Pelvic Organ Prolapse

Introduction

Pelvic organ prolapse is the abnormal descent or herniation of the pelvic organs from their normal attachment sites or their normal position in the pelvis. 

The pelvic structures that may be involved include the uterus (uterine prolapse) or vaginal apex (apical vaginal prolapse), bladder and anterior vagina (cystocele), and/or rectum and posterior vagina (rectocele). 

The pelvic organs are normally supported and kept in their original position by muscles and ligaments of the pelvic floor. 

When there is damage or weakening of these supporting structures, these organs are pushed down towards the vaginal opening.

Many women may have some degree of prolapse when examined; however, most prolapses are not clinically bothersome without specific pelvic symptoms, and they may not require an intervention.

TYPES OF PROLAPSE

Not all genital prolapses are equal. 

They are classified according to severity or degree of prolapse and can vary from very mild to severe. 

For clinical and scientific reasons, more detailed and intricate classification systems are used.

In addition, the prolapse is different depending on where the pelvic floor weakness or damage is and which organ or organs have moved.

Uterine prolapse (apical prolapse): involves the descent of the uterus and cervix down the vaginal canal due to weak or damaged pelvic support structures. The main cause of a prolapsed uterus is childbirth whereby the support tissues are stretched and torn as the baby passes down the vagina. Other causes can involve prolonged constipation, heavy lifting and chronic coughing.

Cystocoele (bladder prolapse or anterior prolapse): involves the descent of the bladder and can be noted as a bulge over the anterior vaginal wall. Sometimes the urethra (small tube from where the urine exists the bladder) is also prolapsed and we use the term Urethrocystocoele.

Rectocoele (rectal prolapse or posterior prolapse): involves the descent of the rectum and can be noted as a bulge over the posterior vaginal wall.

Enterocoele (small bowel prolapse): is similar to a rectocele, but instead involves a higher part of the vagina and the organ pushing down is the small bowel and not the rectum.

Vaginal vault prolapse (apical prolapse): this happens in women who have had a hysterectomy and no longer have the uterus. The top of the vagina descends into the vaginal canal.

CAUSES OF PROLAPSE

Genital prolapse ultimately happens when there is damage or weakening of the muscles and other structures that support the pelvic organs. 

Factors that contribute to the problem are:

Pregnancy and Childbirth probably the most significant cause for prolapse. Pregnancy by itself can contribute to the weakening of the pelvic floor due to hormonal changes and the extra weight and pressure of the baby. The risk increases with vaginal deliveries, number of pregnancies, delivery of large babies, prolonged second stage (pushing stage) of labour and forceps delivery. Quite often the damage that occurs during pregnancy and childbirth goes unnoticed at the time with symptoms only developing later in life.

Menopause/Ageing: The female hormone oestrogen plays an important role in maintaining the strength of the pelvic floor. After menopause, when the ovarian production of oestrogen decreases, the pelvic floor tissues becomes weaker. This may aggravate existing damage and trigger prolapse symptoms which were not noticeable before.

Increased Abdominal Pressure: An increase in intra-abdominal pressure puts strain on the pelvic floor and perineal muscles. If this is significant or sustained over long periods of time, it can exacerbate the prolapse. Some conditions where this could be the case include: obesity, chronic coughing associated with smoking or bronchitis, occupations that require intense physical work or heavy lifting.

Genetic Factors: Some women are born with deficiencies in some of the proteins that make up the connective tissue. They can present with weak bone joints and less resistant ligaments predisposing them to prolapse. This can happen as a result of events that usually would not cause prolapse in other women. Congenital weakness explains why some young women and women who have never had children develop a prolapse.

Symptoms

Genital Prolapse symptoms vary according to the degree of severity of the prolapse and also depending on which organs have changed position. In addition, different women may report different symptoms for similar clinical presentations. 

The most common findings are:

·       The presence of a lump or bulge in the vagina or vaginal entrance.

·       A dragging sensation or feeling that something is falling or pushing down.

·       Pain is usually not very severe and is commonly felt as a dull backache or aching discomfort in the pelvic region.

·       Bowel symptoms – rectal prolapse can cause constipation, difficulty in passing stools or incomplete evacuation requiring repeated visits to the bathroom.

·       Urinary Symptoms – bladder and/or urethral prolapse can cause urinary incontinence. This usually shows as Stress Incontinence or urine leaks with increases in the intra-abdominal pressure caused by coughing, sneezing, laughing, exercise, etc. Other possible symptoms are: increased frequency of urination, incomplete voiding and urinary infections.

·       Sexual problems - prolapsed pelvic organs can limit the depth of penetration or make penetration difficult or painful. The loss of pelvic tone can result in decreased sensation. Women with urinary incontinence may experience urine leaks during intercourse.

·       Emotional problems - prolapse can eventually lead to a loss of self-esteem and a negative self-image. There can also be loss of sexual enjoyment and desire.

Prolapse symptoms may vary over time and even during the day. 

They tend to be more noticeable after long periods of standing or at the end of a working day. 

Other factors that can make symptoms more pronounced or more noticeable are exercise, physical exertion and repetitive sneezing and coughing.

Diagnosis

For most women the diagnosis can be done by physical examination. In addition to a general and abdominal inspection a thorough gynaecological examination is essential. The doctor examines the woman lying down and, if necessary, standing up. Some manoeuvres such as asking the woman to cough or strain my help. In a few cases, it may not be obvious which organ is prolapsed and imaging such as 3D ultrasound or MRI can be used for a more accurate diagnosis.