Pelvic organ prolapse: clinical review

Diagnosis and management of pelvic organ prolapse, covering risk factors, assessment and conducting a vaginal examination.

Section 1: Epidemiology and aetiology
Section 2: Making the diagnosis
Section 3: Managing the condition
Section 4: Prognosis
Section 5: Case study
Section 6: Evidence base


Section 1: Epidemiology and aetiology

Pelvic organ prolapse refers to loss of support for the uterus, bladder or bowel, leading to prolapse of one or more of these compartments into the vagina. Prolapse can have a significant impact on the woman’s quality of life and body image. It is associated with disturbances to bowel, bladder and sexual function.

Primary care professionals have an important role in identifying signs and symptoms, assessing and offering treatment options to patients presenting with pelvic organ prolapse.

Prevalence and incidence

It is difficult to accurately estimate the prevalence and incidence of pelvic organ prolapse because some patients do not have symptoms and others, who do have symptoms, do not present to their doctor. It is estimated that up to 40% of women experience a degree of pelvic organ prolapse in their lifetime.1 The lifetime risk of undergoing prolapse surgery is 11% and up to 11% of patients will have a repeat operation within 11 years.2,3 It is likely that the number of women presenting with prolapse will increase.4

Epidemiology

Risk factors for prolapse include the following.

Age
The risk of prolapse doubles with every decade of life.

Childbirth
Pregnancy and childbirth are associated with pelvic organ prolapse. The incidence of prolapse is 50% in parous women and 2% in nulliparous women. The risk increases with the number of deliveries a woman has. There is also evidence that vaginal tears at birth are associated with increased risk of symptomatic pelvic organ prolapse. Evidence regarding instrumental delivery and birthweight is conflicting.5

Ethnicity
Symptomatic pelvic organ prolapse is most common among hispanic American women and least common in African American women.6

Obesity
The increased risk of pelvic organ prolapse in obese women is likely because of the effects of chronic increased pressure on the pelvic floor.6

Smoking
The increased risk of pelvic organ prolapse in women who smoke is likely because of the chronic cough associated with smoking.7

Occupation
Jobs involving heavy lifting have been associated with pelvic organ prolapse.

Chronic constipation
There is a strong association between chronic constipation and pelvic organ prolapse.8 This is because of an increase in intra-abdominal pressure and pelvic floor muscle denervation from pudendal nerve stretch.9

Estrogen deficiency
Evidence suggests a link between menopause and development of pelvic organ prolapse.10

Family history and genetic risk
There is evidence of an increased risk of prolapse in women with a first degree relative who has pelvic organ prolapse.11

Connective tissue disease
Patients with joint hypermobility syndrome and connective tissue disorders, such as Ehlers-Danlos and Marfan syndromes, have a higher incidence of pelvic organ prolapse.

Classification

Anterior compartment
Prolapse of the anterior compartment is commonly described as a cystocele. The anatomical location may suggest which organ has prolapsed. It is important to consider other possible causes of swelling, including vaginal cysts, abscesses and urinary diverticula.

Middle compartment
In the middle compartment or vaginal apex, the uterus may prolapse. The apex ‘vault’ may prolapse in those who have had a hysterectomy. This is known as post-hysterectomy vaginal vault prolapse, or prolapse of the vaginal cuff.

Posterior compartment
The rectum may prolapse into the posterior part of the vagina. This is known as a rectocele. A digital rectal examination is important to differentiate between a rectocele and an enterocele.

Grading

A number of systems have been used to describe the severity of pelvic organ prolapse. Figure 1 shows a comparison of commonly used grading systems. The two most commonly used systems are the Baden-Walker halfway system and the Pelvic Organ Prolapse Quantification System (POP-Q). The POP-Q system is shown in box 1.

Box 1: The POP-Q system12
Stage
0 No prolapse
1 The most distal portion of the prolapse is more than 1 cm above the hymen
2 The most distal portion of the prolapse is 1 cm or less proximal or distal to the hymenal plane
3 The most distal portion of the prolapse protrudes more than 1 cm below the hymen but protrudes no further than 2cm less than the total vaginal length
4 Vaginal eversion is essentially complete

Ssction 2: Making the diagnosis

When assessing a women presenting with pelvic organ prolapse, aim to find out which symptoms bother the patient and establish comorbidities. Consider the possible cause and factors such as future pregnancy plans, which may affect management options. Request appropriate investigations to establish clinical findings and assess risk of surgery.

History

Key points to ascertain from the history include age, family history of prolapse and symptoms, such as bladder or bowel symptoms, sexual dysfunction, backache or bleeding.

Bladder symptoms include stress incontinence, overactive bladder, voiding dysfunction and recurrent urinary tract infection. Bowel symptoms include obstructed defecation, rectal frequency and urgency, anal incontinence and defecatory disorders.

Ask about sexual dysfunction. A vaginal bulge may interfere with sexual intercourse and cause discomfort. The wide hiatus may cause lack of sensation to the woman or her partner. Importantly, women may avoid sexual intercourse because of a disturbed body image causing loss of confidence, low self-esteem and relationship distress.13

A full obstetric history is required. This should include number of deliveries, mode of delivery, time since last delivery and future pregnancy plans. A gynaecological history should should include previous gynaecological problems and surgery.

Examination

A general examination should include body mass index and assessment for joint hypermobility.

An abdominal examination should check for scars from previous surgery and abdominal masses. Hernias in the umbilicus may signify underlying connective tissue weakness that could predispose to pelvic organ prolapse (and its possible recurrence after surgery).

A vaginal examination should start with inspection to identify atrophy, ulceration of prolapse outside the vulva, leakage of urine on coughing and rectal prolapse on straining. Speculum examination will enable visualisation of the prolapse and identify the compartment involved. Bimanual examination will establish the size, direction, shape, and mobility of the uterus. This will also guide the surgical route if a hysterectomy is required and identify any adnexal masses which may contribute to prolapse. Pelvic floor muscle tone should be assessed during pelvic floor muscle contraction.

A digital rectal examination is rarely required, but may help differentiate a rectocele from an enterocele.


Section 3: Managing the condition

When deciding how to manage pelvic organ prolapse, consider the nature of symptoms and whether they bother the patient. Note the nature and extent of the prolapse, whether the patient wants to have (more) children, sexual activity, age, fitness for surgery and anaesthesia, physical activity, and the outcome of any previous prolapse management. Ensure that the patient has realistic expectations about possible outcomes.

Non-surgical options

Physiotherapy
Depending on the degree of prolapse, physiotherapy aimed at training the pelvic floor muscles can be used.

Pessary
There are many different pessaries available to manage pelvic organ prolapse. Pessaries are inexpensive and effective in treating prolapse symptoms so may be an attractive option for patients. They offer a temporary control of pelvic organ prolapse for as long as they stay in place and provide reasonable patient satisfaction. Despite widespread use, there is limited evidence to recommend one pessary over another.14

The main indications for use are; the patient not wanting to have surgery, pregnancy or wanting to have (more) children, awaiting surgery or being deemed unfit for surgery.

For insertion, a ring pessary is lubricated then squeezed and gently inserted into the vagina. Women should be asked to walk for a few minutes, go to the toilet and try to pass urine. If the pessary falls out or is too tight, a different pessary may be used.

It is important that the pessary is removed regularly - every 3-6 months - to check for vaginal ulceration. This can be performed in the community or in hospital.

Important! A pessary should be removed every 3-6 months.

Problems associated with pessary use include vaginal ulceration, difficult removal, neglected pessary, bleeding, vaginal discharge, pain and constipation.

Surgical options

Surgery is a more definitive treatment option than pessary use but it does not guarantee success. Before deciding on surgery, the risk of recurrence and potential complications must be considered. Choice of surgery will depend on the nature of symptoms and the effect these have on the patient, the nature and extent of prolapse, future pregnancy plans, sexual activity, age, medical problems, associated incontinence, physical activity and previous management.

Anterior compartment prolapse
Anterior compartment prolapse can be managed by an anterior repair. This aims to restore fascial support below the bladder. Potential complications of this procedure include bleeding, infection, voiding dysfunction and recurrence of symptoms.

Posterior compartment prolapse
Posterior compartment prolapse can be managed by a posterior repair. This aims to restore fascial support between the rectum and the vagina. Potential complications of this procedure include bleeding, infection, voiding dysfunction and recurrence of symptoms.

Mid-compartment prolapse
Mid-compartment prolapse can be treated with a vaginal hysterectomy. This aims to restore support to the upper vagina in patients with uterovaginal prolapse who do not want to retain their uterus. Potential complications include bleeding, infection, voiding dysfunction, recurrence of prolapse, painful sexual intercourse and conversion to abdominal hysterectomy.

Surgery for post-hysterectomy vaginal vault prolapse
There are two approaches for vaginal vault prolapse; a vaginal approach is a sacrospinous fixation where the vaginal vault is fixed to the sacrospinous ligament, an abdominal approach is a sacrocolpopexy where the vaginal vault is fixed to the sacral promontory using a piece of mesh.


Section 4: Prognosis

Recurrence of pelvic organ prolapse can occur after surgery. There are many reasons why surgery may be unsuccessful, including lifestyle factors such as obesity and smoking. The risk of failure increases with repeat surgery, so it is important that patients are selected carefully for repeat surgery.


Section 5: Case study

Mrs Jones, is a 57-year-old woman, attends her GP with a troublesome ‘bulge down below’ which has lasted for three years. She has no other relevant symptoms but has been troubled by a cough recently. She is sexually active and has had three vaginal births but has no other medical or surgical history of note.

She works part-time in a fruit shop where she lifts heavy baskets. She smokes 5-10 cigarettes a day and is slightly overweight.

In the first instance, Mrs Jones is advised on exercise and smoking cessation (which may address her cough), and to avoid heavy lifting where possible.

Mrs Jones is examined by the GP, who notices a prolapse through the vaginal introitus. The GP refers her to a gynaecologist who recommends Mrs Jones see a physiotherapist specialising in women’s health.

Despite attending the physiotherapist appointments, Mrs Jones is still troubled by the prolapse, so insertion of a ring pessary is proposed.

At follow-up with her GP, six months later, Mrs Jones seeks an alternative option. She discusses surgical correction of her prolapse. The GP discusses the risks of prolapse surgery - infection, bleeding, DVT/PE, and injury to adjacent structures such as the bowel, bladder. Mrs Jones is also warned of the potential for recurrence of prolapse after surgery. Mrs Jones agrees to go ahead with surgery.


Section 6: Evidence base

Online resources

Dr Abdelmageed Abdelrahman is a trainee in obstetrics and gynaecology, Northern Ireland Deanery

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References

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