Condition: Pelvic Organ Prolapse (POP)
Brief Overview: Pelvic organ prolapse occurs when the muscles and connective tissues supporting the pelvic organs weaken, allowing one or more organs to descend into the vaginal canal. It can affect the bladder, rectum, uterus, vaginal vault, or small bowel. POP is common in women who have had vaginal deliveries and increases with age and menopause.
Types of Pelvic Organ Prolapse (from UpToDate):
- Anterior compartment prolapse – Hernia of anterior vaginal wall often associated with descent of the bladder (cystocele)
- Posterior compartment prolapse – Hernia of the posterior vaginal segment often associated with descent of the rectum (rectocele)
- Enterocele – Hernia of the intestines to or through the vaginal wall.
- Apical compartment prolapse (uterine prolapse, vaginal vault prolapse) – Descent of the apex of the vagina into the lower vagina, to the hymen, or beyond the vaginal introitus. The apex can be either the uterus and cervix, cervix alone, or vaginal vault, depending upon whether the woman has undergone hysterectomy. Apical prolapse is often associated with enterocele.
- Uterine procidentia – Hernia of all three compartments through the vaginal introitus.
Prevalence: According to Cleveland Clinic, “Around 3% to 11% of women experience POP. About 37% of women with pelvic floor disorders, including POP, are between ages 60 and 79. Over half are 80 or older.”
Etiology:
- Vaginal childbirth
- Menopause (decreased estrogen)
- Chronic straining (constipation, cough)
- Prior pelvic surgery
- Aging and connective tissue laxity
- Obesity
Risk Factors:
- Advancing age
- Multiparity
- Menopause
- Obesity
- Elevated intraabdominal pressure – chronic constipation, COPD
- Collagen abnormalities – example: connective tissue disorders
- Family history
Commonly Associated Conditions:
- Urinary incontinence or retention
- Overactive bladder
- Constipation
- Recurrent UTIs
- Sexual dysfunction
Common Medications:
- Hormone replacement therapy
Common Labs, Imaging, and Tests:
- Physical exam
- Imaging: MRI, ultrasound
- Urinalysis
- Urodynamics for urinary symptoms
Common Symptoms:
- Vaginal bulge or pelvic pressure
- Urinary, sexual, or defecatory dysfunction
- Sensation of “something falling out of the vagina”
- Stress urinary incontinence
- Difficulty voiding
- Overactive bladder symptoms (urinary frequency, urgency, urgency urinary incontinence)
- Incontinence with sexual intercourse
- Enuresis
- Constipation, fecal incontinence, fecal urgency
Common Treatments:
- Sometimes no treatment is needed
- Pessary device
- Pelvic floor physical therapy
- Surgery may be indicated
- Dietary modifications (to prevent constipation)
Physical Findings:
- Vaginal bulge or protrusion
- Laxity of anterior, posterior, or apical walls
- Visible descent of involved organ(s)
Potential Complications and Contraindications:
- Urinary retention or infection
- Constipation or incomplete evacuation
- Tissue ulceration or irritation
- Kidney damage
- Quality of life impact
General Health and Lifestyle Guidance:
- Maintain healthy weight
- Treat underlying constipation or chronic cough, if applicable
- Ask your healthcare provider if you should avoid heavy lifting
- Ask your healthcare provider if you should do Kegel exercises, or if pelvic floor physical therapy might be beneficial for you
Suggested Questions to Ask Patients:
- What symptoms are most bothersome to you (urinary, bowel, bulge)?
- Have you noticed worsening with activity or time of day?
- Any incontinence or incomplete emptying?
- Have you had prior pelvic surgery?
- Are you open to pelvic floor therapy, pessary, or surgical options?
Suggested Talking Points:
- Pelvic organ prolapse can involve different pelvic structures.
- Many cases can be managed without surgery.
- Pelvic floor physical therapy and pessaries are effective options.
- Surgery may be indicated and will be tailored to the type of prolapse.
- Always ask your healthcare provider for specific advice on when to call to report symptoms, and when to seek urgent/emergency care.
Sources:
- https://my.clevelandclinic.org/health/diseases/24046-pelvic-organ-prolapse
- https://www.uptodate.com/contents/pelvic-organ-prolapse-in-females-epidemiology-risk-factors-clinical-manifestations-and-management?search=cystocele&source=search_result&selectedTitle=1~52&usage_type=default&display_rank=1
- https://womenshealth.gov/a-z-topics/pelvic-organ-prolapse
- https://www.nhs.uk/conditions/pelvic-organ-prolapse/