Pelvic Organ Prolapse
Pelvic organ prolapse is a hernia of one of the pelvic organs (uterus, vaginal apex, bladder or rectum) and its associated vaginal segment from its normal location. This is a common condition. Diagnosis involves a careful medical history and physical exam, and treatment may include physical exercises, medication or surgery.
Terms used to describe specific types of female genital prolapse include:
Cystocele: Hernia of the bladder with associated descent of the anterior vaginal segment
Cystourethrocele: A cystocele combined with distal prolapse of the urethra
Uterine prolapse: Descent of the uterus and cervix into the lower vagina, the hymenal ring or through the vaginal introitus.
Vaginal vault prolapse: Descent of the vaginal apex (following hysterectomy) into the lower vagina, the hymenal ring or through the vaginal introitus
Rectocele: Hernia of the rectum with associated descent of the posterior vaginal segment
Enterocele: Herniation of the small bowel/peritoneum into the vaginal lumen, most commonly presenting following hysterectomy
The majority of patients with clinically significant prolapse will have at least two or more of the following risk factors, which can cumulatively contribute to worsening prolapse as a woman ages:
having multiple children
forceps or vacuum-assisted vaginal delivery
neurogenic dysfunction of the pelvic floor
connective tissue disorders
prior pelvic surgery with disruption of natural support
chronically increased intra-abdominal pressure
Women with prolapse into the vagina often complain of a sensation of pelvic pressure, a bearing down sensation, inguinal discomfort, dyspareunia (pain with intercourse) or low back pain. These symptoms become progressively worse due to a gradual increase in size of the prolapse over time. The prolapsed vault may protrude from the vagina on standing, leading to discharge and bleeding from chronic ulceration.
Vaginal wall prolapse is often accompanied by a cystocele, rectocele, enterocele or a combination of these disorders.
Women with mild prolapse are appropriately treated with pelvic floor exercises and/or physical therapy with behavioral modification. Women with moderate prolapse and those who are not ideal surgical candidates may benefit from use of a pessary. Surgery is the preferred treatment of severe prolapse because it restores both normal anatomic relationships and vaginal function.
A pessary is a synthetic device placed into the vagina to keep it from bulging beyond it’s normal limits. These devices are designed to hold the vault in place against sudden increases in intraabdominal pressure, and can provide temporary relief of symptoms. A pessary may be advisable for:
women with only slight or moderate prolapse who achieve symptomatic relief with a pessary
women with marked prolapse who are poor operative risks and who can be made fairly comfortable with pessary support
women with marked prolapse who prefer to get by with the inconvenience and limited relief of pessary treatment rather than undergo surgery
younger women with prolapse who plan to have additional children. The beneficial effects of extensive vaginal repairs in such women may be nullified by subsequent pregnancy and childbirth.
Temporary use of a pessary before surgery should be encouraged in women with severe prolapse who develop ulcerations and in postmenopausal women who are not taking hormone replacement therapy. Use of a pessary for two to four weeks while topical estrogen is administered will allow the vaginal mucosa to become as healthy as possible before surgery. In addition, women who desire surgical repair of prolapse but are unable to schedule surgery until the distant future may gain symptomatic relief with a pessary in the interim.
The surgical approach to the management of vaginal vault prolapse depends upon the woman's desire to preserve sexual function.
Women who are not sexually active and who lead a sedentary lifestyle, such as some elderly patients, may consider surgical removal of the vagina (colpectomy) and closing off the space (colpocleisis). For women who wish to preserve sexual function, the condition can be managed either vaginally or abdominally. Vaginal approaches are favored over abdominal when both are possible, but many patients require combined approaches.
Transvaginal sacrospinous colpopexy is performed by suturing one or both sides of the vagina to the sacrospinous ligament to support and lift the vagina. Alternatively, the vagina may be sutured to the iliococcygeus fascia ligament (transvaginal iliococcygeus colpopexy) for support of the apex. Both procedures are performed from a vaginal approach without an abdominal incision.
Transabdominal sacral colpopexy refers to suspension of the vaginal apex from the sacrum using synthetic mesh. This is done through an abdominal incision.
Colpectomy and colpocleisis are reserved for the patient who no longer desires vaginal intercourse or in whom body self-image is not important. The procedure is usually performed under general or spinal anesthesia.
Postoperative care is similar to that of any vaginal reconstructive procedure. The woman begins walking the day following surgery, and normal bowel activity is stimulated with a mild laxative. Continuous bladder drainage is not required, but estrogen therapy, either systemically or locally, is recommended on a permanent basis.
The patient is advised to avoid putting anything in the vagina until complete healing occurs, typically in three to four weeks. She should also avoid sudden and repetitive increases in intra-abdominal pressure, constipation and heavy lifting for that time. She may resume normal activity and return to work when she feels rested and pain free. A postoperative exam will be performed to ensure complete healing before return to work is authorized.
Prognosis depends upon the severity of symptoms, extent of the prolapse, physician experience and patient expectations. Surgery has traditionally been associated with a recurrence/reoperation rate of up to 30 percent, with some centers reporting reoperation in over 50 percent of cases; however, use of site-specific fascial defect repair and graft/mesh augmentation have improved both prognosis and safety.
Women with recurrent pelvic organ prolapse, despite properly executed previous surgery, should be suspected of having generalized connective tissue weakness. Under these circumstances, the use of synthetic material will improve the long-term outcome of the planned surgical reconstruction.