Pelvic organ prolapse

Definition

• Descent of female pelvic organs into the vagina
• Organs include bladder, uterus, vaginal cuff (post-hysterectomy), or bowel
• Apex (cervix)
  • Uterocele or vaginal cuff prolapse or vaginal vault prolapse
  • Uterosacral ligament defect
• Anterior
  • Cystocele, urethrocele
  • Paravaginal tear and/or vesicovaginal facial defect
• Posterior
  • Rectocele involving rectum, perineum, anus, or enterocele
  • Rectovaginal fascia defect and/or levator muscle diastasis

Epidemiology

• Leading indication for hysterectomy in postmenopausal women in the US
  • But apparently it is not a treatment, so I'm not sure why it's an indication
• 40-75% of American women 50-79 years old had some amount of pelvic organ prolapse
• Rarely causes significant morbidity or mortality

Etiology

• Levator ani trauma
• Weakness of pelvic support ligaments
• Collagen deficiency

Risk factors

• Childbirth (most common)
  • Perineal tear risk factor for posterior prolapse
• Increasing age
• Obesity
• Chronic cough, e.g. COPD
• Occupation involving heavy lifting
• Repetitive strain, e.g. chronic constipation
• Hysterectomy

Clinical Presentation

• Most are asymptomatic, but may present with bladder, bowel, or vaginal complaints
• Vaginal
  • Mass in the vagina
  • Pressure or heaviness
• Urinary
  • Incontinence, frequency, urgency
  • Weak stream, incomplete emptying
  • Reduction of prolapse to start or complete void
• Bowel
  • Incontinence of flatus, stool
  • Incomplete emptying
  • Urgency to defecate
• Dyspareunia

Examination

• Examine anterior and posterior walls as well as the cervix
• May see loss of ruggae

Investigations

• Urinalysis
• Post-void residual
• Urodynamic urinary assessment

Staging (Baden-Walker)

• Stage I: >1cm above the level of the hymen
• Stage II: <=1cm distant from the human
• Stage III: >1cm below the hymen but protrudes less than within 2cm of the vaginal opening
• Stage IV: complete eversion of the vagina

Management

• If asymptomatic: no specific intervention
• If symptoms: pessary
• If severe symptoms: surgery
  • Reconstructive
    • Colpopexy
    • Uterosacral suspension, with or without hysterectomy
    • Other ligament suspensions
    • Colporrhaphy
  • Obliterative: vagina closed entirely
    • Colpocleisis