PELVIC ORGAN PROLAPSE
Pelvic organ prolapse (POP) is a hernia of the pelvic organs to or through the vaginal opening. How does this happen? All of the pelvic organs (bladder, uterus, and rectum) are supported by a complex “hammock” of muscles, ligaments, and fibers that attach to the bony anatomy of the pelvis. When these are weakened, those organs can drop.
There are two types of pelvic organ prolapse, asymptomatic and symptomatic. Asymptomatic POP means that while the hernia has taken place, nothing extends beyond the vaginal opening. Meanwhile, symptomatic POP refers to when there is tissue that is protruding past the vaginal opening.
Approximately 200,000 operations are performed yearly in the United States for POP. Although not life-threatening, POP can be life altering and may result in significant quality of life changes in women.
Pelvic Organ Prolapse can be very uncomfortable for some women. But there are many treatment options that can be taken to greatly improve the symptoms of POP, and in some cases, eliminate them. They include the use of pessaries—a medical device used to provide structural support—physical therapy, surgery, or watchful waiting. Suboptimal surgical results as well as high recurrence rates after treatment have prompted many providers to view POP as a chronic disease.
Pelvic Organ Prolapse has been documented as far back as 2000 B.C. Even then, the physical trauma of vaginal childbirth created issues within a mother's body. More than three millenniums later, and women are confronted with this debilitating condition. In addition, risk factors for the development of POP include a family history of POP, obesity, advancing age, prior hysterectomy, and conditions that chronically increase intra-abdominal pressure, such as asthma or constipation.
Patients with mild POP describe feelings of heaviness that is constant. Others note feeling an increase in pressure only after a long day of being on their feet or after heavy physical exercise.
In severe cases of POP, patients commonly report feeling or seeing a “ball” or protrusion from the vagina.
Because POP often occurs with other pelvic floor disorders, symptoms for one pelvic floor problem should prompt questioning for all other disorders.
Depending on where the weakness in the pelvic floor occurs, it may affect one or multiple organs of the pelvis. Weakness of the front side vaginal wall near the bladder results in a cystocele, often called a dropped bladder. An enterocele refers to a weak spot in the vaginal ceiling causing uterine prolapse. Defects of the backside vaginal wall near the rectum results in a rectocele. Determining the location of the weakness is crucial in prescribing the right treatment.
If your physician determines that you are dealing with mild pelvic organ prolapse-asymptomatic—there is a good chance it can improve on its own. Watchful waiting is often the course of action, though it is not possible to identify whose POP will improve with time.
Although there are limited non-surgical management options for POP, pessaries are often employed. Made of silicone, pessaries are devices that provide structural support when placed in the vagina. Since women come in all shapes and sizes, pessaries need to be fitted to the specific shape of the individual.
A successful pessary is one that is comfortable, is retained with Valsalva, and treats POP symptoms adequately. Pessaries do require upkeep and need to be removed and cleaned on a regular basis.
It is not unusual for local vaginal estrogen to be prescribed for use in conjunction with a pessary for comfort, lubrication, and to lower incidence of urinary tract infections.
In addition, there are many useful products that you might find useful in managing your condition.
Many women find relief from Pelvic Organ Prolapse symptoms by performing targeted exercises. Typically, a physical therapist trained in this area can help create a customized plan that includes finding and strengthening the pelvic floor muscles.
While reconstructive surgery for POP is an option, it must be noted that there is a 30% recurrence rate for women choosing this route. Prolapse repairs can be done transvaginally, abdominally, laparoscopically, and/or robotically (when a scope is placed through the belly button). Ultimately, the purpose of the surgery is to correct the anatomy as well as provide better bowel, bladder, and vaginal function.
- Cystocele Repair - This surgery repairs a prolapsed bladder or urethra (urethrocele)
- Hysterectomy - This is a complete removal of the uterus.
- Rectocele Repair - A rectocele repairs the fallen rectum and small bowel (enterocele).
- Vaginal Vault Suspension - Most commonly a laparoscopic procedure to repair the vaginal wall
- Vaginal Obliteration - Closure of the vagina
While abdominal repairs are believed to have higher success rates, the increase in morbidity makes this also one of the riskier options. Less than optimal success rates has inspired physicians to look elsewhere. Vaginal grafts (made of synthetic and biologic materials) are being explored as a long-term solution to POP. Research is currently being conducted to determine if the benefits of using mesh grafts in POP surgical repairs for greater durability sufficiently outweighs the risks of undesirable adverse consequences.
Transvaginal surgeries have nearly a 100% success rate and are usually reserved for elderly patients with multiple medical problems. The vagina is sewn shut and shortened so that it no longer prolapses. After these surgeries, vaginal intercourse is no longer physically possible.