Pelvic Organ Prolapse

WHAT IS PELVIC ORGAN PROLAPSE?

Prolapse comes from the Latin word 'prolabi' which translates "to fall". In medicine this term indicates that an organ has slipped out of its proper place. In the body, the pelvic floor is a network of muscles, ligaments and other tissues that form a sling (or hammock) across the opening of the pelvis that holds up the internal pelvic organs. These muscles, together with their surrounding tissues, are responsible for keeping all of the pelvic organs (bladder, uterus, urethra, small bowel/intestines, and the rectum) in place and functioning correctly. If these muscles are damaged or weakened through normal aging, child birth, pelvic surgery or trauma, the organs lose their normal positioning and the uterus and pelvic contents move into the vaginal vault.

CONTRIBUTING FACTORS

A number of different factors contribute to the weakening of pelvic muscles over time, but the two most significant factors are thought to be pregnancy and aging (menopause). Pregnancy is believed to be the main cause of pelvic organ prolapse, whether the prolapse occurs immediately after pregnancy or 20 years later. A vaginal delivery may weaken or stretch some of the supporting structural muscles in the pelvis. The delivery may damage nerves, leading to muscle weakness. Certain situations in pregnancy and birth further increase the likelihood or the extent of damage, such as a large baby, a long labor and the use of forceps or extractive devices. The aging process, combined with already damaged pelvic floor muscles, further weakens the pelvic muscles. The natural reduction in estrogen at menopause also causes muscles to become less elastic.

Woman who are severely overweight or have large fibroids or pelvic tumors, are at an increased risk of prolapse due to the extra pressure this creates in their abdominal area. Chronic coughing from smoking, asthma or bronchitis, as well as straining during bowel movements, and heavy lifting can also contribute to pelvic floor disorders. Other causes include hysterectomy, nerve disorders, connective tissue disorders, degenerative neurologic conditions and prior pelvic surgery.

SYMPTOMS

The following symptoms may be associated with Pelvic Organ Prolapse:

Vaginal symptoms

  • Sensation or visual presence of vaginal bulge
  • Pelvic or lower abdominal pressure
  • Vaginal heaviness
  • Painful intercourse (Dyspareunia)

Urinary /  Bowel Symptoms

  • Urinary incontinence, urgency, frequency
  • Weak or prolonged urinary stream
  • Feeling of incomplete emptying
  • Positional voiding / defecation
  • Needing to apply manual pressure to urinate or have a bowel movement
  • Constipation / Fecal incontinence

TYPES OF PROLAPSE

Cystocele - develops when the bladder drops down and protrudes into the wall of the vagina. 

Urethrocele - develops when the upper part of the urethra (bladder neck) drops down into the vagina. 

Rectocele - develops when the rectum protrudes into the back of the vagina. 

Enterocele - develops when the small bowel pushes through the top of the vaginal canal.

Uterine Prolapse (also known as Vaginal Vault Prolapse) - develops when the uterus drops into the vagina.

Rectal Prolapse - develops when the rectum protrudes outside the anus.

LIVING WITH PELVIC ORGAN PROLAPSE

Living with prolapse can be a challenge, both physically and emotionally, as the symptoms can disrupt day-to-day life. A doctor can usually diagnosis pelvic floor disorders by performing a pelvic exam, along with other tests, to determine how well the bladder and rectum are functioning. These procedures may help doctors determine the best treatment. If a woman has a problem with passage of urine or urinary incontinence, doctors may use a flexible scope to view the inside of the bladder (Cystoscopy) or the urethra (Urethroscopy). Also the amount of urine the bladder can hold without leakage and the rate of urine flow may be measured. 

TREATMENT OPTIONS FOR PELVIC PROLAPSE

The management / treatment of pelvic organ prolapse will depend on many factors, including the type(s) of prolapse an individual has. Management can include:

  • Observation
  • Conservative treatments such as Pelvic Floor Physical Therapy or Pessary placement
  • Surgical - Vaginal or Abdominal

NON-SURGICAL SUGGESTIONS

Below are a few suggestions that may make living with the prolapse a little easier:

  • Avoid standing for long periods of time. Many woman find their symptoms get worse when they stand and improve when they lie down. 
  • Do pelvic floor exercises.These help prevent prolapse but can also strengthen weakened muscles, and aid recovery after surgical treatment. Kegel exercises target the muscles around the vagina, urethra and the muscles used to stop a stream of urine. 
  • Prevent or correct constipation by eating a high fiber diet.
  • Wear panty liners or incontinence pads. If you occasionally leak small amounts of urine, you could wear an odor controlled panty liner. If you leak urine heavily or more often, you should use incontinence pads. 
  • Carry wet wipes. If you have bladder or bowel symptoms use wet wipes to keep yourself clean as well as reduce odor. 
  • Estrogen vaginal suppositories or creams may be used. These preparations are used to keep the vaginal tissues healthy and can prevent sores from forming. Hormone replacement therapy may help strengthen the vaginal walls and the pelvic floor muscles by increasing the estrogen and collagen levels in the body, but there is little evidence to whether it is effective in treating prolapse. 

SURGERY

Most of the surgical treatments for prolapse aim to lift the prolapse organ back into place. The choice of surgery depends on the type of prolapse you have, your age, whether you want to keep your uterus to have children, whether you are sexually active, the skill of your surgeon, and personal preference. It is very common to have more than one type of prolapse at the same time, so each should be taken into consideration when planning. As with all surgery there can be risks, and the degree of success depends on many factors. The surgical treatments that you choose may repair your prolapse, but they may not relieve all of your symptoms.