Pelvic Organ Prolapse: Symptoms, Causes, Treatment

What are the symptoms of pelvic organ prolapse?

Pelvic organ prolapse (POP) occurs when the pelvic organs (such as the bladder, uterus, rectum, or small intestine) descend from their normal position due to the weakening of the pelvic floor muscles and connective tissues. This can lead to a range of symptoms, which vary depending on the type and severity of the prolapse. Common symptoms include:

1. Sensation of a Bulge or Pressure:

• Vaginal Bulge: A feeling or visible bulge or protrusion of tissue at the opening of the vagina.
• Pressure or Fullness: A sensation of pressure, fullness, or heaviness in the pelvic or vaginal area, often described as feeling like “sitting on a small ball.”

2. Urinary Symptoms:

• Urinary Incontinence: Leakage of urine, particularly when coughing, sneezing, laughing, or during physical activity (stress incontinence).
• Incomplete Bladder Emptying: Difficulty fully emptying the bladder, leading to frequent urination or urinary tract infections (UTIs).
• Urinary Urgency: A sudden, strong urge to urinate.

3. Bowel Symptoms:

• Constipation: Difficulty passing stool or a feeling of incomplete bowel movements.
• Fecal Incontinence: Involuntary leakage of stool.
• Rectal Pressure: A feeling of pressure or discomfort in the rectal area.

4. Sexual Symptoms:

• Discomfort or Pain During Intercourse: Pain or discomfort during sexual intercourse (dyspareunia).
• Decreased Sexual Sensation: A reduction in sexual sensation or satisfaction.

5. General Discomfort:

• Lower Back Pain: Aching or pain in the lower back, which may worsen with prolonged standing or lifting.
• Vaginal Spotting or Vaginal Bleeding: In some cases, there may be minor vaginal bleeding or spotting, especially if there is friction or irritation.

6. Worsening of Symptoms:

• Activity-Related: Symptoms often worsen with prolonged standing, heavy lifting, straining, or physical activity.
• Relief When Lying Down: Symptoms may improve or resolve when lying down.

Types of Pelvic Organ Prolapse and Their Specific Symptoms:

• Cystocele (Bladder Prolapse): May cause urinary symptoms such as incontinence or frequent urination.
• Rectocele (Rectal Prolapse): May cause bowel symptoms like constipation or difficulty with bowel movements.
• Uterine Prolapse: May present with a vaginal bulge and pressure symptoms.
• Enterocele (Small Bowel Prolapse): May cause a sense of fullness or discomfort in the pelvic area.

Asymptomatic Cases:

Some women with pelvic organ prolapse may not experience noticeable symptoms, especially in mild cases. The condition may be discovered during a routine pelvic examination.

When to Seek Medical Attention:

Women experiencing symptoms of pelvic organ prolapse should consult a healthcare provider for evaluation and management, especially if the symptoms interfere with daily activities or quality of life. Early diagnosis and treatment can help manage symptoms and prevent progression.

What are the causes of pelvic organ prolapse?

Pelvic organ prolapse (POP) occurs when the muscles, ligaments, and connective tissues supporting the pelvic organs weaken or stretch, causing one or more of the pelvic organs to descend into or outside the vaginal canal. The causes of this weakening can be multifactorial and often involve a combination of factors, including:

1. Childbirth and Pregnancy:

• Vaginal Delivery: The process of vaginal childbirth, particularly with large babies, prolonged labor, or the use of forceps or vacuum delivery, can stretch and damage the pelvic floor muscles and supporting tissues.
• Multiple Pregnancies: Having multiple pregnancies increases the risk of pelvic floor weakening due to the repeated stretching of the pelvic tissues.

2. Aging and Menopause:

• Aging: As women age, the natural aging process can lead to the weakening and loss of elasticity in the pelvic floor muscles and tissues.
• Menopause: The decrease in estrogen levels during menopause can contribute to the weakening of the pelvic support structures, as estrogen helps maintain the strength and elasticity of these tissues.

3. Increased Intra-Abdominal Pressure:

• Chronic Cough: Conditions such as chronic bronchitis or asthma that cause prolonged coughing can increase intra-abdominal pressure and strain the pelvic floor.
• Chronic Constipation: Straining during bowel movements can increase pressure on the pelvic floor, contributing to prolapse.
• Obesity: Excess body weight increases the pressure on the pelvic floor and can contribute to prolapse.

4. Genetic Factors:

• Connective Tissue Disorders: Some women may have a genetic predisposition to weaker connective tissues, making them more susceptible to pelvic organ prolapse.

5. Pelvic Surgery:

• Hysterectomy: Removal of the uterus can sometimes lead to changes in the support structures of the pelvis, increasing the risk of prolapse of other pelvic organs.

6. Heavy Lifting:

• Occupational or Recreational Activities: Frequent heavy lifting or high-impact activities can strain the pelvic floor muscles and increase the risk of prolapse.

7. Neurological Conditions:

• Nerve Damage: Conditions that affect the nerves controlling the pelvic floor muscles, such as spinal cord injuries, can lead to weakness in these muscles.

8. Hormonal Factors:

• Hormonal Changes: Hormonal changes related to pregnancy, childbirth, and menopause can affect the strength and elasticity of the pelvic tissues.

9. Other Factors:

• Smoking: Smoking can affect tissue health and contribute to chronic coughing, which increases the risk of prolapse.
• Genetic Predisposition: A family history of pelvic organ prolapse may increase an individual’s risk due to inherited connective tissue characteristics.

Summary:

Pelvic organ prolapse is typically the result of a combination of factors that weaken the pelvic floor muscles and supporting tissues. Understanding these causes can help in managing and preventing prolapse, particularly in women who are at higher risk. Regular pelvic floor exercises, healthy weight management, and avoiding activities that increase intra-abdominal pressure are important preventive measures.

How is the diagnosis of pelvic organ prolapse made?

The diagnosis of pelvic organ prolapse (POP) is generally made through a combination of medical history, physical examination, and, in some cases, imaging studies. Here is a detailed approach to diagnosing pelvic organ prolapse:

1. Medical History:

• Symptom Inquiry: The healthcare provider will ask about symptoms such as vaginal bulging, pelvic pressure or discomfort, urinary issues (e.g., incontinence, frequent urination), bowel issues (e.g., constipation, fecal incontinence), and sexual difficulties.
• Obstetric History: Information about previous pregnancies, childbirth experiences, and any history of pelvic surgery is important.
• Lifestyle Factors: Questions about activities that increase intra-abdominal pressure (e.g., heavy lifting, chronic coughing) and weight are also relevant.

2. Physical Examination:

• Pelvic Examination: The primary method for diagnosing POP involves a thorough pelvic exam, which may include:
  • Visual Inspection: The provider may look for signs of prolapse at the vaginal opening.
  • Palpation: The provider will use their fingers to palpate the pelvic organs and assess for any abnormal bulging or tenderness.
  • Stress Testing: The patient may be asked to perform maneuvers such as coughing, bearing down, or standing to assess for changes in prolapse.
• Speculum Examination: A speculum may be inserted into the vagina to allow the provider to visualize the vaginal walls and cervix more clearly.

3. Imaging Studies:

• Ultrasound: Transvaginal or pelvic ultrasound can be used to evaluate the position and movement of pelvic organs and assess the extent of prolapse.
• MRI: Magnetic Resonance Imaging (MRI) can provide detailed images of the pelvic structures and is sometimes used in complex cases or for pre-surgical planning.
• Defecography: This specialized imaging test evaluates the function of the rectum and can help diagnose rectocele or other bowel-related prolapses.
• Cystoscopy: A procedure in which a thin tube with a camera is inserted into the bladder through the urethra to examine the interior of the bladder and urethra.

4. Pelvic Floor Function Tests:

• Urodynamic Testing: This involves a series of tests to evaluate how well the bladder and urethra are functioning, which can help identify any associated urinary issues.
• Manometry: Measures the strength and function of the pelvic floor muscles.

5. Additional Evaluations:

• QOL Assessments: Quality of life questionnaires may be used to assess how symptoms are affecting the patient’s daily life and well-being.
• Digital Rectal Examination: Sometimes performed to evaluate for rectal prolapse or related issues.

Summary:

The diagnosis of pelvic organ prolapse typically involves a combination of a detailed medical history, a thorough pelvic examination, and imaging studies if needed. The goal is to assess the extent and type of prolapse, as well as any associated symptoms, to guide appropriate management and treatment.

What is the treatment for pelvic organ prolapse?

The treatment for pelvic organ prolapse (POP) depends on the severity of the prolapse, the symptoms experienced, the patient’s overall health, and her preferences. Treatment options generally fall into non-surgical and surgical categories. Here’s a comprehensive overview:

Non-Surgical Treatments

1. Pelvic Floor Exercises:

• Kegel Exercises: Strengthening the pelvic floor muscles through Kegel exercises can improve support and reduce symptoms of prolapse. These exercises involve contracting and relaxing the pelvic floor muscles.
• Physical Therapy: Specialized pelvic floor physical therapy may include exercises, manual therapy, and biofeedback to improve muscle strength and function.

1. Pessaries:

• Support Devices: Pessaries are devices inserted into the vagina to support the pelvic organs and alleviate symptoms. They come in various shapes and sizes and are fitted by a healthcare provider.
• Management and Care: Regular follow-up is needed to ensure proper fit and to manage any potential complications, such as irritation or discharge.

1. Lifestyle Modifications:

• Weight Management: Maintaining a healthy weight can reduce pressure on the pelvic floor.
• Avoiding Heavy Lifting: Reducing activities that increase intra-abdominal pressure can help manage symptoms.
• Dietary Changes: Addressing constipation through diet and hydration can alleviate straining during bowel movements.

1. Medications:

• Hormone Therapy: Estrogen therapy may be considered for postmenopausal women to help improve the strength and elasticity of the pelvic tissues, though it is not always used for this purpose.
• Medications for Symptoms: Medications may be used to manage associated symptoms, such as urinary incontinence.

Surgical Treatments

1. Pelvic Floor Repair Surgery:

• Anterior Repair (Cystocele Repair): Surgery to correct a prolapsed bladder by repairing the supportive tissue in the anterior vaginal wall.
• Posterior Repair (Rectocele Repair): Surgery to repair a prolapsed rectum by reconstructing the posterior vaginal wall.
• Uterine Suspension or Hysterectomy: For uterine prolapse, surgical options may include suspending the uterus or performing a hysterectomy (removal of the uterus).

1. Sacrocolpopexy:

• Mesh Repair: This procedure involves attaching a mesh to the pelvic organs to provide support and correct prolapse. It is often used for severe cases of prolapse.

1. Sacrospinous Ligament Fixation:

• Ligament Suspension: This procedure involves attaching the vaginal wall to the sacrospinous ligament to provide support.

1. Colpocleisis:

• Vaginal Closure: This procedure is typically considered for older women or those who are not sexually active. It involves partially or completely closing the vaginal canal.

Post-Treatment Care

1. Follow-Up:

• Regular Check-Ups: Post-treatment follow-ups are important to monitor recovery and ensure the success of the treatment.
• Rehabilitation: Continued pelvic floor exercises and physical therapy may be recommended to maintain strength and function.

1. Complications Management:

• Monitoring for Recurrence: Prolapse can recur, so ongoing monitoring is important, especially after surgical treatments.

1. Education and Support:

• Patient Education: Providing information about managing symptoms, using pessaries, and performing pelvic floor exercises.
• Support Groups: Participation in support groups or counseling may be beneficial for emotional support and coping strategies.

Summary

Treatment for pelvic organ prolapse is individualized based on the severity of the condition, symptoms, and patient preferences. Non-surgical options are often considered first, with surgical interventions reserved for more severe cases or when non-surgical treatments are ineffective. Regular follow-up and lifestyle adjustments play a crucial role in managing and preventing prolapse.