The organs within a woman’s pelvis consist of uterus (womb, vagina, bladder and bowel. (Fig 1) Normally they are held in place by a supportive hammock of muscles, ligaments and tissue that lie across the pelvis known as the “pelvic floor”. When this supporting tissue is weakened, it no longer holds these organs in the correct position, causing the pelvic organs to fall out or prolapse.
Pelvic organ prolapse (POP) is a bulge or lump in the vagina, which may affect the quality of life.
Symptoms may include heavy, dragging feeling or lump in the vagina, increased on coughing or on increased abdominal pressure, bladder or bowel problems, incomplete voiding, a need to correct the prolapse to void or defecate and discomfort with sexual intercourse. You may not have any symptoms at all and may find out that there is POP during a routine gynaecological examination. A small amount of prolapse (especially in the elderly) is normal.
What causes POP?
The main cause is injury to the ligaments, muscles and tissues of the pelvic floor, which make up the natural supporting tissue. It is more likely to result from:
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Pregnancy & childbirth:
During pregnancy, the hormonal changes and extra weight weaken the pelvic floor muscles. Pregnancy and childbirth are the commonest causes of weakening of the pelvic floor, especially if the baby is large, one has had an assisted delivery (ventose or forceps) or multiple deliveries. Although the injuries have occurred during pregnancy and childbirth, the prolapse can manifest mays years later when tissues weaken due to menopause. -
Menopause and aging:
POP is more common as one gets older, particularly after menopause. After menopause, the body produces less female hormone estrogen that keeps vaginal tissue and the pelvic supporting tissue healthy. -
Constipation:
Persistent straining due to chronic constipation can weaken the pelvic floor - Obesity
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Smoking and chronic cough:
Repeated raised intra-abdominal pressure due to chronic coughing can weaken pelvic musculature and floor. -
Inherited risk
Some women may have inherited a condition which causes weakening of the pelvic tissues increasing the likelihood of developing POP. Such women may develop POP at a young age immediately after being sexually active, even before the first birth. (nulliparous prolapse) -
Post-hysterectomy
Uterus is one of the main organ where the supports to the vagina are attached. During hysterectomy (on removal of the uterus) if these supports are not reattached to the vagina, the top of the vagina can evert or prolapse (Vault or post-hysterectomy prolapse)
What are the different types of POP?
There are different types of POP depending on which organ is bulging into the vagina. It is common to have more than one type of organ prolapse (mixed prolapse) at the same time.
Anterior wall prolapse (Cystocele)
The weakening of the fascia supporting the bladder is torn or damaged leading to bulging of the bladder through the anterior vaginal wall. (Fig 2) The bulge forms a cul-de-sac which leads to storage of urine in the sac even after voiding. This leads to incomplete voiding, urinary frequency and increased risk of recurrent urinary tract infection.
Posterior wall prolapse (Rectocele) When the rectum bulges through the back of the vagina. (Fig 3 )The stools can get stuck in this bulge and some woman may have to digitally evacuate their bowel to empty the sac.
Uterine prolapse
When the uterus bulges through the vagina. Eventually the uterus will drag the bladder and the rectum which are attached to it, down and protrude outside the vagina. (Fig 4) Depending on the severity of the descent there are different degrees of prolapse graded from 1-4 (mild to severe). A complete prolapse is called Procedentia, where the uterus is completely outside the vaginal opening.
Enterocele
Support to the top of the vagina weakens, allowing bulging of the intestines into the upper vagina.
Vault Prolapse
After the uterus is removed (hysterectomy), the supports holding the vagina (if not reattached) can weaken and the vagina can evert and bulge down through the vagina.(Fig 5) Quite often when the hysterectomy is performed, the tissues already weakened during childbirth are not recognised. If support for the vagina is not created at the time of the hysterectomy, post-hysterectomy prolapse can be seen in up to 10% of cases.
How is POP diagnosed?
A prolapse is diagnosed by performing a vaginal examination. The doctor will do a speculum (plastic or metal instrument to separate the vaginal walls) examination into the vagina to see exactly which organs are prolapsing. The examination is done with the patient lying dorsal on the examination table or occasionally standing. To improve visualisation the doctor may ask the patient to cough or increase the abdominal pressure (Valsalva). The examination is done with the bladder empty. A separate examination may be done with a full bladder to check for urinary incontinence or leaking. A rectal examination (inserting a finger in the rectum) may be performed to visualise a rectocele.
Will I need any tests?
Urine test to check for infection if the patient has urgency or frequency. Patients with cystocele may need a sonography to check if any urine is stagnating in the bladder (USG pelvis pre/post void). If the patient has urinary leakage and incontinence the patient may be referred for special bladder tests known as Urodynamics. In patients with complex multi-organ prolapse involving the uterus/vagina, bladder or rectum the doctor may ask for a Dynamic MRI to assess the injury better.
What are the treatment options?
If you only have mild prolapse or have no symptoms, the doctor may choose a "wait and see" approach.
Lifestyle changes may include maintaining a healthy weight, reducing /quitting smoking, treatment of constipation and chronic cough, avoiding lifting heavy weights or high impact exercise.
Pelvic floor exercises (Kegal’s) may be effective in symptomatic relief in mild prolapse when carried out regularly over a period of time. The exercise will help strengthening the pelvic floor while you are waiting for surgery.
Vaginal creams or hormones
may be prescribed to heal any ulcers on the vaginal lining or improve the epithelium in menopausal patients.
Pessary is a plastic or silicone device that fits into the vagina to support the pelvic organs and hold up the uterus. They are advised if the patient is symptomatic, but does not wish to undergo surgery, is planning a pregnancy in the future or is not medically fit for surgery. There are various types of pessaries available in the market. Your doctor will select the correct type and size suitable for you. It is important to select the correct fit for the patient to prevent inflammation or ulceration of the vagina due to pressure. The pessaries can be removed, cleaned and refitted from time to time under medical supervision. It is possible to have sex with some types of pessary, although the patient or his partner may be aware of it.
Surgery
Not everyone with prolapse needs surgery, however most patients with moderate to severe prolapse with symptoms will benefit from surgery.