Pelvic organ prolapse
|Pelvic organ prolapse|
|Other names: Genital prolapse|
|Anatomy of the female pelvic showing commonly prolapsed organs|
|Symptoms||Pressure in the vagina, bulging out the vagina, urinary incontinence|
|Usual onset||Older age|
|Types||Cystocele, rectocele, uterine prolapse, enterocele|
|Diagnostic method||Based on smptoms and examination|
|Treatment||High fiber diet, pelvic floor exercises, pessary, surgery|
|Frequency||108 million women (2.8% as of 2017)|
Pelvic organ prolapse (POP) is when one or more pelvic organs decent from their normal positions. In women this generally occurs into the vagina. Many women have no symptoms. When symptoms occur these may include a feeling of pressure in the vagina, bulging coming out the vagina, or urinary incontinence. It is a type of pelvic floor disorder.
Risk factors include vaginal childbirth, obesity, chronic cough, constipation, menopause, and a family history of the condition. The underlying mechanism involves weakness or damage to the pelvic floor. Types include cystocele (bladder), rectocele (rectum), uterine prolapse (uterus), and enterocele (small bowel). Diagnosis is based on symptoms and examination.
Treatment may involve a high fiber diet, pelvic floor exercises, a removable device placed in the vagina known as a pessary, or surgery. Surgery is generally only recommended if the prolapse is causing significant problems. Pelvic organ prolapse affected about 108 million women in 2017 (2.8% of women). Older women are more commonly affected, particularly those in their 70s. Men are very rarely affected.
Signs and symptoms
- Anterior vaginal wall prolapse
- Posterior vaginal wall prolapse
- Apical vaginal prolapse
Pelvic organ prolapses are graded either via the Baden–Walker System, Shaw's System, or the Pelvic Organ Prolapse Quantification (POP-Q) System.
- Upper 2/3 cystocele
- Lower 1/3 urethrocele
- Upper 1/3 enterocele
- Middle 1/3 rectocele
- Lower 1/3 deficient perenium
- Grade 0 Normal position
- Grade 1 descent into vagina not reaching introitus
- Grade 2 descent up to the introitus
- Grade 3 descent outside the introitus
- Grade 4 Procidentia
|Grade||Posterior urethral descent, lowest part other sites|
|0||normal position for each respective site|
|1||descent halfway to the hymen|
|2||descent to the hymen|
|3||descent halfway past the hymen|
|4||maximum possible descent for each site|
|0||No prolapse anterior and posterior points are all −3 cm, and C or D is between −TVL and −(TVL−2) cm.|
|1||The 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).|
|2||The most distal prolapse is between 1 cm above and 1 cm below the hymen (at least one point is −1, 0, or +1).|
|3||The most distal prolapse is more than 1 cm below the hymen but no further than 2 cm less than TVL.|
|4||Represents complete procidentia or vault eversion; the most distal prolapse protrudes to at least (TVL−2) cm.|
Vaginal prolapses are treated according to the severity of symptoms.
A pessary, a rubber or silicone rubber device fitted to the patient which is inserted into the vagina and may be retained for up to several months. 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. Pessaries require a provider to fit the device, but most can be removed, cleaned, and replaced by the woman herself. Pessaries should be offered to women considering surgery as a non-surgical alternative.
With surgery (for example native tissue repair, biological graft repair, absorbable and non-absorbable mesh repair, colpopexy, colpocleisis). Surgery is used to treat symptoms such as bowel or urinary problems, pain, or a prolapse sensation.
A 2016 Cochrane review concluded that evidence does not support the use of transvaginal surgical mesh compared with native tissue repair for anterior compartment prolapse owing to increased morbidity. Safety and efficacy of many newer meshes is unknown. The use of a transvaginal mesh in treating vaginal prolapses is associated with side effects including pain, infection, and organ perforation and serious complications are "not rare." A number of class action lawsuits have been filed and settled against several manufacturers of transvaginal mesh. Transvaginal permanent mesh may reduce a women's perception of vaginal prolapse and probably the risk of recurrent prolapse and of having repeat surgery for prolapse. On the other hand, transvaginal mesh probably has a greater risk of bladder injury and of needing repeat surgery for stress urinary incontinence or mesh exposure.
Genital prolapse occurs in about 316 million women worldwide as of 2010 (9.3% of all females).
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