Female Pelvic Organ Prolapse

Pelvic organ prolapse is a very common condition, particularly among older women. It's estimated that half of women who have children will experience some form of prolapse in later life, but because many women don't seek help from their doctor the actual number of women affected by prolapse is unknown.

Prolapse may also be designated as uterine prolapse, genital prolapse, uterovaginal prolapse, pelvic relaxation, pelvic floor dysfunction, urogenital prolapse or vaginal wall prolapse.

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Prolapse of the anterior (front) vaginal wall:

  • Cystocele (bladder prolapse);
    • When the bladder prolapses, it falls towards the vagina and creates a large bulge in the front vaginal wall. It's common for both the bladder and the urethra (see below) to prolapse together. This is called a cystourethrocele and is the most common type of prolapse in women.
Cystocele: image 1 of 2 thumb Cystocele: image 2 of 2 thumb

 

  • Urethrocele (prolapse of the urethra);
    • When the urethra (the tube that carries urine from the bladder) slips out of place, it also pushes against the front of the vaginal wall, but lower down, near the opening of the vagina. This usually happens together with a cystocele
  • Prolapse of the posterior (back) vaginal wall:
    • Enterocele (prolapse of the small bowel);
      • Part of the small intestine that lies just behind the uterus (in a space called the Pouch of Douglas) may slip down between the rectum and the back wall of the vagina. This often occurs at the same time as a rectocele or uterine prolapse.
    • Rectocele (prolapse of the rectum or large bowel);
      • This occurs when the end of the large bowel (rectum) loses support and bulges into the back wall of the vagina. It is different from a rectal prolapse (when the rectum falls out of the anus).
Rectocele: image 1 of 2 thumb Rectocele: image 2 of 2 thumb

 

  • Uterine and vaginal vault prolapse (apical or top):
    • Uterine prolapse;
      • Uterine prolapse is when the womb drops down into the vagina. It is the second most common type of prolapse and is classified into three grades depending on how far the womb has fallen.
        • Grade 1: the uterus has dropped slightly. At this stage many women may not be aware they have a prolapse. It may not cause any symptoms and is usually diagnosed as a result of an examination for a separate health issue.
        • Grade 2: the uterus has dropped further into the vagina and the cervix (neck or tip of the womb) can be seen outside the vaginal opening.
        • Grade 3: most of the uterus has fallen through the vaginal opening. This is the most severe form of uterine prolapse and is also called proccidentia.
  • Vaginal Vault Prolapse

    The vaginal vault is the top of the vagina. It can only fall in on itself after a woman's womb has been removed (hysterectomy). Vault prolapse occurs in about 15% of women who have had a hysterectomy for uterine prolapse, and in about 1% of women who have had a hysterectomy for other reasons.
Proccidentia: image 1 of 3 thumb Proccidentia: image 2 of 3 thumb Proccidentia: image 3 of 3 thumb

 

Normal pelvic anatomy is maintained by:

  • Pelvic floor muscles
  • Connective tissue
  • Vaginal axis:
    • Pelvic floor muscles: Which are in a state of chronic contraction
      • Close the urogenital hiatus
      • Lift the pelvic organs
      • Relieve strain on the ligaments
    • Connective tissue
      • Allows dissipation of musculoskeletal forces
      • Suspends uterus and vagina from pelvic sidewalls
      • Provides three levels of support
    • Vaginal axis
      • Almost horizontal in nulliparous women
      • More vertical axis predisposes to prolapse
  • There are still many issues yet to be resolved:
    • Prevalence
    • Definitions
    • Classification
    • Pathogenesis
    • Management
  • Statistics:
    • Ratio of surgery for prolapse vs incontinence: 2:1
    • Prevalence of 31% in women aged 20-59yrs.
    • Responsible for 20% of women awaiting major gynaecological surgery in the UK.
    • > 1/2 million prolapse surgeries /yr (USA)
    • 11% lifetime risk of at least one operation.
    • Re-operation in nearly 1/3rd.
  • Compounding Problems:
    • Embarrassment leads to silence
    • Time constraints lead to inadequate attention
    • Knowledge limits lead to patient acceptance (changing)
    • Technology limits lead to inadequate investigation (especially rural areas)
    • Resource limits lead to inadequate access
    • Quality of Life Impact:
      • Impact on lifestyle and avoidance of activities
      • Fear of losing bladder control
      • Embarrassment
      • Impact on relationships/sexual satisfaction
      • Increased dependence on caregivers
      • Discomfort and skin irritation
  • Factors associated with Female Pelvic Organ Prolapse:
    • Age
    • Parity
    • Big babies
    • Menopause
    • Obesity
    • > 1 Termination of pregnancy
    • Occupation
    • Home delivery
    • Family history
  • Pathogenesis (causation):
    • Childbirth
    • Connective tissue factors
    • Menopause
    • Chronic elevation of intra-abdominal pressure
    • Iatrogenic
  • Childbirth:
    • Strongest risk factor in Oxford-FPA study (1997)
    • May predispose to prolapse by:
    • Disruption of tissue
    • Denervation of pelvic floor muscles
    • Hormonal effects in pregnancy
    • Pressure of uterus and contents
    • Denervation (stretch or crush injury to pudendal nerve)
    • Connective tissue changes or injury (fascia)
    • Mechanical disruption of muscles and sphincter
    • Pelvic floor musculature is weaker following vaginal delivery
    • 50% of women with symptomatic prolapse have levator ani denervation
    • Pudendal Nerve Denervation:
      • Related to length of 2nd stage/Parity/Birthweight
      • Occurs after vaginal delivery but not abdominal delivery
      • Evidence of neuropathy in women with rectal and vaginal prolapse
      • Pudendal nerve studies
      • EMG of pubococcygeus
    • Pelvic floor damage/dysfunction can result from:
      • Vaginal delivery
      • Pregnancy itself
      • Ageing
      • Estrogen deficiency
      • Neurological
  • Connective tissue (CT) factors:
    • Main components are Collagen and Elastin
    • Collagen has great tissue strength and flexibility
    • CT is living tissue and undergoes remodelling
    • More likely to be damaged by rupture than stretching
    • Predisposition towards prolapse may be a result of abnormal CT
  • Hormone Effects:
    • Common embryonic origin of bladder urethra and vagina from urogenital sinus
    • High concentration of oestrogen receptors in tissues of pelvic support
    • General collagen deficiency state in postmenopausal women due to the lack of oestrogen
    • Urethral coaptation affected by loss of oestrogen
    • However; HRT not very effective!
  • Increased Intra-abdominal Pressure:
    • Pulmonary disease
    • Constipation/straining
    • Lifting
    • Exercise
    • Ascites/hepatomegaly
    • Obesity
  • Symptoms of Female Pelvic Organ Prolapse:
    • Urinary:
      • Frequency
      • Urgency
      • Poor/Intermittent/Completely obstructed flow
      • Stress Incontinence
    • Sexual: Dyspareunia
      • Inhibited intromission
      • Expulsion
      • Altered sensation
    • Bowel:
      • Faecal trapping (digital splinting)
      • Faecal incontinence
      • Incontinence of Flatus
    • Other
      • Can see it/Feel it
      • Back pain
      • Dragging sensation
      • Increased discharge
      • Skin irritation

The Treatment of Pelvic Organ Prolapse

  • Non-surgical Treatment:
    • Physiotherapy
      • Pelvic floor exercises
      • Vaginal cones
      • Devices for reinforcement

As a general rule the vaginal pessaries, which come in many different shapes and are fitted for size, are removed every 3-4 months.

The doctor then checks the health of the vaginal wall tissues with a speculum examination and, if satisfied that the vaginal walls are in good condition, will replace the same pessary after it has been washed and cleansed.


The patient should be placed on local (vaginal) oestrogen treatment (creams or pessaries) which reduce the risk of excoriation, infection and breakdown of the vaginal skin.

These oestrogen therapies are distinct from HRT and are essential for vaginal health in the presence of these long term foreign bodies.
Vaginal ring pessaries tend to be favoured by women who have not completed their family, who are too frail to undergo surgery or as a temporary measure whilst awaiting definitive surgery.

The Surgical Management of Prolapses

  • Principles of Pelvic Reconstructive Surgery:
    • Restoration of pelvic structures to normal anatomical relationships
    • Restore and maintain urinary &/or faecal continence
    • Maintain coital function
    • Correct co-existing pelvic pathology
    • Obtain a durable result
  • Patient assessment:
    • Careful history
    • Physical examination
    • Neurological assessment
    • Urodynamic evaluation
    • Anorectal investigations
  • Factors affecting choice of operation:
    • Surgeons' own expertise, experience and preference
    • Pre-op voiding or bowel dysfunction
    • Duration of efficacy
    • Complications
    • Learning curve
    • Quality of life factors
    • First or repeat surgery
    • The need to treat other pathology
    • Fitness of the patient
    • Underlying pathology
    • Success rates for different procedures
  • Summary - Female Pelvic Organ Prolapse
    • Uterovaginal prolapse is multifactorial in origin
    • Treatment needs to be individualised
    • Approach often needs to be multidisciplinary
    • Quality of life assessment is essential
  • Future Issues:
    • Risk prediction models (like in maternal-fetal medicine and oncology)
    • Computer technology/neural network technology
    • Cooperative efforts: Colorectal/Gynaecologyn/Urology
  • Future Research:
    • MRI pelvimetry (new fast scan technology)
    • Collagen/DNA/muscle studies
    • Nerve studies
  • Considerations:
    • Age
    • Family history
    • Number of children planned
    • Can women at risk of pelvic organ prolapse be identified?
    • Joint hypermobility as a clinical marker
    • Skin elasticity assessment
    • DNA assessment

Types Of Surgery Offered By Dr. Onuma For Pelvic Organ Prolapse

Factors To Be Considered:

  • Age
  • Sexual activity
  • Sexual function (present and desired)
  • Desire for future fertility
  • Pre or post menopausal status
  • Specific desire of individual
  • Desire for preservation or conservation of uterus
  • Associated pathology (including but not limited to menstrual dysfunction and urinary incontinence)
  • Previous gynaecological, colorectal, urological and abdomino-pelvic surgery
  • Past medical history
  • Specific findings on physical examination
  • Findings of ancillary tests

Dr Onuma has a particular interest and expertise in laparoscopic and minimal access pelvic floor and urogynaecological surgery. He often combines laparoscopic (key hole) surgery with vaginal surgery using mimimal access techniques. He rarely resorts to open surgery which means that his patients have a faster recovery with less pain and increased mobility and function.

Operation Types

  • Laparoscopically assisted vaginal hysterectomy
  • Total laparoscopic hysterectomy
  • Vaginal hysterectomy
  • Laparoscopic vaginal vault suspension (± mesh)
  • Laparoscopic sacrocolpopexy
  • Laser Vaginal Rejuvenation
  • Designer Laser Vaginoplasty
  • Vaginal approach to prolapse repair incorporating mesh
  • Laparoscopic paravaginal repairs

All of these procedures can be combined with minimal access incontinence surgery such as:

  • TVT (Retropubic)
  • TVT O (Transobturator)
  • Monarch TVT (Transobturator)
  • Laparoscopic Burch Colposuspension
  • Paraurethral injections

Minimally invasive surgery:

  • One of the greatest trends in the history of surgery is the advent of minimally invasive techniques for a wide spectrum of surgeries. Minimally invasive means performing surgery in many cases without large, open incisions and sometimes under sedation and local anesthesia. For patients, this can translate into much less postoperative discomfort, lower risk of infection, faster recovery and little scarring. The great benefits offered by minimally invasive options challenge the standard of care for many conditions and should always be considered. The physician at the Institute is a national expert in minimally invasive reconstructive pelvic surgery.

Laparoscopy:

  • At the Institute, laparoscopy is used in vaginal reconstruction and support of the bladder and the urethra. Laparoscopy means visual examination of the abdomen by means of a laparoscope. Laparoscopy (often called "belly button surgery", or endoscopy) is a surgical technique involving small incisions in the abdomen (usually three) through which major surgical procedures can be performed. One of the incisions is made in the belly button, the other two on either side of the abdomen.
    The laparoscope (which looks like a tiny telescope) is placed through the belly button incision and attached to a small video camera. The video image is shown on a TV monitor in the operating room. The surgeon using instruments passed through the other two incisions performs the surgery guided by the TV images.

Less Hospitalization - Many laparoscopic cases are done as outpatient (< 23 hours) or an overnight stay. Major operations using a traditional incision often require a hospital stay of several days.

Quicker Recovery Time - Since laparoscopic surgery does not require the abdomen to be opened with a large abdominal incision, you take less time to heal, require less pain medication and are able to resume normal activities in a shorter period of time.

Decreased Scar Formation - Since the abdominal incisions are small, less internal scarring or adhesions can form. Laparoscopy significantly reduces the scar formation (adhesions) and internal abdominal pain associated with these adhesions.