Pelvic Organ Prolapse
Pelvic organ prolapse (POP) is characterized by descent of pelvic organs from their normal positions. In women, the condition usually occurs when the pelvic floor collapses after gynecological cancer treatment, childbirth or heavy lifting.
In men, it may occur after the prostate gland is removed. The injury occurs to fascia membranes and other connective structures that can result in cystocele, rectocele or both. Treatment can involve dietary and lifestyle changes, physical therapy, or surgery.
Types
- Anterior vaginal wall prolapse
- Cystocele (bladder into vagina)
- Urethrocele (urethra into vagina)
- Cystourethrocele (both bladder and urethra)
- Posterior vaginal wall prolapse
- Enterocele (small intestine into vagina)
- Rectocele (rectum into vagina)
- Sigmoidocele
- Apical vaginal prolapse
- Uterine prolapse (uterus into vagina)
- Vaginal vault prolapse (roof of vagina) – after hysterectomy
Grading
Pelvic organ prolapses are graded either via the Baden–Walker System, Shaw's System, or the Pelvic Organ Prolapse Quantification (POP-Q) System.
Shaw's System
Anterior wall
- Upper 2/3 cystocele
- Lower 1/3 urethrocele
Posterior wall
- Upper 1/3 enterocele
- Middle 1/3 rectocele
- Lower 1/3 deficient perenium
Uterine prolapse
- Grade 0 Normal position
- Grade 1 descent into vagina not reaching introitus
- Grade 2 descent up to the introitus
- Grade 3 descent outside the introitus
- Grade 4 Procidentia
Baden–Walker
| Grade | Posterior urethral descent, lowest part other sites |
|---|---|
| 0 | normal position for each respective site |
| 1 | descent halfway to the hymen |
| 2 | descent to the hymen |
| 3 | descent halfway past the hymen |
| 4 | maximum possible descent for each site |
POP-Q
| Stage | Description |
|---|---|
| 0 | No prolapse anterior and posterior points are all −3 cm, and C or D is between −TVL and −(TVL−2) cm. |
| 1 | The criteria for stage 0 are not met, and the most distal prolapse is more than 1 cm above the level of the hymen (less than −1 cm). |
| 2 | The most distal prolapse is between 1 cm above and 1 cm below the hymen (at least one point is −1, 0, or +1). |
| 3 | The most distal prolapse is more than 1 cm below the hymen but no further than 2 cm less than TVL. |
| 4 | Represents complete procidentia or vault eversion; the most distal prolapse protrudes to at least (TVL−2) cm. |
Management
Vaginal prolapses are treated according to the severity of symptoms.
Non-surgical
With conservative measures (changes in diet and fitness, Kegel exercises, pelvic floor physical therapy.
With a pessary, a rubber or silicone rubber device fitted to the patient which is inserted into the vagina and may be retained for up to several months. Pessaries are a good choice of treatment for women who wish to maintain fertility, are poor surgical candidates, or who may not be able to attend physical therapy. Pessaries require a provider to fit the device, but most can be removed, cleaned, and replaced by the woman herself. Pessaries should be offered to women considering surgery as a non-surgical alternative.
Surgery
With surgery (for example native tissue repair, biological graft repair, absorbable and non-absorbable mesh repair, colpopexy, colpocleisis). Surgery is used to treat symptoms such as bowel or urinary problems, pain, or a prolapse sensation. A 2016 Cochrane review concluded that evidence does not support the use of transvaginal surgical mesh compared with native tissue repair for anterior compartment prolapse owing to increased morbidity. Safety and efficacy of many newer meshes is unknown. The use of a transvaginal mesh in treating vaginal prolapses is associated with side effects including pain, infection, and organ perforation. According to the FDA, serious complications are "not rare." A number of class action lawsuits have been filed and settled against several manufacturers of TVM devices.
Compared to native tissue repair, transvaginal permanent mesh probably reduces women's perception of vaginal prolapse sensation and probably reduces the risk of recurrent prolapse and of having repeat surgery for prolapse. On the other hand, transvaginal mesh probably has a greater risk of bladder injury and of needing repeat surgery for stress urinary incontinence or mesh exposure.
Epidemiology
Genital prolapse occurs in about 316 million women worldwide as of 2010 (9.3% of all females).
Research
To study POP, various animal models are employed: non-human primates, sheep, pigs, rats, and others.
See also
- Perineometer
- Pessary