Pelvic Organ Prolapse

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Pelvic Organ Prolapse - Dr. Danny Mounir

Pelvic organ prolapse, or POP, is the dropping of the pelvic organs caused by the loss of normal support of the vagina.

POP occurs when there is weakness or damage to the normal support of the pelvic floor. The pelvic floor holds up the pelvic organs, including the vagina, cervix, uterus, bladder, urethra, intestines, and rectum. If the muscles of the pelvic floor and layers of connective tissue, which are called fascia, become weakened, stretched, or are torn the pelvic organs may fall downward. The organs drop down from where they should be and can cause trouble. In severe cases, women may feel or see tissue coming out of the opening of their vagina. Typically, the tissue coming out is from a prolapsing cervix and uterus or the walls of the vagina.

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Am I at Risk?

Pelvic organ prolapse is common in women. The incidence increases after childbearing and as women increase in age.

Childbirth (vaginal or operative vaginal delivery) can cause injury to the muscles or fascia of the pelvic floor. The increased pressure of childbirth on the internal organs in the abdomen can lead to POP. Operative vaginal deliveries (forceps or vacuum deliveries) may also increase the risk of pelvic floor injury and increase a woman’s risk of developing prolapse. Route of delivery is a very important and complicated topic—discuss the risks and benefits with your doctor.

Though pregnancy and vaginal birth does contribute to the development of pelvic floor disorders, there are women who have delivered many times who never developed prolapse. And, others who have never been pregnant who leak urine and stool. Risk factors, which predispose, cause, promote, or worsen pelvic organ prolapse, include:

Genetics

  • POP is a hereditary disorder, meaning that it runs in families. Our genes influence the strength of our bones, muscles and connective tissue. Some women are born with weaker tissues and are a higher risk for prolapse.
  • Caucasian women are more likely than African American women to develop pelvic organ prolapse.

Lifestyle

  • Smoking increases your risk of developing POP.

Pelvic Floor Injury

  • Injury to any part of the pelvic floor can occur during vaginal delivery, surgery, pelvic radiation, or fractures to the back and pelvis caused by falls or motor vehicle accidents.
  • Hysterectomy and other procedures are done to treat pelvic organ prolapse also are associated with the future development of prolapse.

Other Health Conditions

  • Chronic constipation and chronic straining.
  • Chronic coughing.
  • Obesity—obese women have a 40 to 75% increased risk of pelvic organ prolapse.
  • Menopause
  • Nerve and muscle diseases, which contribute to the deterioration of pelvic floor strength.
  • Heavy lifting and intense repetitive activity such as CrossFit.

The Female Pelvic and Reconstructive Surgery clinic is a part of CLS Health. CLS Health is a multi-specialty group with over ninety providers providing comprehensive inpatient and outpatient care in Baytown, Friendswood, Webster, Pasadena, League City, and surrounding areas. For more information, or to schedule an appointment with Dr. Danny Mounir, call 281-993-9817

Common complaints of women with prolapse are being unable to wear a tampon, urinary and/or fecal incontinence, vaginal dryness or irritation, and pain with intercourse. Symptoms often progress very gradually. And you may make changes in physical or social activities that go unnoticed by others until they become extreme.

Though most women with POP often have no symptoms, some women experience:

  • Discomfort (usually pressure or fullness).
  • Bleeding from the exposed skin that rubs on pads or underwear.
  • Urinary symptoms of leakage, difficulty starting the stream of urine, frequent urinary tract infections.
  • Difficult bowel movements—the need to strain or push on the vagina to have a bowel movement.
  • A bulge near the opening of the vagina or have a pressure sensation in their pelvic region and or lower abdomen.

As POP worsens, you may notice:

  • A bulging, pressure or heavy sensation in the vagina that worsens by the end of the day or during bowel movements.
  • The feeling of “sitting on a ball”.
  • Needing to push stool out of the rectum by placing fingers into or around the vagina during a bowel movement.
  • Difficulty starting to urinate or a weak or spraying stream of urine.
  • Urinary frequency or the sensation that you are unable to empty the bladder well.
  • Lower back discomfort.
  • The need to lift up the bulging vagina or uterus to start urination.
  • Urinary leakage with intercourse. Though unusual, severe prolapse can block the flow of urine and cause recurrent urinary tract infections or even kidney damage.

 

Types of Prolapse

Anterior Vaginal Wall Prolapse (Cystocele or Urethrocele)

Anterior vaginal wall prolapse often occurs at the top of the vagina where the uterus used to be in women who have had a hysterectomy. This type of prolapse occurs when the bladder’s supportive tissue, called fascia, stretch or detach from the attachments securing it to the pelvic bones. With this loss of support, the bladder falls down into the vagina. As this condition worsens, the prolapsed pelvic organs may bulge outside the opening of the vagina. Other symptoms may include:

  • Urinary frequency, nighttime voiding, loss of bladder control, and recurrent bladder infections—usually due to the bladder not emptying well.
  • Stress urinary incontinence (SUI) with activity such as laughing, coughing, sneezing, or exercise) cause by weakened support for the urethra.

Posterior Wall Prolapse (Rectocele or Enterocele)

This type of prolapse occurs when the support tissue or fascia between the vagina and rectum stretches or detaches from its attachment to the pelvic bones. With this loss of support, the rectum or intestines fall (prolapse) into the vagina. Symptoms typically include:

  • A bulge sensation.
  • Problems having a bowel movement such as straining more with bowel movements and the feeling of not completely emptying the bowels.
  • The need to put your finger in or around the vagina or rectum to help empty bowels.

Apical Prolapse (Vaginal Vault Prolapse) or Uterine Prolapse

If a woman has had a hysterectomy, the top part of the vagina (vault) can become detached from the ligaments and muscles of the pelvic floor. Often, uterine or vault prolapse is associated with loss of anterior or posterior vaginal wall support. When the cervix protrudes outside the vagina, it can develop ulcers from rubbing on underwear, sometimes these ulcers will bleed if they become irritated. Most women experience symptoms of bulge or pressure sensation in the pelvis.

Rectal Prolapse

Like the vagina and uterus, ligaments, and muscles securely attach the rectum to the pelvis. Infrequently, the supporting structures stretch or detach from the rectal wall and the rectum falls out through the anus. Early on, women may notice a soft, red tissue protruding from the anus after a bowel movement. It can be confused with a large hemorrhoid. Other symptoms may include:

  • Pain during bowel movements.
  • Mucus or blood discharge from the protruding tissue.
  • Loss of control of bowel movements.

Risk factors for rectal prolapse include conditions associated with straining such as chronic constipation or diarrhea, nerve and muscle weakness (paralysis or multiple sclerosis), and advancing age are risk.

 

Currently we don’t know the cause of the prolapse and it is probably caused by a combination of things. Because there are probably different causes, there is no single way to prevent these problems.

Currently, a woman cannot change her genetic risk, which influences the strength of her connective tissue. However, women can make lifestyle choices to help reduce their risk of developing POP.

 

Pelvic Muscle Exercises

Pelvic muscle exercises (Kegel) strengthen or retrain the nerves and muscles of the pelvic floor. Regular daily exercising of the pelvic muscles can improve and even prevent urinary incontinence. This may be particularly helpful for younger women. Though pelvic floor exercises do not correct the prolapse, they may help control symptoms and limit the worsening of prolapse.

Over a period of time, you can strengthen your pelvic muscles and potentially decrease your symptoms of urgency or frequency. Go for 4 to 8 sets of 10 squeezes over the course of each day—in several weeks you’ll start to notice a difference.

To decrease your risk, make choices, which avoid increasing pressure inside the abdomen and on the pelvic floor.

 

DO

DON’T

Maintain a Normal Weight

  • Overweight women are at a significantly increased risk of developing prolapse.
  • If you are overweight, lose weight.
Smoke

  • Smoking increases your risk of POP.
  • If you smoke, quit.
Choose High Fiber and Drink Plenty of Fluids

  • A diet with plenty of fiber and fluids helps to maintain regular bowel function.
  • Constipation increases your risk for POP.
Strain During Bowel Movements

  • Chronic straining and constipation increase your chance of developing prolapse.
  • This is especially true for rectocele, rectum or intestines fall (prolapse) into the vagina.
Exercise Your Body and Pelvic Muscles

  • Physical activity helps maintain normal weight, as well as regular good bowel function.
  • Pelvic floor muscle exercises (Kegels) improve the strength of the pelvic floor and limit the likelihood of developing prolapse.
Perform Repetitive Strenuous Activities

  • Strong muscles are important for general health, especially as you age.
  • However, extreme repetitive activities put a stress on the pelvic area.
  • This increases your risk of UI and pelvic injury.
Get Your Health Checked

  • Chronic cough increases abdominal and pelvic pressure—see a doctor and get it treated.
  • Persistent constipation also requires further evaluation and treatment.
Use Your Lower Back or Abdomen for Heavy Lifting

  • Learn how to lift safely with your legs.
  • Use your leg and arm muscles as much as possible.

 

POP can worsen one’s quality of life. You don’t have to learn to live with it. Seek medical health and treatment whenever your symptoms have a negative impact on your life. You don’t have to wait until your symptoms are really bad.

During the initial appointment, your doctor will try to determine the severity of the prolapse. For example, your doctor will consider your age, symptoms of vaginal bulge, and difficulty having sex due to the feeling of the bulge. So, to help your doctor provide the best diagnosis for you, be open about difficulties with sexual relations.

POP is typically diagnosed by a simple pelvic exam as part of a complete physical exam. Your doctor may use a:

  • Speculum to examine the different parts of the vagina to determine which part of the vagina is prolapsing and to what extent.
  • Pelvic Organ Prolapse Quantification, or POP-Q, measurement system to assess severity of prolapse and track changes.

In addition, other exams or studies may help your doctor assess symptoms associated with prolapse:

  • Urodynamics: Bladder function study that assesses evaluates urinary incontinence or difficulty with urinating.
  • Cystoscopy: Procedure that uses a camera to look into the bladder for any anatomical abnormalities that could be contributing to urinary symptoms.
  • Defecography: Radiologic study to look at prolapse symptoms associated with bowel function.
  • Pelvic Ultrasound: Radiologic study that looks at reproductive organs, bladder, or muscles of the pelvic floor.
  • Pelvic Floor MRI: Radiologic study that assesses the muscles, organs, and support of the pelvic floor and helps to evaluate how the pelvic floor functions with straining.
  • CT Scan of Abdomen and Pelvis: Radiologic study that helps rule out other medical conditions that may have similar symptoms to prolapse

arrowIf you notice prolapsed pelvic organs, carefully describe the location of the bulging tissue (opening of the anus or the vagina). This is important information for your doctor to consider during diagnosis—rectal and vaginal prolapse may be present simultaneously. However, treatment options for a rectocele or posterior vaginal wall prolapsed and rectal prolapse are different.

Seeking medical help does not mean that you have to have surgery right away. Some women start with more conservative treatment like physical therapy and go on to surgery only if their symptoms from prolapse are not under control.

When considering your treatment options, it is best to work with your urogynecologist to make a plan that works best for you. A lot depends on your individual problems, and more depends on your preferences.

Urogyns and other doctors typically recommend a variety of therapies to relieve symptoms of prolapse, urinary or fecal incontinence, or other pelvic floor disorder symptoms.

With the dropping of the organs of the pelvic floor, many of the symptoms of POP are incontinence-related. Therefore, treatment approaches may help control symptoms of urinary or fecal incontinence.

With most types of pelvic organ prolapse, you have the following conservative (non-surgical) treatment options:

  • Watch for Now
    Not all prolapse requires treatment. The goals of treatment are to improve your quality of life. So, if the prolapse is not causing discomfort or interfering with the things you enjoy doing, your doctor may suggest holding off on treatment and watching for now.

Depending on your treatment preference, the severity of your symptoms, and your general health, POP surgery may be recommended. There are different types of POP surgeries. Before proceeding, please also review the mesh information and POP FAQs.

Work with your urogyn or provider, develop the most appropriate treatment plan that takes into consideration your overall health, lifestyle, and personal goals.

Surgery

Surgeons perform about 300,000 procedures for correction of POP each year in the United States. However, many more women suffer from this condition as they manage their prolapsed without surgery.

Many times, surgery is chosen when a vaginal pessary is either not desired or cannot be retained comfortably. There are several different surgical techniques which are effective. In addition to the experience and training of the surgeon, specific choices offered depend on you:

  • Anatomy
  • Overall health, prior surgeries and current medical conditions
  • Desire to retain sexual function

Whether or not to have surgery for prolapse is an individual decision. The success or failure of someone else’s operation should never be the deciding factor for you. Every woman’s situation is different. There is no single operation that is right for every patient. You and your urogynecologist must decide on the best option together.

Engage in a detailed discussion with your urogynecologist that includes an evaluation of your overall health, lifestyle, and activity goals (including sexual function) along with the risks of each procedure. This discussion will help you to determine the best procedure for you.

Pelvic reconstructive surgery can be performed through an incision in the vagina, through an incision made through the abdominal wall, or through a series of small incisions in the abdomen through which the surgeon places a laparoscope and instruments. Surgeons can also perform it with the assistance of a robot. Discuss the advantages and disadvantage of each of these approaches with your urogynecologist.

Doctors may suggest surgery if other treatments have failed. The goal of all reconstructive pelvic floor procedures is to restore normal pelvic floor anatomy and give the patient her best chance at maintaining a normal quality of life, including sexual intercourse if desired.

Surgery is a major decision you must make with your physician. You may find the tools below helpful in preparing for surgery. One presents questions to ask your doctor during your pre-op visit, providing an overview of what you can expect when preparing for surgery, and general recommendations for how you can prepare for surgery. The other offers information about mesh.

 

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