–5 seconds; then rest for the same length of time. Build up to 10-second contractions, with 10 seconds of rest in between.

Pessary.
For women who aren’t good surgical candidates or want to delay surgery one alternative is a vaginal pessary — a device similar to a diaphragm or cervical cap that’s inserted in the vagina to help support the pelvic area (see illustration).

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Surgical treatment.

Before undergoing surgical repair of a prolapse, you’ll need to have a thorough pelvic exam, to ensure that all problems have been identified. Be sure your surgeon has expertise in the field of pelvic reconstruction.

Surgical techniques.

Pelvic reconstruction surgery may be performed through the vagina or abdominally; both procedures are equally effective.

Complications.

Possible complications of pelvic reconstructive surgery include urinary tract infection, temporary or permanent incontinence, infection, bleeding, and — rarely — damage to the urinary tract that requires additional corrective surgery. Some women may develop chronic irritation or pain during intercourse from a suture or scar tissue.

There’s also a risk of recurrence, which seems to be highest for cystocele and lowest for rectocele, usually around 20% lifetime risk. The chance of recurrence will also be reduced if a woman avoids stress, such as heavy lifting or straining during a bowel movement, and performs Kegel exercises regularly before and after surgery.

Cystocele - When surgery is necessary

If you have noticeable, uncomfortable symptoms, cystocele may require surgery. This surgery is elective and designed to relieve symptoms related to the cystocele. In most cases, surgery consists of a vaginal repair. In this procedure,  the surgeon moves the prolapsed bladder back into place, removing redundant tissue and tightening the muscles and ligaments of your pelvic floor. While the benefits of this type of surgery can last for many years, there's some risk of recurrence. This is partly because of downward forces of gravity resulting in stretching of tissues again. The life time risk of recurrence is 20%.

If the cystocele recurs, you may need surgery again. If the cystocele is associated with a prolapsed uterus, your doctor may recommend removing the uterus (hysterectomy) to help correct the problem and prevent recurrence.

Dealing with incontinence

If your cystocele is accompanied by stress incontinence, your doctor may recommend one of a number of procedures to support the urethra (urethral suspension). See incontinence and TOT.

A rectocele – when surgery is necessary

If the rectocele protrudes outside your vagina and is especially bothersome, you may opt for surgery. More commonly, your doctor may suggest surgery if the rectocele accompanies another condition, such as a cystocele, an enterocele or uterine prolapse. In these cases, surgical repair for each condition can be completed at the same time.

Surgery usually consists of removing excess, stretched tissue that forms the rectocele. In most cases, this is done using a vaginal surgical approach. Occasionally, the surgical repair may involve using a mesh patch to support and strengthen the wall between the rectum and vagina.


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