Definition of "Pelvic organ prolapse"

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Pelvic organ prolapse (aka vaginal prolapse, female genital prolapse) is where a portion of the vaginal canal protrudes/prolapses from the opening of the vagina.

Patient information

What is pelvic organ prolapse?
It's where something usually found inside the body, pokes out of the vagina.

Pathophysiology
  • Pelvic floor collapses as a result of childbirth or heavy lifting, which can tear soft tissue, that is, herniating fascia membranes so that the vaginal wall collapses, resulting in cystocele, rectocele, or both

Patient information

Why does pelvic organ prolapse occur?
It's usually as a result of childbirth. Especially in women who've had multiple births, or large children. It can also happen in heavy lifting. What happens is that it damages wall-like structures that divide organs from one another, causing things to poke out. It's a bit like when you stretch dough for your pizza too much, you start getting a hole in the middle.

Classification

Pelvic organ prolapse can be graded according to Shaw's system, including:

  • Vaginal vault prolapse, which may occur after a hysterectomy, as there is no uterus supporting the interior end of the vagina
  • Anterior wall:
    • Lower 1/3: Urethrocele (urethra into vagina), where there is weakening of the tissues that hold the urethra in place, leading to descent of the anterior distal wall of the vagina
    • Upper 2/3: Cystocele (bladder into vagina), where the tough fibrous wall between a woman's bladder and vagina, the pubocervical fascia, is torn by childbirth, allowing the bladder to herniate into the vagina. It often occurs with urethroceles, known as cystourethrocele
  • Posterior wall:
    • Lower 1/3: Deficient perenium (i.e. wall between the vagina and anus)
    • Middle 1/3: Rectocele (rectum into vagina), caused by a tear in the rectovaginal septum (i.e. tough fibrous divider between the rectum and vagina), causing rectal tissue to bulge through this tear into the vagina as a herniation. It is caused by childbirth or hysterectomy
    • Upper 1/3: Enterocele (small intestine into vagina), which may also obstruct the rectum, causing obstructed defecation
  • Uterine prolapse (uterus into vagina):
    • Grade 0: Normal position
    • Grade 1: Descent into vagina not reaching introitus (aka vaginal orifice, i.e. just behind the opening of the urethra)
    • Grade 2: Descent up to the introitus
    • Grade 3: Descent outside the introitus
    • Grade 4: Procidentia (i.e. prolapse so severe the uterus is permanently protruding out of the vagina)


Source: ACOG

Patient information

There are so many words here. Urethrocele. Cystocele. Rectocele. Enterocele. Uterine prolapse. Procidentia. What's what?
The ending "-cele" means a "hernia". Hernia is anything that pokes out of where it shouldn't. As seen on the picture, on the front wall, the lower "urethra" can pull down - that's called a urethrocele. The higher "bladder" can also pull down - that's called a cystocele. On the back wall, the lower "rectum" can pull down - that's called a rectocele. The higher "small intestine" can pull down - that's called an enterocele. Uterine prolapse is where the middle "uterus" falls down. And procidentia is where the uterus prolapses so much it is permanently sticking out of the vagina, so it gets it's own special name .

Other types include:

  • Vaginal vault prolapse (roof of vagina), after hysterectomy (i.e. removal of the uterus), causing the roof of the vagina to fall down
Tx
  • Conservative:
    • Dietary and lifestyle changes, fitness
    • Physiotherapy, Kegel/pelvic floor exercises
    • Pessary, which is a device inserted into the vagina to provide structural support. Types include:
      • Ring pessary, used for grade 1-2 uterovaginal prolapses. It is the most common and easiest to use
      • Hodge pessary, for less severe cystoceles in women with a narrow pubic arch
      • Gehrung pessary, for cystoceles and rectoceles
      • Cube pessary, used for grade 3+ uterovaginal prolapse. It has no drainage and thus has to be removed nightly
      • Donut pessary, also used for grade 3+ uterovaginal prolapse. Compared with a ring pessary, it remains in place by having a larger diameter. To reach this diameter, it can be inflatable
      • Gellhorn pessary,  also used in grade 3+ uterovaginal prolapse, with decreased perineal support. It remains in place by fitting against the cervix or vaginal cuff, and avoiding having to rely on tissue further down the tract
  • Surgery, which is used to Tx Sx such as bowel or urinary problems, pain, or prolapse sensation
    • It includes lifting the internal contents back internally, followed by:
      • Transvaginal surgical mesh, in the from of a patch or sling, similar to its use for abdominal hernia
      • Colpocleisis, which is closure of the vagina
    • Hysterectomy (i.e. surgical removal of the uterus)
    • Laparoscopic hysteropexy
    • Sacrohysteropexy, a mesh-augmented procedure where the apex of the vagina is attached to the sacrum by a piece of mesh, thereby resuspending the prolapsed uterus to lift it and hold into place. It allows for normal sexual function and preserves childbearing function
    • Manchester operation (aka Fothergill operation), which reduces the cystourethrocele, and repositions the uterus within the pelvis

Patient information

What can you do about it?
Abdominal pressure puts pressure on things falling down, so we want to address that with lifestyle changes, to address things like weight loss. We can also try to improve muscle strength, because muscle is tough. It's strong. And it can help keep things in place. If that doesn't work, we use a pessary, which is a device inserted into the vagina to keep things from falling out. Essentially, it's a bit like a cap, physically blocking things from falling through. Another option is surgery, we can use a surgical mesh to keep things in place that way too. In postmenopausal women, they usually aren't concerned with sex anymore, so we can also permanently close the vagina.

Epidemiology
  • Occurs in 9.3% of all females
See also
  • Urinary incontinence (can be caused by pelvic organ prolapse)

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