Pelvic Organ Prolapse

Prolapse definition & types of prolapse

Pelvic organ prolapse is a very common condition, particularly among older women. It is estimated that 50% of all women have mild prolapse and 10% have moderate to severe prolapse. However, many women are reluctant to seek help from their doctors because of embarrassment, or they are unaware that the condition can cause problems and that treatment is readily available.

Pelvic organ prolapse occurs when the pelvic floor muscle and its associated fascial and the ligamentous supports become weak or damaged and can no longer adequately support the pelvic organs.

There are a number of different types of prolapse that can occur in a woman's pelvic area and these are divided into three categories according to the part of the vagina they affect, namely front wall, back wall and top of the vagina. It is common to have prolapse in all three compartments.

While prolapse is not considered a life threatening condition, it does cause a great deal of discomfort and distress for women.

Cystocoele (bladder prolapse)
When the bladder prolapses, it pushes through the vagina and creates a large bulge in the front vaginal wall. It is common for both the bladder and the urethra to prolapse together. This is called a cystourethrocoele and is the commonest type of prolapse in women.

Urethrocoele (prolapse of the urethra)
This happens when the urethra (the tube that carries urine from the bladder) pushes through the front of the vaginal wall. This usually occurs with a cystocoele.

Rectocoele (prolapse of the rectum or large bowel)
This occurs when the end of the large bowel (rectum) loses support and bulges through the back wall of the vagina. It is different from a rectal prolapse (when the rectum falls out of the anus).

Enterocoele (prolapse of the small bowel)
Part of the small intestine in the pelvis may slip down between the rectum and the back wall of the vagina. This often occurs at the same time as a rectocoele or uterine prolapse.

Uterine prolapse (prolapse of the womb)
Uterine prolapse occurs when the womb drops down into the vagina. It is the second commonest type of prolapse and is usually classified into four grades depending on how far the womb has fallen.

• Grade 1: The uterus has dropped slightly. At this stage, many women may not be aware they have a prolapse. It may not cause any symptoms and is usually diagnosed as a result of an examination for a separate health issue.
• Grade 2: The uterus has dropped further into the vagina and the cervix (neck or tip of the womb) can be seen at or just outside the vaginal opening.
• Grade 3: A significant portion of the uterus has fallen through the vaginal opening.
• Grade 4: The whole uterus has fallen through the vaginal opening. This is the most severe form and is called a procidentia.
  

Vaginal vault prolapse
The vaginal vault is the top of the vagina. Vaginal vault prolapse can only happen after a woman's womb has been removed (hysterectomy). It occurs in about 10% of women who have had a hysterectomy.

Causes of pelvic organ prolapse

A number of different factors contribute to the weakening of pelvic floor muscles and damage to the ligamentous and fascial supports over time. The two most significant factors are thought to be pregnancy and ageing.

Pregnancy and childbirth
Pregnancy is believed to contribute significantly to pelvic organ prolapse. The weight of the baby, and the physical trauma of labour and birth damages tissues that never fully regain their strength and elasticity. Large babies, long labour and the use of forceps or vacuum during birth also contribute significantly to prolapse.

Women with multiple deliveries are at a higher risk of prolapse. Caesarean section may seem to be protective against prolapse, but the majority of studies till date suggest that there is only slight, if any, protection. Furthermore, caesarean section is associated with other operative risks and complications.

Ageing and menopause
Ageing further weakens the pelvic floor muscles, and the natural reduction in oestrogen after menopause also reduces muscle elasticity.

Obesity, large fibroids or tumours
Women who are severely overweight, or have large fibroids or pelvic tumours, are at an increased risk of prolapse.

Chronic coughing or straining
Chronic (long-term) coughing from smoking, asthma or bronchitis, or the straining associated with constipation increases a woman's risk of prolapse.

Heavy lifting
Heavy lifting strains and damages pelvic muscles and women in professions that involve regular manual labour or lifting, such as nursing, have an increased risk of prolapse.

Congenital
Women with genetic conditions such as collagen deficiency (Marfan or Ehlers-Danlos syndrome) have an increased risk of prolapse.

Previous pelvic surgery
Pelvic surgery, including hysterectomy or bladder repair procedures may damage nerves and tissues in the pelvic area, thereby increasing a woman's risk of prolapse.

Spinal cord conditions and injury
Spinal cord injury and medical conditions such as muscular dystrophy and multiple sclerosis dramatically increase a woman's risk of prolapse.

Ethnicity
Studies show that white and Hispanic women have the highest rate of pelvic organ prolapse, followed by Asian and black women.

Prolapse: symptoms and diagnosis

Women with mild prolapse may have discomfort but are unaware they have a prolapse. When symptoms do occur, they tend to be related to the organ that has prolapsed.

A bladder or urethra prolapse may cause incontinence (involuntary urine leakage), frequent or urgent need to urinate or difficulty in urinating. Some women may need to insert a finger in their vagina and push the bladder back into place in order to empty their bladder completely.

A prolapse of the small or large bowel (rectum) may cause constipation or difficulty in defaecating. Some women may need to insert a finger in their vagina and push the bowel back into place in order to empty their bowels.

Women with uterine prolapse may feel a dragging sensation or heaviness in their pelvic area, often described as feeling 'like my insides are falling out'. In severe prolapse where the uterus is bulging out of the vagina, the vaginal skin may become irritated, leading to ulceration and infection.

Prevention measures

There are a number of things you can do to reduce your risk of prolapse or help prevent a mild prolapse from worsening:

• The most effective preventive measure is doing regular pelvic floor exercises (Kegel exercises) throughout your adult life as it helps keep the pelvic muscles toned and strong.
• If you are significantly overweight, try to lose weight.
• If you smoke, try to cut down or stop.
• Avoid lifting heavy objects.
• Eat a high fibre diet (fresh fruits, vegetables, bran) to help prevent constipation.
• If you are post-menopausal, some doctors may suggest you use hormone therapy to reduce prolapse symptoms or prevent an existing prolapse from becoming worse. However, there is little scientific evidence to support the claim that hormonal therapy prevents prolapse.
  

Non-surgical treatments

Non-surgical treatments are used when a woman feels her prolapse symptoms are mild, and do not warrant surgery. When there are other medical conditions which do not allow for surgery to be safely performed, or when a woman wants a temporary measure while contemplating surgery, non-surgical treatments can be used. If a woman has not completed her family, non-surgical treatments is ideal. Definitive surgical treatment can be delayed till child bearing is no longer required.

Physiotherapy (pelvic floor exercises)
As recommended by NICE guidelines in the UK, pelvic floor exercises should be performed for at least 3 months, and should comprise of at least 8 contractions performed 3 times per day. If pelvic floor exercise is found to be beneficial, it should be continued for as long as possible to relieve and prevent worsening of symptoms.

Vaginal pessary
A vaginal pessary is inserted into the vagina to hold the prolapsed organ(s) in place. Pessaries are made of latex or silicone and come in many different shapes and sizes, with ring pessaries being the commonest available.

Pessaries are generally recommended as a temporary treatment for women who are waiting for surgery, women who are pregnant or want to have more children in the future, and women who are unfit or choose not to have surgery.

Pessaries need to be individually fitted and you may need to try a few different shapes and sizes before you find one that feels comfortable and stays in place. After the pessary has been fitted, your doctor will ask you to walk around, sit, squat, cough and strain to check if it's comfortable and that it remains in place and not fall out.

If the pessary is relieving your symptoms and you are not having difficulties with it, you'll be scheduled for follow-up visits every 4 to 6 months. At your follow-up visits, the doctor will remove the pessary to check whether if it is causing any skin ulcerations, and also whether the prolapse is getting worse. After which, a new pessary will be inserted.

If you have any difficulties with the pessary or if you have any unusual discharge, bleeding or pain, please contact your doctor immediately.

Some pessaries may interfere with sexual intercourse, but a ring pessary may be left in place during sex if it's comfortable for you.

Some women experience a bad-smelling discharge when they use a pessary. Some people are allergic to latex or develop allergies after using latex products. Inform your doctor promptly if you experience any of the aforementioned symptoms.

Surgical Treatments

Most of the surgical treatments for prolapse aim to lift the prolapsed organ(s) back into place. Vaginal hysterectomy (removal of the uterus via the vaginal route for uterine prolapse) may be performed. The choice of surgery depends on the type of prolapse you have, your health, age, whether you want to keep your uterus or have children in the future, whether you are sexually active, and lastly, your personal preference.

Treating prolapse of the bladder and urethra
Anterior repair (Anterior colporrhaphy)
This procedure is used to treat prolapse of the bladder (cystocoele), urethra (urethrocoele) or both (cystourethrocoele).

The operation is done through the vagina with general or regional anaesthesia. It involves making a cut in the front (anterior) wall of the vagina so the bladder and/or urethra can be pushed back into place. Once this is done, the surgeon stitches together existing tissues to provide new support for the bladder and urethra, and then removes the excess skin from the vaginal wall, after which the vaginal wall is repaired.

The main complications of an anterior repair that occur rarely are injury to bladder, bleeding, infection, de novo urgency/urge incontinence, stress urinary incontinence and voiding disorders.

Repair with mesh
If you have had recurrent or severe anterior wall prolapse, a mesh may be used to help support the vaginal wall and keep the prolapsed organ(s) in place. This may provide better long-term support, but may also cause additional complications such as, inflammation or erosion of surrounding tissues, an increased risk of painful sex (dyspareunia), and infection with possible abscess formation, which occur rarely. (provide link to mesh PIL)

Treating prolapse of the small bowel and rectum
Posterior repair (Posterior colporrhaphy/colpoperineorraphy)
Posterior repair is used to treat prolapse of the rectum (rectocoele) and small bowel (enterocoele). The operation is done through the vagina, under a general or regional anaesthesia. The procedure is similar to an anterior repair (above). A cut is made in the back (posterior) wall of the vagina and the rectum and/or small bowel is pushed back into place. The doctor stitches together the existing tissues to create a new support for the prolapsed organ(s) and then removes the excess skin from the vaginal wall, after which the vaginal wall is repaired.

The main complications of posterior repair are bleeding, infection, rectal perforation, and painful sex (dyspareunia). These complications are rare.

Treating Uterine Prolapse
There are two surgical approaches to treating uterine prolapse: removing the uterus altogether (hysterectomy) or lifting it and holding it in place (Manchester procedure vs hysteropexy).

Removing the Uterus

Hysterectomy
Hysterectomy (removal of the womb) is considered for treatment for uterine prolapse. Despite this, it still may not relieve all of your symptoms.

A hysterectomy for prolapse is done through the vagina (vaginal hysterectomy), but if your uterus is very large it may need to be removed abdominally (abdominal hysterectomy). The procedure is done under general or regional anaesthesia and involves dividing the ligaments that hold the uterus in place, removing the uterus, closing off the top of the vagina and then shortening and reattaching the ligaments to hold the vagina up.

Hysterectomy is a major operation and after having this surgery:

• Women have 10% risk of developing vaginal vault prolapse.
• Women who have not yet gone through the menopause will no longer have periods or be able to get pregnant. If a woman's ovaries are removed during hysterectomy, she may experience sudden menopause
  

Suspending the uterus
Treatments that suspend rather than remove the uterus can be done for women who want to keep their uterus or have children in the future. Procedures can be done either vaginally or abdominally, with good results using both approaches.

Conserving the uterus

Sacrohysteropexy
This procedure uses a strip of synthetic mesh to hold the uterus in place. The operation is done abdominally, either through a horizontal cut above the pubic hairline or through keyhole surgery (laparoscopy). The doctor attaches one end of the mesh to the cervix and top of the vagina and the other to the back of the bony pelvis. Once in place, the mesh supports the uterus. There are few complications associated with sacrohysteropexy, but there is a risk that the mesh may erode into surrounding tissues or cause inflammation. In severe cases, the mesh may need to be removed. There is also a risk of bone infection of the pelvis which is rare but difficult to treat. If you are planning to have children after the procedure, a pregnancy may damage the repair and cause the prolapse to recur. To help prevent this, you may be advised to have a scheduled caesarean section rather than a vaginal birth.

Sacrospinous ligament hysteropexy
This operation holds the uterus up by stitching the cervix to one of the pelvic ligaments (called the sacrospinous ligament) using sutures. The procedure is done vaginally and is therefore less invasive than sacrohysteropexy.

While complications are rare, there is a risk of rectal perforation, bleeding and injury to the pudendal and sciatic nerves that can lead to severe pain in your legs, buttocks, genital and pelvic area. There is also slightly increased risk of cystourethrocele recurrence.

Manchester procedure
The Manchester procedure can be used in woman who wants to conserve her uterus as an alternative to hysterectomy for treating uterine prolapse. The procedure is done vaginally and involves removing the cervix (which may be elongated) and pushing the uterus back into place by shortening the ligaments that support it.

The operation has a very good success rate. In severe cases of prolapse, it can be combined with a vaginal sacrospinous ligament hysteropexy.

Treating vaginal vault prolapse (womb previously removed)

Sacrospinous ligament fixation (SSF)
This is an operation that is performed through the vaginal route to support the vagina (after previous surgery to remove the womb) by attaching the roof of the vagina to the right sacrospinous ligament. This procedure is often done concurrently with surgery to remove the womb or to correct bladder or rectal prolapse in the vagina.

The objective of the operation is to relieve the symptoms, restore vaginal anatomy and sexual function. The surgery may be done under general or regional anesthesia. Painkillers and antibiotics will generally be prescribed after the procedure.

Sacrospinous ligament fixation is a safe operation. However, like all surgical operations, complications may occasionally occur. These include bleeding, infection, injury to surrounding tissues (e.g. rectum and nerves), injury to the pudendal and sciatic nerves that can lead to severe pain in your legs, buttocks, genital and pelvic area, conversion into an abdominal operation to correct complications, blood clot formation in the legs or lungs, and recurrence of prolapse.

Sacrocolpopexy
This procedure uses synthetic mesh to support the top of the vagina when there is vault prolapse. During the operation, the doctor stitches one end of the mesh to the top of the vagina and the other end to back of the bony pelvis. It is done abdominally, either through keyhole surgery (laparoscopy) or a larger cut just above the pubic line.

Complications are uncommon but there is a risk that the mesh may cause inflammation and erode the tissue around it. If this is severe, the mesh will need to be removed. There is also a risk of bone infection of the pelvis, which is rare but difficult to treat.

This is a major procedure and may not be appropriate for women who are frail or in poor health.