What is Pelvic Organ Prolapse?

Pelvic organ prolapse is a general term that refers to the relaxation of support of pelvic organs. Most women describe this as having a “fallen bladder” or “fallen vagina.” They may become aware of it by seeing a vaginal bulge, or feeling a sensation of sitting on a ball, or sensing a pelvic heaviness or strain especially when they have been on their feet for a long time. Prolapse is not an all or nothing condition. A woman can experience prolapse of only one organ, or may have prolapse of several. The severity of support defects can vary between patients and even vary with different pelvic organs within the same patient. Prolapse can progress in severity overtime.

Organs that can commonly prolapse from the pelvis through the vagina include: bladder, rectum, small bowel, and uterus. The terms that doctors may use to describe prolapse of these organs are: cystocele, rectocele, enterocele, and uterine prolapse. Complete eversion of the vagina with the uterus falling outside of the vagina is termed procidentia. After removal of the uterus by hysterectomy, the top of the vagina is referred to as the apex or vault. Complete eversion of the vagina after a hysterectomy which produces a large bulge which can appear like a baby’s head crowning is termed vault prolapse.


What Causes Prolapse?

Medical science does not know all the causes of prolapse, nor can the cause be certain in each case. Several things have been implicated as significant risk factors for pelvic organ prolapse. High on the list of potential risk factors are pregnancy and child birth. The role of episiotomy at the time of vaginal delivery in causing pelvic floor dysfunction is controversial. The forces placed on a woman’s pelvic ligaments and muscles are extreme in childbirth and even just strain on these structures by a pregnant uterus is not without effect. Vaginal tears or other birth injury, a prolonged 2nd stage of labor, or vaginal delivery in general may lead to nerve, muscle, and connective tissue injury. The number of children delivered (parity) also appears to be a significant risk for prolapse development with higher rates in women who deliver higher numbers of children. So does that mean that our friends who have never had children will not ever develop prolapse? No, they can too. Potential risk factors unrelated to reproduction are : hysterectomy (especially if performed for uterine prolapse), other pelvic surgery, aging (0.1% for 20-29 years old), menopause, obesity, chronic obstructive pulmonary disease, smoking, constipation, and congenital factors.

Do women who run or work out all the time avoid this problem?

Interestingly, very physically fit women can also develop pelvic organ prolapse. In fact, studies evaluating the pelvises of elite female atheletes by MRI have shown that many of their pelvises show features of weakened pelvic support, not the opposite. Additionally, some obstetrical studies suggest that they have unexpected difficulty with progression of labor. We are all at risk!

What symptoms does pelvic organ prolapse cause?

Prolapse can be asymptomatic, meaning the woman may not be aware she has any prolapse at all. Other times women see or feel a vaginal bulge. Some describe the feeling as sitting on a ball. Women may complain of a pelvic heaviness or pressure that worsens with time such that it is worse at the end of the day, especially if she has been on her feet all day. If the prolapse is large enough, a woman may notice irritation and abrasion to the skin over the vaginal bulge due to friction between her skin and underwear. Symptoms may also be related to specific pelvic organ functions such as urination or defecation. A large prolapse may need to be manually pushed back into the vagina to assist in bladder emptying or defecation. Women may notice some difficulty with vaginal penetration during sexual activity. However, despite the variety of symptoms, prolapse is almost never a dangerous condition.

Is prolapse preventable?

Some specialists in female pelvic medicine suggest that cesarean section delivery is protective of the pelvic floor against prolapse and incontinence; however, elective cesarean section for the purpose of protecting the pelvic floor is controversial . Certainly, prolapse does not occur in every woman who delivers one or more children vaginally, suggesting that there are other risk factors at play. What those factors are is not clear. Genetic research may reveal that some women are genetically predisposed to prolapse due to differences in connective tissue collagen type or content.

Pelvic floor muscle exercises have been shown to improve urinary incontinence but their effect on the prevention of pelvic organ prolapse has not been studied. In theory, since prolapse is due to weakness in connective tissue support in addition to muscle weakness, pelvic exercises that target only the muscle component and are limited in benefit at that are not likely to correct any prolapse. Whether regular pelvic floor exercise would help avoid prolapse before it happens or prevent recurrence after surgery for prolapse is not known. I usually tell my patients that pelvic floor exercises may or may not be beneficial to the prevention of prolapse or to stopping its progression, but they are never harmful and provide other benefits. For that reason, if my patient is motivated to do them I will encourage her to do so.


Does prolapse interfere with sex?

Most of the time prolapse won’t interfere with sex. The bulge just gets pushed back in by the penetrating penis. However, high grade prolapse may make penetration more difficult. Additionally, high grade prolapse  is most often seen in postmenopausal women in their 60’s or older, and their partners tend to be of the same age or older. If their partners are experiencing erections that are less rigid, they may already be experiencing trouble with penetration which the prolapse exacerbates. Urologists (who are always full of humorous analogies and anecdotes regarding genitalia) have a question they pose to men to assess their erection rigidity, “Do you stuff it or stick it?” If he has to stuff anyway, the prolapse will make that harder.

Prolapse is frequently associated with decreased pelvic muscle tone. Whether this is due to a muscular defect, a nerve defect or both is not clear. Women with these kind of defects often describe a feeling of “everything down there feeling loose and stretched out.” They may even state that they “don’t feel anything down there like I used to.” A prolapse repair can achieve restoration of the anatomy, but it does not restore the muscle tone or nerve function. It is highly unlikely that a woman would improve her sexual sensation or sense of muscle tone by prolapse surgery. The temptation to “tighten things up” for women may present itself but that comes at a high risk of shortening the vagina and causing pain with intercourse afterward.

Whether prolapse surgery translates into an improved sexual experience for a woman’s male partner has not been studied to my knowledge. If the woman hopes to achieve improvement of her muscular “grasp” on the penis during intercourse, I would advise her to pursue pelvic floor exercises alone or in combination with biofeedback from an experience pelvic floor physical therapist.


Who should I see about symptoms of prolapse?

In general. only female pelvic medicine and reconstructive surgery specialists address prolapse care. If you don’t know of such a specialist in your community, ask your friends and your primary care physician for a recommendation and then do your own research. Specialists may be urologists, gynecologist or “urogynecologists.” Check their background. Do they have a good reputation, acceptable experience and specialized training such as a fellowship? These are just some of the things I suggest you consider, but other qualities that may be just as important can only be assessed by meeting the specialist such as their attitude, ability to communicate and passion for their work.

What should I expect at the doctor's office?

The doctor should introduce herself, welcome you to her practice and make you feel comfortable about being there. Then she will ask you why you have come. She will also ask you many questions about associated symptoms, past and present medical conditions, family medical history, surgical history, medications and allergies. She will perform a physical exam including a pelvic exam in most cases. More invasive procedures such catheterization or cystoscopy are not routine for the evaluation of prolapse, so don’t be afraid to see the specialist.

What are my options if I have prolapse?

Do nothing

The option to not choose intervention is reasonable. Prolapse is a quality of life issue, so if the woman isn’t bothered then nothing needs to be done. If she is bothered but only minimally or only occasionally, the risks and costs of intervention may outweigh any benefit . A woman should not be talked into taking action for prolapse that doesn’t bother her except in rare instances in which the prolapse is associated with more dangerous conditions.

Pessaries

A pessary is an ancient treatment. Hippocrates gave a description of a pomegranate placed in the vagina as a pessary to compress a prolapsing uterus. Today’s pessaries are “plastic” devices in a variety of shapes and sizes that are worn in the vagina to compress and contain a bulge within the vagina. This is a nonsurgical treatment for prolapse. Although it does not correct the problem, it contains it while it is worn. It does have to be removed and cleaned periodically which most patients can do for themselves, and it has to be removed for intercourse. Similar to a diaphragm in look, it does not protect against pregnancy in women who may be fertile.

Pessaries are fit to each patient, meaning that the treating physician examines the patient to assess the depth, caliber if the vagina, the size and location of the prolapse, and the health and thickness of the vaginal tissues. From this assessment the doctor or nurse chooses a pessary shape and size. The pessary should fit snugly but not uncomfortably. Patients are usually asked to “test drive” it in the office, meaning that they should walk around with it in and make sure that they have no pain. They may even try urinating before they leave the office.

Not all women are good candidates for pessaries. A woman with very thin and delicate tissues related to severe loss of estrogen may be at risk for bleeding, irritation and ulceration of her vaginal tissues by the pessary. If she is a candidate for topical vaginal estrogen supplementation then she may find that use of this topical medication for a month before pessary fitting will counteract and reduce that risk. If she cannot have topical estrogen due to a personal history of breast cancer, then non hormonal products like Replens or Trimosan ointment can be tried with the pessary. If at follow up visits, the vaginal tissues are found to be very irritated or ulcerated despite the added creams, the pessary should be discontinued.  Patients with pessaries should have regular follow up with their doctors.

Some women have a vaginal opening (introitus) that is loose and does not have the muscular resistance to retain the pessary. These women can find that with exertion or activity the pessary falls out. Some women who may be able to retain a pessary during the day will have it pop out when they strain to have a bowel movement. If it does fall into the toilet, she can fish it out, clean it and reuse it. A pessary costs about $40-$60.

Although most women can be taught how to remove, clean and replace their pessary as often as they like and at least every 8 to 10 weeks, some can’t for various reasons. These women will come to the doctor’s office on a scheduled basis where either the doctor or a nurse will perform this necessary maintenance for her. This situation is not ideal, but necessary for the infirmed or frail elderly.

A pessary must be removed for most sexual activity. If you are bothered enough to consider a pessary and healthy enough to have this fixed, you probably will want to go ahead and get it fixed. If you don’t have time for recovery right now for whatever reason, maybe a pessary is going to be a bridge option until you have the time for surgery. For the elderly and or ill woman, pessaries may be a tremendous improvement in quality of life over her bothersome prolapse.

Surgery

It is possible to surgically repair prolapse. Surgery is meant to restore the anatomy to a normal position within the pelvis and from the patient’s standpoint, it will get rid of the vaginal bulge, but women should not expect that they achieve the pelvis of a 20 year old again. In other words, “revirgination” as I have heard it called is not the goal of pelvic reconstruction, nor is it possible in my opinion. Prolapse surgery can be accomplished either from an abdominal approach in which an incision is made on the lower abdomen, or from a vaginal approach in which all incisions are through the vagina. Hospital stay is usually much shorter with vaginal surgeries (1 day vs. several days), but activity restrictions and recovery time may be fairly similar for the two approaches.

Sometimes people refer to these surgeries as a bladder lift or bladder tack. Although the bladder may indeed be elevated, usually so too is the top of the vagina because any vaginal bulge large enough to protrude outside of the vagina likely does so because the support of the top of the vagina is also weak.

It is not uncommon that when I meet a woman in my office for the first time, she often tells me that whatever problem she is seeking help for now, first occurred “right after the birth of my first child.” In most cases, she also tells me that it wasn’t very bad back then or she used to be able to anticipate trouble and prepare for it, but now she can’t. Whether aging accounts for the apparent change in severity of the condition or whether the problem actually progresses is not known, but this story is so common as to suggest that both are possibilities.

If the doctor tells you that you have prolapse but you have not noticed it or been bothered by it, don’t worry about. Do not have surgery for prolapse that does not bother you. It may progress and you can elect for surgery when it bothers you or causes some other problem. Even if you retain some urine because of it but aren’t having many infections why take any risk for a benign condition that doesn’t bother you? If however you are bothered by the prolapse, ask yourself whether you want a chance at correcting the problem or whether your goal is to avoid surgery at all costs. If you know that you either can’t have surgery or don’t want to have surgery at all, then the decision is easy, you are going to try a pessary. If you are healthy and you feel ready to accept the risks of surgery and the time needed for recovery than you are in a good place to consider surgical repair.


Copyright © 2014 Harriette Scarpero and PrattWebSolutions