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CLINICAL SCIENCE
Pelvic organ prolapse

Summary

Pelvic organ prolapse (POP or female genital prolapse) is the protrusion of bladder, rectum, intestines, uterus, cervix, or vaginal apex into the vaginal vault
due to decreased pelvic floor support. It is commonly seen in women of advanced age. Other risk factors include multiparity (particularly vaginal births), prior
pelvic surgery, connective tissue disorders, and increased intra-abdominal pressure secondary to obesity or chronic constipation. Patients present with a
sensation of vaginal pressure, discomfort, and/or pain. The protruded pelvic organ is visualized and assessed during inspection. Low-grade prolapse can be
managed conservatively with pelvic floor (Kegel) exercises or a vaginal pessary to support the pelvic floor. Pelvic floor repair surgery is indicated for women
with symptomatic prolapse who do not respond to or decline conservative management. Complications include urinary or fecal retention or incontinence,
abdominal/pelvic pain, and avoidance of sexual activity because of embarrassment or discomfort.

Overview

Anatomical overview: The pelvic floor is supported by a continuous endopelvic fascia, which consists of :
Uterosacral ligament complex (suspends the uterus and vaginal apex from the sacrum and lateral pelvis)
Paravaginal attachments
Perineal body, perineal membrane, and the perineal muscles
Definition: herniation into or descent of pelvic organs to or beyond the vaginal walls
Partial/subtotal prolapse: pelvic organs are only partially outside the vaginal opening.
Total prolapse: pelvic organs are everted and located outside of the vaginal opening .
Specific sites
Anterior vaginal wall prolapse : herniated anterior vaginal wall, which is often associated with a cystocele (descent of the bladder) or urethrocele
(descent of the urethra); can be due to weakness of the pubocervical fascia
Posterior vaginal wall prolapse : herniated posterior vaginal wall , which is associated with a rectocele (descent of the rectum) or enterocele (herniated
section of the intestines); can be due to weakness of the rectovaginal fascia
Uterine prolapse: descent of the uterus
Vaginal vault prolapse: descent of the apex of the vagina
Uterine procidentia: protrusion of all vaginal walls or cervix beyond the vaginal introitus
References:[1]

Epidemiology

POP is a common disorder in older women.

References:[1]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Risk factors
POP is due to an insufficiency of the pelvic floor muscles and the ligamentous supportive structure of the uterus and vagina , which may be caused by:
Multiple vaginal deliveries and/or traumatic births
Low estrogen levels (e.g., during menopause)
Congenital connective tissue disorders
Previous pelvic surgery (e.g., hysterectomy)
Increase intraabdominal pressure (e.g., cough related to chronic lung disease and/or smoking, ascites, obesity, pelvic tumors, or constipation.)
Diabetes mellitus

References:[1][2]
Clinical features

Feeling of pressure on or discomfort around the perineum (“sensation of vaginal fullness”)

Lower back and pelvic pain (may become worse with prolonged standing or walking)
Rectal fullness, constipation, incomplete rectal emptying
Prolapse of the anterior (in cystocele/urethrocele) or the posterior (in enterocele/rectocele) vaginal wall, possibly with excessive vaginal discharge on
inspection, bimanual examination, and speculum examination of the patient in lithotomy position; occurs at rest and with increased abdominal pressure
Weakened pelvic floor muscle and anal sphincter tone

Patients with POP may present with concurrent complications!

References:[1][2]

Diagnostics

Usually a clinical diagnosis relying on the Pelvic Organ Prolapse Quantitation system ( POP-Q)
Stage 0: no prolapse
Stage 1: The most distal portion of prolapse is more than 1 cm above the level of the hymen.
Stage 2: The most distal portion of prolapse is 1 cm or less proximal or distal to the hymenal plane.
Stage 3: The most distal portion of prolapse is more than 1 cm from the hymenal plane but no more than 2 cm less than the vaginal length.
Stage 4: The vagina is completely everted or uterine procidentia has occurred.

References:[3][4]

Treatment

Conservative treatment
First-line treatment for all cases of POP. May be definitive treatment for patients with manageable symptoms ( low-grade POP) who would like to avoid
complications of surgery or patients at high risk of surgical complications.
Insertion of a vaginal pessary (to support the pelvic organs)
Reduction of modifiable risk factors (e.g., avoid smoking to prevent a chronic cough, weight loss, prevent constipation)
Kegel exercises: pelvic floor muscle training (also as a preventive measure)

Surgery
Indicated for symptomatic prolapse if conservative treatment fails or the patient declines it.
Obliterative surgery: vagina is closed off or narrowed to provide more support for pelvic organs.
Reconstructive surgery (abdominal or vaginal approach): to restore the original position of the descended pelvic organs
Sacrocolpopexy (with vaginal vault suspension and hysterectomy): fixation of the vaginal apex to the sacrum for the repair of apical or vaginal vault
prolapse, with suspension and hysterectomy
Suspension techniques: prolapsed organ is fixated or suspended using native tissues such as the endopelvic fascia, iliococcygeus muscle, uterosacral
ligament, or sacrospinous ligaments.
Colporrhaphy: reinforcement of the anterior or posterior vaginal wall for the repair of cystocele or rectocele
Sacrohysteropexy: fixation of the cervix to the sacrum for the repair of uterine prolapse
References:[2][5]

Complications

Pressure ulcers with hemorrhage

Ascending infections
Urinary disorders
Stress incontinence
"Masked" urinary incontinence
Obstructive uropathy
Defecation disorders (e.g., constipation or fecal incontinence if the anal sphincter is weakened)
Sexual dysfunction
Surgical complications (e.g., recurrence)
References:[6]

We list the most important complications. The selection is not exhaustive.

last updated 03/25/2019

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