Pelvic Organ Prolapse

last authored: Jan 2011, Riki Dayan
last reviewed: July 2011, Wayne Asher

 

 

 

Introduction

Pelvic organ prolapse is the downward decent of the pelvic organs resulting in the protrusion of the vagina and/or uterine cervix and does not include rectal prolapse. The type of pelvic organ prolapse depends on the organ protruding into the vaginal canal and includes uterine prolapse, cystocele (bladder), urethrocele (urethra), enterocele (peritoneum and small bowel) and rectocele (rectum). Prolapse is caused by the loss of muscular and/or connective tissue supports to the pelvic organs.

 

 

 

The Case of Victoria C

Victoria is a 60 year old post menopausal woman who has come into your office complaining of a ‘bulge’ protruding from her vagina. She notices that the protrusion increases when she coughs or sneezes and gets worse as the day continues. She describes the mass as having a heavy pulling sensation in her pelvis and complains that she can no longer wear tampons.

After taking Victoria’s medical history you learn that five years ago she had a hysterectomy after the delivery of her third child. Victoria does not smoke, has never dealt with on-going constipation and has not had any incontinence problems.

- What do you think could be the main causal factor in Victoria’s prolapse?
- What type of prolapse do you suspect Victoria has?
- Are there other conditions that could present with similar symptoms?

return to top

 

 

Causes and Risk Factors

Prolapse is caused by a loss of muscle and/or connective tissue support to the pelvic organs. Loss of support can result from chronic increases in intra-abdominal pressure, pelvic surgery, muscle damage and/or genetic predisposition.

 

Risk factors include:

return to top

 

 

 

Pathophysiology

Prolapse is caused by the loss of connective tissue and/or muscular support of the organs. The levator ani and coccygeus muscles that make up the pelvic diaphragm provide upper support of the pelvic organs. Weaknesses in the supporting structures of the levator ani muscles, or in the muscles themselves, can cause an enlargement of the urogenital hiatus and/or changes in the vaginal axis, predisposing women to prolapse. The endopelvic fasciae and suspensory ligaments that attach the uterus and vagina to the pelvic walls also provide upper support. Lower support for the pelvic organs is supplied by the perineal membrane and associated muscles anteriorly and the anal sphincter posteriorly.

The pelvic diaphragm provides support to pelvic organs in resisting increases in intra-abdominal pressure. In cases where the supporting muscles are damaged or weak, the connective tissue and ligaments must support the organs without the assistance of the muscular pelvic floor, resulting in a strain on connective tissue supports. If the connective tissue is already weak, the tissue may undergo further damage and prolapse may result. Often, prolapse involves weakness in both muscular and connective tissue supports.


Classification

The anatomical classification of pelvic organ prolapse is based on which part of the vaginal wall is protruding and is separated into four parts – anterior vaginal wall, apical vaginal wall (middle compartment), posterior vaginal wall, and perineal body defects. Anterior vaginal wall prolapse includes cystocele and urethrocele. Cystocele results from weakness in the central, lateral or combined supports of the anterior vaginal wall. Urethrocele is uncommon and often results from urethral hypermobility. Apical vaginal wall prolapse includes enterocele and uterine prolapse. Posterior vaginal wall prolapse is often the result of rectocele and can occur low, mid-vaginally or high. Also, vaginal vault eversion (post-hysterectomy) and uterovaginal prolapse can occur in conjunction with cystocele, enterocele, and rectocele. The last category of prolapse, perineal body defects, is a weakening of the lower pelvic support and often results in multiple organ prolapse.

return to top

 

 

 

Signs and Symptoms

  • history
  • physical exam

History

It is important to note that not all women with pelvic organ prolapse will experience symptoms and often prolapse will only be treated in the presence of symptoms. A clinical history of symptoms should be separated into four primary areas – lower urinary tract, bowel, sexual and other local symptoms. The history should also explore the patient’s exposure to risk factors that may predispose them to prolapse.

Lower urinary tract symptoms, such as incontinence, occur in some women in conjunction with prolapse. In 80% of clinically continent women with severe prolapse, a pessary or speculum being used by a clinician during an exam can produce stress incontinence. This is termed latent, masked, occult or potential stress incontinence and is often found in women with cystocele. The mechanism is likely because of a relief of compression on the urethra or urethral kinking resulting in incontinence. Other lower urinary tract symptoms to explore include storage symptoms, symptoms of bladder over activity, and voiding symptoms (such as frequency, nocturia, and urgency). Voiding symptoms, such as difficulty voiding, are often associated with severe cystocele prolapse. Difficulty voiding is likely caused by a urethral kink or external pressure on the urethra. Finally, it is also important to remember that incontinence symptoms are a common complaint in women without prolapse and become more common with aging.

Bowel symptoms often occur in women with rectoceles. Stool can get trapped in the rectal bulge and cause difficult defecation and/or excessive straining (tenesmus). Patients that experience difficulty defecating may need to manually splint to reduce their rectal reservoir or may need to manually evacuate the rectum. Constipation may also be associated with rectocele, or it may be a factor that predisposes the patient to prolapse.

Sexual symptoms are often results of multi-causal and multidimensional problems that involve psychological, physiological and interpersonal factors. Dealing with sexual problems goes beyond the scope of this chapter but a simple evaluation of symptoms can be valuable. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ) is a condition-specific questionnaire on sexual function in women with pelvic organ prolapse and urinary incontinence. The questionnaire has been validated and shown to be reliable (Rogers et al, 2001).

The last part of the clinical history should consider other local symptoms. These include vaginal pressure or heaviness, vaginal or perineal pain, awareness of tissue protruding from vagina, lower back pain, abdominal pressure or pain, and palpation of a mass.

Physical Exam

A physical exam of the abdomen and pelvis should be done. The abdominal exam should evaluate the skin, surgical incisions, and presence of hernias or abdominal masses. The pelvic exam should be done in the lithotomy position, however some suggest that the pelvic exam should be completed in a semi-upright or upright position to assess the full extent of prolapse. The examiner should assess for prolapse both with and without straining in order to fully understand the degree of prolapse.

The external and internal genitalia should be examined for dermatologic lesions, inflammatory conditions, estrogen deficiency, urine or abnormal vaginal discharge, pelvic organ prolapse and abnormal pelvic masses. The pelvic exam should be done with full bladder to assess stress incontinence. Another exam should be completed on an empty bladder to assess pelvic organ prolapses and masses. Completion of a bimanual examination to assess pelvic organs, anterior vaginal wall, apical wall (cervix, uterus, vault), posterior vaginal wall, rectovaginal septum, perineal body, anal sphincter, urogenital hiatus and assessment of pelvic floor muscle strength. A urinalysis test, post-void residual urine test and Q-tip test (urethral hypermobility) may also be useful in assessing cystoceles and urethroceles.

Clinical Classification

Clinical classification uses the Pelvic Organ Prolapse Quantification (POPQ) system. Degree of prolapse is measured with the patient in the dorsal lithotomy position and while the patient is straining. The hymenal ring, rather than the introitus, is used as the principal reference point for measure the degree of prolapse. Negative numbers (in centimeters) are given to structures that have not prolapsed beyond the hymen and positive numbers are given to structures that have prolapsed beyond the hymen.

 

The POPQ system divides prolapse into four stages outlined below:

  • Stage 0 = no prolapse
  • Stage I = most distal portion of prolapse is more than 1 cm above the level of the hymen
  • Stage II = most distal portion of the prolapse is 1 cm of less proximal or distal to the hymenal plane
  • Stage III = the most distal portion of the prolapse protrudes more than 1 cm below the hymen but protrudes no farther than 2 cm less than the total vaginal length (ie. not all of the vagina has prolapsed)
  • Stage IV = vaginal eversion is essentially complete

return to top

 

 

 

Investigations

  • lab investigations
  • diagnostic imaging

Lab Investigations

Urinalysis and culture should be taken to identify if an infection is present. Voided cytology should be taken to identify malignant cells, which indicate a carcinoma. Cystometry can be done to identify stress or masked incontinence.

Diagnostic Imaging

Although uncommon, some cases may indicate that further testing is necessary to determine the type and degree of prolapse.

Urodynamic testing can be done in prolapse with urethral obstruction

Ultrasound and cystoscopy can be useful to differentiate the type of prolapse in patients with severe and/or multiple organ prolapse and to rule out the presence of tumours

MRI may also be used to identify prolapsed organs in patients with complex organ prolapse

return to top

 

 

 

Differential Diagnosis

The differential should diagnose between different types of prolapse and coexisting prolapse. Patient history and physical exams should correlate with the type of prolapse diagnosed. Other conditions to be considered include:

return to top

 

 

 

Treatments

There are several types of pessary devices that can be used to help support the vaginal walls and its associated support systems. The American Academy of Family Physicians has provided guidance on how to use pessaries for uterine prolapse (Viera and Larkins-Pettigrew; 2000).

Physiotherapy can use pelvic muscle exercises to strengthen pelvic floor support and should be considered as a non-invasive treatment option. Lifestyle changes cannot cure prolapse but can assist in alleviating symptoms and slow worsening. These include loosing weight if obese or overweight and avoiding constipation, heavy lifting and smoking.

Finally, surgery can be done to help and/or correct prolapse by removing and/or reinforcing tissue.

return to top

 

 

 

Consequences and Course

If left untreated uterine prolapse will gradually worsen. Additionally, the cervical or vaginal epithelium may become damaged or ulcerated and lead to a secondary infection. In this case the patient may present with vaginal bleeding, discharge or pain.

return to top

 

 

 

Resources and References

Rogers G, Villarreal A, Kammerer-Doak D, Qualis C. Sexual function in women with and without urinary incontinence and/or pelvic organ prolapse. International Urogynecology Journal and Pelvic Floor Dysfunction. 2001 Nov;12(6):361-365.

Viera A, Larkins-Pettigrew M. Practical use of the pessary. Journal of American Family Physicians 2000;61:2716-2726.

return to top

 

 

Topic Development

authors: Riki Dayan, 2011

reviewers: Wayne Asher, 2011

 

return to top