Pelvic Organ Prolapse

Background

• Pelvic organ displacement and prolapse results from loss of connective tissue and muscular support of the pelvic floor.
  • The most common anatomic defect is in the anterior vaginal wall resulting in bladder prolapse (cystocele).
  • When the posterior vaginal wall is affected the prolapse involves the rectum (rectocele) and occasionally the small intestine (enterocele).
  • When the vaginal apex is affected the prolapse involves the uterus and cervix (uterine prolapse) or if post hysterectomy the vaginal cuff (vaginal vault prolapse). The small intestine (enterocele), colon (sigmoidocele), or bladder (cystocele) may also be involved in the prolapse.
• Factors associated with an increased risk of pelvic organ prolapse include history of vaginal delivery, advancing age, increasing parity, and obesity.
• Stress urinary incontinence occurs in up to 40% of women with mild-to-moderate pelvic organ prolapse while symptoms associated with urinary outlet obstruction are more likely to occur in women with advanced prolapse.

Evaluation

• Diagnosis is usually made clinically by pelvic exam and most women require little to no additional testing beyond history and physical exam to make the diagnosis.
• Urodynamic testing may be used to assess extent of urinary incontinence and efficiency of bladder voiding and/or to determine potential for occult stress incontinence.
• Endometrial biopsy and/or ultrasound to assess for uterine disease may be indicated in women with a history of abnormal uterine bleeding prior to surgical intervention for pelvic organ prolapse.

Management

• Consider watchful waiting in any woman with pelvic organ prolapse on physical exam but without bothersome symptoms.
• Treatment is indicated only if prolapse causes bothersome bulge and pressure symptoms, sexual dysfunction, lower urinary tract dysfunction, and/or defecatory dysfunction.
• Pelvic floor muscle training may improve symptoms of pelvic organ prolapse.
• Offer vaginal pessary as an alternative to surgery to all women considering treatment of pelvic organ prolapse (Strong recommendation).
• Surgical correction of pelvic organ prolapse is usually delayed until all anticipated childbearing has been completed.
• The surgical approach to pelvic organ prolapse is either reconstructive or obliterative.
  • The goal of reconstructive surgery is correction of pelvic prolapse and relief of associated symptoms while maintaining sexual function.
  • The goal of obliterative surgery is to minimize surgical time and complications by correcting pelvic prolapse by closure of the vaginal canal and narrowing of the genital hiatus. This approach is reserved for older women who do not desire to maintain use of vagina for intercourse.