Gab Kovacs1 and Paula Briggs2
(1)
Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
(2)
Sexual and Reproductive Health, Southport and Ormskirk Hospital, Southport, UK
Definition
Incidence
Aetilogy and Pathogenesis
Clinical Assessment
History
Examination
Investigations
Treatment
Conservative Management
Surgical
Complications
Prognosis
Definition
Pelvic organ prolapse can be divided into three types (Fig. 9.1):
Fig. 9.1
Types of utero-vaginal prolapse
· Anterior prolapse – prolapse of the bladder through the anterior vaginal wall (or less commonly the urethra).
· Posterior prolapse – prolapse of the rectum or small bowel (enterocoele) through the posterior vaginal wall.
· Vault prolapse – prolapse of the uterine body (or the vaginal vault after hysterectomy).
Incidence
It is estimated that about 50 % of women over 50 experience some degree of prolapse.
Aetilogy and Pathogenesis
The aetiology of POP is multifactorial and only a few items on the aetiological shopping list are relevant:
· Congenital – there are genetic factors related to connective tissue quality, which predispose to the development of a POP.
· Traumatic – the excessive stretching of the ligaments, fascia and other connective tissue during childbirth results in collagen breakdown, with the new collagen being less resilient. The more deliveries, the bigger the babies, the longer the second stage of labour, the greater the potential damage to the tissues.
· Denegenerative – with advancing age, skeletal muscle tone and volume are reduced. This can contribute to the development of POP.
Obestity which can become more common with advancing age is also a contributory factor.
· Endocrine – the ligamentous structures, pelvic muscles and fascia all contain oestrogen receptors, and lack of oestrogen after the menopause has some effect on POP. Progesterone receptors are fewer, and lack of progesterone is less significant.
· Iatrogenic – complicated operative deliveries and previous pelvic floor repair operations may be a contributory factor.
Clinical Assessment
History
The principal symptom experienced is the sensation of “something coming down”.
· Discomfort is sometimes reported as a “dragging feeling”.
· Whether there are associated urinary or bowel symptoms depends on the type of prolapse. A rectocoele may be associated with difficulty with defaecation.
· Urinary symptoms are described in detail in Chap. 10.
Examination
Abdominal Examination
Should always precede vaginal examination to exclude an abdominal or pelvic mass pushing the pelvic organs down.
Speculum Examination
This is usually carried out in the dorsal position, although using a Sim’s speculum, in the left lateral position, may have a place. The vagina is inspected for anterior or posterior bulges. It is often not possible to diagnose whether an enterocoele (the bulge contains small bowel) is present until the time of surgery.
The degree of uterine prolapse/descent is determined according to the Pelvic Organ Prolapse Quantification System (POP- Q) as:
· Stage 0 – No prolapse
· Stage I – descent of the cervix. Cervix more than 1 cm above the hymen.
· Stage II – descent within 1 cm above or below the hymen.
· Stage III – descent more than 1 cm past the hymen..
· Stage IV – complete vault eversion- also called procidentia.
The presence of stress incontinence can be diagnosed by asking the patient with a full bladder to cough – a swab in a sponge holder should be held at the ready near the urethra to catch any urine before spraying the examiner.
Bimanual Examination
A routine bimanual examination should be undertaken, assessing the size of the uterus, its mobility, and the presence of any pelvic lesions, e.g. ovarian cysts.
Investigations
There are no investigations required for POP per se. Investigations to assess urinary symptoms are discussed in Chap. 10.
Treatment
Conservative Management
Conservative management of POP should be considered prior to surgical intervention.
· In women who are overweight, weight loss should be recommended as a first line treatment.
· Pelvic floor exercises – “Kegel’s” exercises, are recommended several times a day. In order to do these exercises, women need to identify the appropriate muscles by stopping the flow of urine mid stream. They should then learn to contract these muscles for 10 s, relax for 10 s and repeat ten sets at least three times daily.
Directed pelvic floor physiotherapy is highly recommended. Pelvic floor exercises have a positive effect on prolapse symptoms and severity, as reported in a Cochrane analysis.
· Pessaries can be used to manage POP. There are many different types of pessaries available made of either silicone or inert plastic. Ring pessaries are the first line option as they are easy to insert and remove. More advanced-stage prolapse may require the use of a space occupying pessary. These pessaries are not suitable for women who are sexually active.
Hormonal -
· Local oestrogen (delivered directly to the vagina) is a useful treatment for women with atrophic vaginitis. It may also be helpful for women suffering from incontinence. This treatment is suitable for all women.
There are a variety of different ways of delivering this form of therapy including creams, tablets and via a vaginal ring impregnated with a low dose of oestradiol which is released at a steady rate over a period of 3 months.
Surgical
Surgical management of prolapse is determined by the compartment affected, the size of the prolapse and most importantly by informed patient choice.
A variety of options are available including fascial repairs or ligamentous anchors. The repair operation is usually done by a vaginal approach, but laparoscopic pelvic floor repair is gaining in popularity.
Complications
This depends on the type of POP and its severity. Rectocoele may cause difficulty with defaecation, and cystocoele may cause urinary symptoms (see Chap. 10). A uterine prolapse may cause cervical ulceration, discharge and bleeding.
Prognosis
POP without treatment may get worse with time and age.