Pelvic organ prolapse is an abnormal herniation of pelvic organs from their normal anatomic position. It is the third most common reason for elective hysterectomy.
11% of women undergo surgery for prolapse or incontinence in their lifetime.
Levels of vaginal support
| Level | Structure | Defect |
|---|---|---|
| Level I | Cardinal and uterosacral ligaments. Holds the | Defect leads to apical prolapse associated with uterine descent and enterocele |
| Level II | Paravaginal attachments contiguous with cardinal and uterosacral complex | Defect leads to lateral or paravaginal prolapse which is associated with cystocele |
| Leve III | Perineal body, perineal musculature and connective tissue supporting the distal 1/3 of the vagina | Defect leads to anterior and posterior prolapse |
Types of prolapse
| Defect | Prolapse |
|---|---|
| Anterior vaginal wall prolapse | Cystocele or urethrocele or cystourethrocele |
| Lateral vaginal wall/ paravaginal prolapse (most common defect) | Cystocele |
| Posterior vaginal wall prolapse | Rectocele (more distal) or enterocele (more proximal) |
| Apical vaginal wall prolapse | Enetrocele or uterine prolapse |
Grading of uterine prolapse
| Degree | Descreption |
|---|---|
| 1st degree | Cervix protrudes below its normal level on valsava |
| 2nd degree | Cervix protrudes from vulva on straining |
| 3rd degree (complete procidentia) | Whole uterus is completely prolapse outisde the vulva, even without valsava |
- Risk factors
- Multiparity
- Older age
- Low oestrogen levels decrease the strength of pelvic ligaments
- Other obstetric risk factors
- Macrosomia
- Prolonged second stage
- Episiotomy
- Lacerations
- Epidural analegesia
- Forceps use
- Connective tissue disease, e.g., Marfan syndrome and Ehler Danlos syndorme
- Race
- Common in whites and hispanics
- Increased abdominal pressure, e.g., chronic constipation
- Pathophysiology
- Pelvic floor support is provided by the levator ani (iliococcygeus, pubococcygeous, and puborectalis), fascia and ligaments
- Direct damage to these structures or nerves can weaken the pelvic floor
- Fascia and ligaments get weaker with age, causing pelvic organ prolapse
- Signs and symptoms
- Bulge symptoms (more specific to pelvic organ prolapse)
- Sensation of vaginal protrusion or pressure
- “Heaviness”
- Urinary symptoms
- Stress incontinence
- Urgency and Frequency
- Weak or prolonged stream and hesitancy
- Feeling of incomplete emptying
- Difficulty with complete emptying
- Bowel symptoms
- Feeling of incomplete emptying
- Incontinence
- Digital evacuation
- Sexual symptoms
- Dyspareunia
- Pain
- Back pain
- Genital pain
- Bulge symptoms (more specific to pelvic organ prolapse)
- Physical examination
- Visual examination while standings, with and without valsava
- Bimanual examination
- Bivalve speculum examination
- Split speculum examinaiton
- Note the anatomic position of the prolapsed portion
- Note the presence or absence of rugae on the prolapsed portion (rugae presents = lateral or paravaginal defect)
- Approximate the distance or extent of prolapse in relation to hymen
- Investigations
- Urodynamic testing
- Cystometry to measure pressure in the bladder during filling
- Uroflowmetry to measure volume and speed of urine flow over time
- Pressure flow studies to meausre the bladder pressure required to urinate and flow rate at a given pressure
- Pelvic floor electromyography (EMG) to measure the electrical activity of muscles and detect neuromuscular abnormalities
- Simple cystometrics where ****saline or sterile water is infused into the bladder. Then the patients is asked to indicate when they feel the liquid, when their bladder feels full, and when they experience an urge to urinate
- Pelvic floor ultrasound (trans-anal, trans-perineal, and vaginal views) to capture images during coughing or straining to see how pelvic organs move
- Anorectla manometry and defecography (proctography)
- Urodynamic testing
- Treatment
- Pessaries are the first-line treatment for pelvic organ prolapse
- Evaluate for vaginal atrophy before placing pessaries
- Ring pessaries are for first and second degree prolapse
- Gellhorn pessaries are for third degree prolapse
- Kegel (pelvic floor) exercises
- Surgery
- Obliterative or reconstructive surgery can be performed
- A hysterectomy can be considered if the patient is fit, elderly, and has completed family life
- Pessaries are the first-line treatment for pelvic organ prolapse