Pelvic Organ Prolapse

Updated: Jun 20, 2016
  • Author: George Lazarou, MD, FACOG, FACS; Chief Editor: Kris Strohbehn, MD  more...
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Overview

Background

With the gradual increase in life expectancy in developed countries over the past century, obstetrician-gynecologists are expected to be familiar with disorders of the elderly population. Pelvic organ prolapse (POP) and urinary incontinence (UI) are common conditions affecting many adult women today.

Pelvic organ prolapse is the abnormal descent or herniation of the pelvic organs from their normal attachment sites or their normal position in the pelvis. The pelvic structures that may be involved include the uterus (uterine prolapse) or vaginal apex (apical vaginal prolapse), anterior vagina (cystocele), or posterior vagina (rectocele). Many parous women may have some degree of prolapse when examined; however, most prolapses are not clinically bothersome without specific pelvic symptoms, and they may not require an intervention.

In this article, the authors discuss the clinical presentation, pathophysiology, evaluation, and management of pelvic organ prolapse.

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History of the Procedure

Pelvic organ prolapse and its consequences have been reported since 2000 BC. Hippocrates described numerous nonsurgical treatments for pelvic organ prolapse. In 98 CE, Soranus of Rome first described the removal of the prolapsed uterus when it became black. The first successful vaginal hysterectomy for the cure of uterine prolapse was self-performed by a peasant woman named Faith Raworth, as described by Willouby in 1670. She was so debilitated by uterine prolapse that she pulled down on the cervix and slashed off the prolapse with a sharp knife. She survived the hemorrhage and continued to live the rest of her life debilitated by urinary incontinence. From the early 1800s through the turn of the century, various surgical approaches have been described to correct pelvic organ prolapse.

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Problem

Pelvic organ prolapse is a defect of a specific vaginal segment characterized by descent of the vagina and associated pelvic organ. Patients may present with varying degrees of prolapse. In the most severe case (complete pelvic organ prolapse), the pelvic organ protrudes completely through the genital hiatus. In such cases of pelvic relaxation, multiple defects are associated in the anterior, lateral, posterior, and apical compartments.

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Epidemiology

Frequency

The exact prevalence of pelvic organ prolapse is difficult to determine. However, the lifetime risk of requiring at least 1 operation to correct incontinence or prolapse is estimated at approximately 11%. [1] About 200,000 inpatient procedures are performed annually in the United States. [2]

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Etiology

Pelvic floor defects may be created as a result of childbirth and are caused by the stretching and tearing of the endopelvic fascia and the levator muscles and perineal body. Pregnancy itself, without vaginal birth has been sited as a risk factor as well. A study by Handa et al suggests that vaginal birth and operative vaginal birth increase an individual’s risk for urinary incontinence and pelvic organ prolapse 5-10 years after delivery when compared with cesarean delivery without labor. [3]

Partial pudendal and perineal neuropathies are also associated with labor. [4] Impaired nerve transmission to the muscles of the pelvic floor may predispose the muscles to decreased tone, leading to further sagging and stretching. Therefore, multiparous women are at particular risk for pelvic organ prolapse. Genital atrophy and hypoestrogenism also play important contributory roles in the pathogenesis of prolapse. However, the exact mechanisms are not completely understood. Prolapse may potentially result from pelvic tumors, sacral nerve disorders, and diabetic neuropathy.

Other medical conditions that may result in prolapse are those associated with increases in intra-abdominal pressure (eg, obesity, chronic pulmonary disease, smoking, constipation). Certain rare abnormalities in connective tissue (collagen), such as Marfan disease, have also been linked to genitourinary prolapse. [5] A thorough evaluation and definition of all support defects is of critical importance because most women with pelvic organ prolapse have multiple defects. [6]

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Presentation

In a 1999 study of Swedish women aged 20-59 years, Samuelsson and colleagues found that, although signs of pelvic organ prolapse are frequently observed, the condition seldom causes symptoms. [7] Minimal pelvic organ prolapse generally does not require therapy because the patient is usually asymptomatic. However, vaginal or uterine descent at or through the introitus can become symptomatic. Symptoms of pelvic organ prolapse may include a sensation of vaginal fullness or pressure, sacral back pain with standing, vaginal spotting from ulceration of the protruding cervix or vagina, coital difficulty, lower abdominal discomfort, and voiding and defecatory difficulties. Typically, the patient feels a bulge in the lower vagina or the cervix protruding through the vaginal introitus.

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Indications

Identification of concomitant pelvic defects before surgery facilitates simultaneous repair of other defects and minimizes the chance for recurrence. Optimally, surgeons should plan the most appropriate procedures necessary to correct all defects in the same surgical setting. When a patient presents with complaints of pelvic organ prolapse, a detailed history and a site-specific assessment of all pelvic floor defects are critical to the evaluation. Patients are often referred for asymptomatic prolapse. Shull's axiom that "the asymptomatic patient cannot be made to feel better by medical or surgical therapy" provides good advice. [8] The gynecologist's responsibility is to address the individual needs and wishes of the patient.

Quality of life assessment by standardized questionnaires (eg, Pelvic Floor Distress Inventory – short form 20, Pelvic Floor Impact Questionnaire – short form 7, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire – PISQ 12) are also helpful in determining appropriate treatment. A detailed sexual history is crucial, and focused questions or questionnaires should include quality-of-life measures. Voiding difficulties and urinary frequency, urgency, or incontinence are common symptoms associated with pelvic organ prolapse. If present, these symptoms should be investigated because advanced prolapse may contribute to lower urinary tract dysfunction, including hydronephrosis and obstructive nephropathy. Surgery for the correction of incontinence may also be less successful in patients with pelvic organ prolapse. [9]

Voiding dysfunction is also common for some patients with advanced degrees of pelvic organ prolapse because they may often have concomitant descent of the anterior vaginal wall. An anatomic kinking of the urethra may cause obstructive voiding and urinary retention. The preoperative evaluation should include determination of the postvoid residual urine volume to exclude obstruction as a consequence of urethral kinking or incomplete emptying secondary to poor bladder contractility.

Evaluation

A thorough preoperative assessment can prevent many postoperative complications. The author has previously reported on a series of patients with significant anterior vaginal wall prolapse who exhibited urinary retention. Each patient underwent preoperative prolapse reduction testing using a pessary. This test was found to have high sensitivity, specificity, and positive predictive value for the postoperative cure of urinary retention. In this series, reconstructive pelvic surgery cured most patients with urinary retention problems. [10]

Note significant medical history (eg, obesity, asthma, long-term steroid use) that may have contributed to prolapse or urinary incontinence. If possible, attempting to correct some of these problems before any surgical treatment may be wise. Recurrences may be more likely if such conditions are not addressed.

A site-specific physical evaluation is essential. Methods for noting pelvic floor relaxation include (1) the Baden halfway system, (2) the International Continence Society (ICS) classification using the Pelvic Organ Prolapse Quantification (POPQ) system, and (3) the revised New York Classification (NYC) system. [11, 12, 13]

Most clinicians routinely use the ICS classification (POP-Q) system, which is classified as follows:

  • Stage 0 - No prolapse
  • Stage I - Descent of the most distal portion of prolapse is more than 1 cm above the level of the hymen.
  • Stage II - Maximal descent of prolapse is between 1 cm above and 1 cm below the hymen.
  • Stage III - Prolapse extends more than 1 cm beyond the hymen, but no more than within 2 cm of the total vaginal length.
  • Stage IV - Total or complete vaginal eversion

Evaluate the patient in both the lithotomy and standing positions, during relaxation, and during maximal straining. To perform the evaluation, place a standard double-bladed speculum in the vaginal vault to visually examine the vagina and cervix. The speculum is removed and taken apart, leaving only the posterior blade, which is then replaced into the posterior vagina, allowing visualization of the anterior wall. The monovalve speculum is then everted to view the posterior wall. Note the point of maximal descent of the anterior, lateral, and apical walls in relation to the ischial spines and hymen. Next, place 2 fingers into the vagina such that each finger opposes the ipsilateral vaginal wall, and ask the patient to bear down. After evaluating the lateral vaginal support system, assess the apex (cervix and apical vagina). Repeat the examination with the patient standing and bearing down to note the maximum descent of the uterine prolapse.

Next, grade the strength and quality of pelvic floor contraction, asking the patient to tighten the levators around the examining finger. Assess the external genitalia, noting estrogen status, diameter of the introitus, and length of perineal body. Perform a careful bimanual examination and note uterine size, mobility, and adnexa. Lastly, perform a rectal examination, assessing the external sphincter tone and checking for the presence of rectocele or enterocele.

When the patient has significant anterior vaginal wall prolapse (cystocele), it is important to exclude the development of postoperative potential incontinence (PI) prior to management of pelvic organ prolapse. By definition, PI is the development of incontinence only when the prolapse is reduced. This unmasking of urinary incontinence is a result of a possible unkinking of the urethra with the prolapse reduced. If potential incontinence is not addressed before reconstructive surgery, up to 30% of patients may become incontinent after surgical repair. [14]

To test for potential incontinence, a cystometrogram is performed, and the bladder is retrograde filled to maximum capacity (or at least 300 mL) with sterile water or saline while the pelvic organ prolapse is replaced and elevated digitally or with an appropriately fitted pessary. If the patient leaks urine during Valsalva or with cough, the patient may benefit from an anti-incontinence procedure performed concomitantly with the pelvic organ prolapse surgery.

This approach of performing adequate testing (urodynamics) prior to management of pelvic organ prolapse (especially during sacrocolpopexy surgery) is supported by several studies. [15] However, other authors have challenged the accuracy and predictability of urodynamics prior to open sacrocolpopexy (Colpopexy and Urinary Reduction Efforts [CARE] trial) and advocated a prophylactic Burch colposuspension be performed concomitantly with sacrocolpopexy to reduce postoperative development of stress urinary incontinence. [16] In a recent study of practice questionnaire of American Urogynecological Society (AUGS) members, most clinicians (57%) would not perform a prophylactic anti-incontinence procedure (Burch colposuspension) at the time of sacrocolpopexy, illustrating the existing ongoing debate on the issue of preoperative testing and management of PI. [17]

Appropriate management of significant pelvic organ prolapse that is bothersome to the patient includes a trial of pessary or surgery. For patients in whom conservative management has failed, a variety of surgical approaches to correct pelvic organ prolapse are available.

When planning the appropriate approach, the surgeon must consider operative risk, coital activity, and vaginal canal anatomy. The following list illustrates variables that must be considered.

Important considerations for nonsurgical or surgical decision making

See the list below:

  • Medical condition and age
  • Severity of symptoms
  • Patient's choice (ie, surgery or no surgery)
  • Patient's suitability for surgery
  • Presence of other pelvic conditions requiring simultaneous treatment, including urinary or fecal incontinence
  • Presence or absence of urethral hypermobility
  • Presence or absence of pelvic floor neuropathy
  • History of previous pelvic surgery
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Relevant Anatomy

Knowledge of the anatomy of the pelvis is essential to understanding prolapse. Teleologic reasoning aids in the understanding of pelvic organ prolapse. The pelvic floor evolved in primates, particularly humans, who as bipeds spend most of their waking hours in the upright position. As the name suggests, the floor of the pelvis is the lowest boundary on which all the pelvic and abdominal contents rest. The pelvic floor is composed of a sling of several muscle groups (levators) and ligaments (endopelvic fascia) connected at the perimeter to the 360° ovoid bony pelvis.

Furthermore, knowledge of the biaxial orientation of the vagina and uterus is critical to understanding the anatomic and functional relationships and to proper surgical restoration of the pelvic supports.

In the supine position, the upper vagina is almost horizontal and superior to the levator plate. [18] The uterus and apical vagina have 2 principal support systems. Active support is provided by the levator ani; passive support is provided by the condensations of the endopelvic fascia (ie, uterosacral-cardinal ligament complex, pubocervical fascia, rectovaginal septum) and their attachments to the pelvis and pelvic sidewalls through the arcus tendineus fascia pelvis. The levator ani muscles are fused posteriorly to the rectum and attach to the coccyx. The genital hiatus is the perforation on the pelvic floor through which the urethra, vagina, and rectum pass.

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Contraindications

Contraindications to surgical correction of pelvic organ prolapse are based on the patient's comorbidities and her ability to tolerate surgery. Patients with mild pelvic organ prolapse do not require surgery because they are usually asymptomatic.

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