Pelvic organ prolapse (POP) is a hernia of the pelvic organs to or through the vaginal opening. Approximately 200,000 operations are performed yearly in the United States for POP. Although not life threatening, POP is life altering and results in significant quality of life changes in women.
What is Pelvic Prolapse?
The pelvic organs (bladder, uterus and rectum) are supported by a complex “hammock” that includes the pelvic muscles, ligaments, and their attachment to the bony anatomy of the pelvis. Damage to these support systems results in descent of the pelvic organs. Pelvic Prolapse is not a new problem. Pelvic Prolapse and its consequences have been written about since 2000 B.C. While minor degrees of Pelvic Prolapse affect up to 50% of women who have had a vaginal delivery, only 20% have symptomatic Pelvic Prolapse that prompts women to seek care. In general, mild cases of Pelvic Prolapse have no symptoms and do not require medical intervention, while more severe cases are generally bothersome to women.
Treatment options for Pelvic Prolapse are limited and include the use of pessaries,surgery or watchful waiting. Disappointing surgical results as well as high recurrence rates after treatment unfortunately have led many women to avoid seeking treatment.
Risk factors for the development of Pelvic Prolapse include difficult vaginal deliveries, family history of Pelvic Prolapse, obesity, advancing age, prior hysterectomy, and conditions such as chronic constipation or habitual coughing.
Commonly, women with severe Pelvic Prolapse report feeling or seeing a “ball” or protrusion from the vagina. Women with mild Pelvic Prolapse may also describe feelings of heaviness or pressure that may be present all the time or only after a long day of being on their feet or after heavy physical exercise. During a routine vaginal exam, the degree of prolapse can be determined. Pelvic Prolapse commonly occurs with other pelvic floor disorders including bladder and bowel problems such as urinary or anal incontinence, constipation and overactive bladder. Symptoms for one pelvic floor problem should prompt questioning for all other disorders as women often have more than one pelvic floor problem. Fortunately, mild Pelvic Prolapse rarely affects sexual function although more severe Pelvic Prolapse may lead to decreased rates of sexual activity.
Prolapse or support problems can affect one or multiple organs of the pelvis. Weakness of the frontside vaginal wall near the bladder results in a cystocele, often called a “dropped bladder”. Weakness of the vaginal ceiling results in uterine prolapse, known as an enterocele. Defects of the backside vaginal wall near the rectum results in a rectocele.
Mild pelvic organ prolapse that is asymptomatic does not require treatment. Some prolapse will improve on its own with watchful waiting, although it is not possible to identify whose Pelvic Prolapse will improve with time. Pessaries represent non-surgical options for managing symptomatic prolapse. Pessaries are medical-grade plastic devices that come in a variety of shapes and sizes and are placed in the vagina to provide support to the pelvic organs. Since women come in all shapes and sizes, pessaries need to be fitted to the individual.
There are many different types of pessaries and multiple sizes of each type. Fitting is by trial and error. A successful pessary is one that is comfortable and relieves prolapse symptoms by providing support of the displaced organ(s). Topical estrogen cream is considered helpful in preventing and even treating vaginal ulcers that may develop with pessary use. Pessaries should be removed and cleaned regularly, depending on amount of vaginal discharge, type of pessary, and patient preference. While vaginal discharge may develop with pessary use, it rarely is associated with an infection and therefore antibiotics are not typically needed. Most women can learn to care for their pessaries themselves. However, women who cannot care for their pessaries need to have the pessary removed and cleaned on a regular basis by their health care provider, e.g. every three months.
Although there are limited non-surgical management options for Pelvic Prolapse, there is emerging information that pelvic floor exercises, or Kegels, may have some limited effectiveness in addressing symptoms of Pelvic Prolapse.
Reconstructive surgery is a mainstay of treatment for Pelvic Prolapse. Approximately 11% of women will have surgery for Pelvic Prolapse and/or urinary incontinence prior to 80 years of age. Unfortunately, nearly 30% of these women will need another surgery due to failure or recurrence of prolapse or treatment of another, often related pelvic floor problem.
Prolapse repairs can be done through a vaginal approach, abdominal incision or through a laparoscope (when a scope is placed through the belly button). More recently, robot-assisted procedures are being done for prolapse. Early data on minimally invasive approaches, including the robot and laparoscope, indicate reduced recovery time, shorter hospital stays, and less blood loss for the patient.
Because few surgeons are fully trained in the robotic technique, data collection is continuing.
What is the best surgery for the treatment of Pelvic Prolapse? Since women are individuals, the best treatment is a decision that needs to be made between a woman and her surgeon. In general, open abdominal repairs using graft materials are thought to have higher success rates at the cost of increased morbidity. Because of less than optimal success rates with traditional repairs, pelvic surgeons are constantly looking for new surgeries to approach this problem. Many surgeons are using vaginal graft materials (made of synthetic and biologic materials) in attempts to improve long-term success rates. However, little research has been done to prove that this improves results without increasing complications.
Research is currently being done to determine if the use of vaginal graft materials in Pelvic Prolapse surgical repairs is more effective and longer lasting than use of a woman’s own tissue for repair. For women who never plan on having sexual intercourse again, there are relatively simple surgeries that have nearly a 100% success rate. In these techniques the vagina is shortened so that it can no longer prolapse. After these surgeries, vaginal intercourse is impossible. These techniques are ideally suited for the elderly patient with severe prolapse and multiple medical problems that would otherwise place her at increased risk with an invasive, reconstructive approach.
As the population grows older, the number of women who develop Pelvic Prolapse will increase. Preventive strategies have yet to be identified and are needed. Some risk factors for Pelvic Prolapse cannot be changed (such as your family history), but others, including constipation, can. While evidence suggests that women having three or more vaginal deliveries are at two to three times greater risk of Pelvic Prolapse than others, the risks of cesarean versus vaginal delivery as a prevention strategy remain unsupported by research.