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Also known as
POP, Genital prolapse, Pelvic floor prolapse, Vaginal prolapse, Pelvic relaxation, Descensus, Procidentia, Dropped pelvic organs, Herniation of pelvic organs
Definition
Pelvic organ prolapse (POP) is a gynecological condition characterized by the descent of pelvic structures into the vagina due to ligament or muscular weakness.1 It is subcategorized according to the compartment of descent: cystocele characterizes anterior wall herniation, rectocele refers to the posterior vaginal wall descent, and vaginal vault prolapse characterizes the descent of the uterus, cervix, or apex of the vagina.2
The condition occurs when the normal pelvic support is compromised by the weakening of the interaction between the levator ani muscle group and connective tissue attachments that stabilize the vagina at varying levels.3 With normal pelvic support, the vagina lies horizontally on top of the levator and muscles. Damage causes the levator ani muscles to become more vertical in orientation, opening the vagina and thus shifting support to the connective tissue attachments.4
Pelvic organ prolapse is multifactorial in etiology.5 Combinations of anatomical, physiological, genetic, lifestyle, and reproductive factors contribute to pelvic floor dysfunction throughout a woman’s lifespan. Many studies have correlated parity with a high incidence of POP.6 Additionally, prior pelvic surgeries or conditions associated with sustained episodes of increased intraabdominal pressure, such as heavy lifting, obesity, chronic cough, and constipation, can increase the risk of developing POP.7
Clinical Context
Pelvic organ prolapse (POP) is a common condition that significantly impacts women’s quality of life. The incidence is highly associated with increased age.8 Many women with symptomatic POP suffer physical and emotional distress, leading to a negative impact on social, physical, and psychological well-being.9 Although the exact prevalence is unknown, an analysis of hospital procedure codes reveals that approximately 200,000 surgeries for POP treatment are performed annually in the United States.10 Although about 41% to 50% of women present with POP on physical examination, only about 3% are symptomatic.11 The incidence of pelvic organ prolapse is projected to increase by 46%, to 4.9 million, by 2050.12
The majority of patients who present with pelvic organ prolapse do not report symptoms. Patients with symptoms, however, often describe a sense or feeling of a bulge protruding through the vaginal opening.13 A physical examination is essential to diagnose and subcategorize the type of prolapse. Exam findings vary depending on the bladder and rectum’s fullness. Women who present with procidentia (prolapse of all 3 compartments) can complain of vaginal discharge secondary to vaginal chafing or epithelial erosion.
Patients with POP have a high rate of coexisting pelvic floor disorders: 40% present with urinary incontinence, 37% present with overactive bladder, and 50% present with fecal incontinence.14 Patients should be routinely screened for alternative pathologies. In many cases, prolapse can mask hidden stress urinary incontinence.15 Due to urethral kinking or urethral pressure, bladder outlet obstruction can occur. Pelvic organ prolapse may negatively affect sexual activity, body image, and quality of life.
Both conservative and surgical management may be appropriate depending on the patient’s age, desire for future fertility and coital function, symptoms severity, and concomitant medical problems. The compartment of descent additionally dictates treatment. Goals of management include symptomatic relief, maintenance or improvement of sexual function, prevention of new support defects and incontinence, and restoration of adequate pelvic support.16
Treatment options include:
- Observation and close follow-up – Appropriate in women with mild, asymptomatic cases.
- Pelvic floor muscle training (Kegel exercises) – Allows systematic contraction of the levator ani muscles, strengthening the pelvic floor. These exercises have been proven to improve symptoms of stress, urge, and mixed incontinence and can be useful in women with mild POP.17
- Pessary management – Two-thirds of patients with symptomatic POP choose management with a pessary, and up to 77% continue use after 1 year.18 Pessaries are devices, often made of medical-grade silicone, positioned in the vagina to restore normal pelvic anatomy. They are an option for all stages of prolapse, useful to prevent progression and delay surgery.
- Surgical intervention – Various procedures, both abdominal and vaginal, are performed to restore pelvic floor function and relieve symptoms. Options include:
- Colpoclesis (obliterative procedure)
- Sacrospinous fixation
- Iliococcygeus suspension
- Uterosacral suspension
- Abdominal sacrocolpopexy (laparotomy, laparoscopy, or robotic-assisted)19