W. Stuart Reynolds, MD, MPH
Roger R. Dmochowski, MD, MMHC, FACS
BASICS
DESCRIPTION
• Pelvic organ prolapse (POP): The descent of one or more of the anterior vaginal wall, posterior vaginal wall, uterus/cervix, or apex of vagina (vaginal vault or cuff after hysterectomy)
• Cystocele: Anatomic defect of the anterior vaginal wall in which bladder prolapses into the vagina
• Enterocele: Anatomic defect of the vaginal apex typically; small intestine prolapses into the vagina
• Rectocele: Anatomic defect of the posterior vagina; the rectum prolapses into the vagina
• Defects in many or all vaginal compartments (anterior, posterior, apex) may occur together
EPIDEMIOLOGY
Incidence
Insufficient data to conclusively establish incidence rates
Prevalence
• Estimates vary, based on definitions, symptoms, and/or physical exam findings
– 3% of US women report symptoms of vaginal bulging
– 40% of US women have POP on exam
• Women have an 11% lifetime risk of undergoing surgery for POP and/or UI by age 80
RISK FACTORS
• Age
• Race/ethnicity (Hispanic > White > African American)
• Parity
• Obesity
• Hysterectomy
• Prior POP surgery
• Menopause
• Pelvic strain (high impact activity or work)
Genetics
• Increased familial risk (sisters and mothers)
– 2.5 times more common if positive family history for POP
• Inheritable collagen disorders (eg, Ehlers–Danlos syndrome)
• Genome-wide studies ongoing with several potential candidate genes identified, most related to elastin and collagen metabolism (eg, LAMC-1)
PATHOPHYSIOLOGY
• Integrated support to the bony pelvis through the endopelvic fascial structures, suspensory ligaments, levator ani muscles, and pelvic organs help maintain the pelvic organs in the proper anatomic position in the pelvis.
• Classically, three levels of vaginal support are described:
– Level I: Uterosacral and cardinal ligaments support upper 1/3 of vagina, cervix, and uterus.
– Level II: Pubocervical and rectovaginal fascia attach laterally to the arcus tendineus fascia pelvis to support midportion of vagina
– Level III: Direct attachment of vagina to urethra, perineal body, and levator ani muscles
• Damage or weakness to the muscular and connective tissue supporting mechanisms, including innervation, contribute to POP
ASSOCIATED CONDITIONS
• Urinary incontinence
– Stress urinary incontinence (SUI)
Present in 65% of POP
– Occult SUI (“masked” or “latent” SUI)
SUI only observed after reduction of POP
Present in 25–80% of women with POP, especially with advanced stages
• Lower urinary tract symptoms
– Overactive bladder
– Voiding dysfunction
Advanced POP (stage III or greater) may result in urethral “kinking” resulting in bladder outlet obstruction
• Upper urinary tract obstruction
– Advanced POP may result in bilateral ureteral obstruction with hydronephrosis
• Bowel dysfunction
– Constipation
– Fecal/anal incontinence
• Sexual dysfunction
– Dyspareunia
GENERAL PREVENTION
• Weight management
• Protective role of elective cesarean section debatable
DIAGNOSIS
HISTORY
• Assess for prolapse symptoms
– Vaginal bulging, including visualization or palpation of a “bulge” in the vagina
– Pelvic pressure, heaviness, or dragging sensation
– Vaginal mucosal irritation, bleeding, discharge, and/or infection
– Splinting/digitation: Applying manual pressure to vagina or rectum to assist with voiding or defecation
– Low backache, temporally associated with POP
• Assess for other pelvic floor symptoms
– Urinary incontinence and voiding dysfunction
– Constipation/anal incontinence
– Dyspareunia
PHYSICAL EXAM
• Useful to employ POP staging
– POP quantification system (POPQ)
Stage 0: No prolapse is demonstrated
Stage I: Most distal portion of the prolapse is >1 cm above the level of the hymen
Stage II: Most distal portion of the prolapse is 1 cm or less proximal to or distal to the plane of the hymen
Stage III: The most distal portion of the prolapse is >1 cm below the plane of the hymen
Stage IV: Complete eversion of the total length of the lower genital tract is demonstrated
• Assessment of urinary incontinence
– Provocative maneuvers (cough and Valsalva) to demonstrate urethral leakage; repeated with prolapse reduced to detect occult SUI
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis and urine culture, as indicated
• Serum creatinine, BUN: May be abnormal in advanced POP with bladder outlet or ureteral obstruction
Imaging
• Routine imaging is not indicated; imaging may supplement exam with complex cases
• Defecography
– Assesses defecatory dysfunction, including degree of rectocele and rectal emptying
• Voiding cystourethrogram
– Assesses degree bladder prolapse and bladder neck function; may detect fistula, vesicoureteral reflux, or urethral diverticulum
• Pelvic ultrasound
– Allows dynamic assessment of pelvic organs and bladder volume
• Magnetic resonance imaging (MRI)
– Allows dynamic imaging of functional relationships among the pelvic floor viscera and supporting structures, and assesses pelvic pathology
– Expensive; clinical utility over exam alone not established
Diagnostic Procedures/Surgery
• Postvoid residual (PVR) urine volume
• Urodynamic testing
– Routine use not indicated; clinical utility not established
– May detect voiding dysfunction or occult incontinence with POP reduction
– Urethral function tests (leak point pressure, urethral pressure profilometry) assess urethral function and degree of SUI, if any
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Uterovaginal prolapse
• Cystocele
• Enterocele
• Rectocele
• Soft tissue vaginal mass
• Urethral diverticulum
TREATMENT
GENERAL MEASURES
• Management is primarily surgical
• Bowel regimen for constipation
• Hormone replacement, topical vaginal, for atrophic vaginitis
– Estrogen alone in postmenopausal with after hysterectomy; estrogen and progesterone if uterus present, even if postmenopausal
MEDICATION
First Line
N/A
Second Line
N/A
SURGERY/OTHER PROCEDURES
ALERT
The FDA has identified safety concerns with use of synthetic mesh materials for POP repair, specifically for transvaginal placement of synthetic mesh/prosthetics (See “Additional Reading”).
• Transvaginal approach
– Allows for concomitant repair of anterior, posterior, and apical compartment defects and anti-incontinence procedures
– Augmentation of native tissue repairs with biologic or synthetic materials/grafts
Outcomes improved with augmented materials, but graft materials may pose safety concerns (1)[A]
Transvaginal “mesh kits”: Prepackaged medical devices for transvaginal placement of mesh material
– Anterior colporrhaphy or paravaginal repair
– Posterior colporrhaphy, perineorrhaphy
– Vaginal apical/vault suspension
Sacrospinous ligament fixation
Uterosacral ligament fixation
• Abdominal approach
– Abdominal sacrocolpopexy (ASC)
Open, laparoscopic, or robotic approaches
Vaginal apex fixation to the presacral fascia at S3–S4 using biologic or synthetic material
• Hysterectomy
– Transvaginal or transabdominal approach
– Complete vs. supracervical
Potential increased risk of vaginal mesh exposure after ASC in setting of hysterectomy; supracervical hysterectomy may be protective (2)[B]
• Colpocleisis
– Closure or removal of the entire vagina
Reserved for those who are not candidates for more extensive surgery or do not plan future vaginal intercourse
Partial colpocleisis (Le Fort colpocleisis)
Total colpocleisis
• Concomitant anti-incontinence procedure
– Retropubic colposuspension (Burch)
Prophylactic Burch procedure with ASC can decrease subsequent SUI by 50% (3)[A]
– Suburethral sling, including midurethral (MUS) and pubovaginal, synthetic or biologic graft materials
Prophylactic, synthetic MUS at time of vaginal POP surgery reduces need for additional surgery in women at 12 mo (OR 0.48, 95% CI 0.30–0.77) (4)[A]
Number of slings needed to prevent 1 case of SUI at 12 mo is 6 (4)[A]
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Vaginal pessary: Supportive and space-occupying devices for nonsurgical management of POP
– Requires routine maintenance and care (removal, cleaning, vaginal inspection)
Complementary & Alternative Therapies
• Pelvic floor muscle training
– Pelvic muscle strengthening can improve stage and symptoms, best with supervision of a physical therapist
ONGOING CARE
PROGNOSIS
• Recurrent POP
– Historically 30% recurrence rate after surgery
COMPLICATIONS
• Mesh material complications occur in 10% of women (1)[B]
• Perioperative complications of bleeding, pelvic organ injury, bladder dysfunction, infection
• Postoperative complications include vaginal and pelvic pain, vaginal shortening or narrowing, dyspareunia
FOLLOW-UP
Patient Monitoring
• Evaluation for recurrent or de novo POP through history and exam
• Evaluation for urinary incontinence after POP surgery, if anti-incontinence procedure not performed
• Routine evaluation for complications related to synthetic mesh materials, if used in POP surgery
– Patient history for vaginal symptoms, discharge, bleeding, dyspareunia
– Physical exam for vaginal exposures
– Cystoscopy for lower urinary tract perforations, as indicated
Patient Resources
Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU). http://www.sufuorg.com/Patient-Education/Learn-About-Pelvic-Disorders.aspx
REFERENCES
1. Maher CM, Feiner B, Baessler K, et al. Surgical management of pelvic organ prolapse in women: The updated summary version Cochrane review. Int Urogynecol J. 2011;22:1445–1457.
2. Diwadker GB, Barber MD, Feiner B, et al. Complication and reoperation rates after apical vaginal prolapse surgical repair: A systematic review. Obstet Gynecol. 2009;113:367–373.
3. Brubaker L, Cundiff GW, Fine P, et al. Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med. 2006;354:1557–1566.
4. Wei JT, Nygaard I, Richter HE, et al. A midurethral sling to reduce incontinence after vaginal prolapse repair. N Engl J Med. 2012;366:2358–2367.
ADDITIONAL READING
• FDA Safety Communication. Urogynecologic surgical mesh: Update on the safety and effectiveness of transvaginal placement for pelvic organ prolapse, 2011: www.fda.gov.
• Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010;29:4–20.
See Also (Topic, Algorithm, Media)
• Cystocele
• Cystocele Grading
• Incontinence, Urinary, Adult Female
• Pelvic Organ Prolapse (Cystocele and Enterocoele) Image 
• Pelvic Organ Prolapse Quantification System (POP-Q)
• Pelvic Organ Prolapse Terminology
• Prolapse, Staging Systems
• Urethra, Caruncle
• Urethrocele
CODES
ICD9
• 618.00 Unspecified prolapse of vaginal walls
• 618.6 Vaginal enterocele, congenital or acquired
• 618.9 Unspecified genital prolapse
ICD10
• N81.5 Vaginal enterocele
• N81.9 Female genital prolapse, unspecified
• N81.10 Cystocele, unspecified
CLINICAL/SURGICAL PEARLS
• Complete assessment of all vaginal compartments for POP staging is essential, including occult SUI.
• Nonsurgical treatments with pelvic floor muscle exercises and vaginal pessary should be offered prior to surgical intervention.
• Surgical repair with augmentation materials improves outcomes, but may pose serious safety risks.
• Patients must be informed of ongoing FDA concerns regarding safety of synthetic mesh materials used in POP surgery.
• Patient monitoring for recurrence and delayed mesh-related complications is imperative.