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Pelvic Organ Prolapse

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Pelvic Organ Prolapse

Basics

Description

Weakening or injury of pelvic supportive structures (connective tissue, pelvic floor muscles, and nerves) results in prolapse of pelvic organs.

Urinalysis or urine culture to rule out infection (2)[C], (3)[C]

Severe prolapse left untreated may result in urinary retention, frequent UTIs, pyelonephritis, vaginal ulcerations, erosions, and infections.

1Abrams P, Andersson KE, Birder L. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourol Urodyn. 2010;29(1):213 " 240. (Level III)2Weber AM, Richter HE. Pelvic organ prolapse. Obstet Gynecol. 2005;106:615 " 634. (Level III)3Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet. 2007;369(9566):1027 " 1038. (Level III)4 ACOG practice bulletin no. 85: pelvic organ prolapse. Obstet Gynecol. 2007;110(3):717 " 729. (Level III)

1Sung VW, Hampton BS. Epidemiology of pelvic floor dysfunction. Obstet Gynecol Clin North Am. 2009;36(3):421 " 443. (Level III)

  • Pelvic organ prolapse occurs when the normal supports of the pelvic organs fail, allowing the pelvic organs to "prolapse "  or protrude into the vagina.
  • Pelvic organ prolapse can be further defined by which vaginal compartment has prolapsed:Apical or upper vaginaUterusVaginal vaultAnterior vaginal wallCystoceleParavaginalUrethrocelePosterior vaginal wallEnteroceleRectocelePerineal deficiency
  • Apical or upper vaginaUterusVaginal vault
  • Anterior vaginal wallCystoceleParavaginalUrethrocele
  • Posterior vaginal wallEnteroceleRectocelePerineal deficiency
  • Uterus
  • Vaginal vault
  • Cystocele
  • Paravaginal
  • Urethrocele
  • Enterocele
  • Rectocele
  • Perineal deficiency

Epidemiology

  • In general, it is difficult to study given the long latency period.
  • The prevalence of pelvic organ prolapse increases with age; therefore, the changing demographics of the population will result in more affected women.
  • The direct cost of surgery for prolapse is estimated to be greater than $1 billion/year.
  • Lifetime risk for undergoing surgery for prolapse or incontinence is 11% in the US.
  • Anterior vaginal prolapse ( "bladder prolapse, "  "cystocele " ): 9.3 cases per 100 women per year
  • Posterior vaginal prolapse ( "rectocele " ): 5.7 cases per 100 women per year
  • Uterine prolapse: 1.5 cases per 100 women per year
  • Anterior vaginal prolapse: 24 " “34%
  • Posterior vaginal prolapse: 13 " “18%
  • Uterine prolapse: 4 " “14%

Risk Factors

  • Predisposing factors (congenital)Neurologic, connective tissue, musculoskeletalGenetic
  • Inciting factors (acquired)ChildbirthPelvic surgeryNeurologic injury
  • Promoting factorsObesitySmokingChronic straining, constipationFrequent heavy liftingMenopause
  • Decompensating factorsAgingPoor mobilityEnvironmentMedication
  • Neurologic, connective tissue, musculoskeletal
  • Genetic
  • Childbirth
  • Pelvic surgery
  • Neurologic injury
  • Obesity
  • Smoking
  • Chronic straining, constipation
  • Frequent heavy lifting
  • Menopause
  • Aging
  • Poor mobility
  • Environment
  • Medication

Pathophysiology

Etiology

  • Likely multifactorial
  • ChildbirthLabor and delivery may result in direct damage to connective tissue supports and muscles (disruption).Indirect damage may result in injury to nerves and muscles (ischemia, compression, stretching).Pudendal nerve latency has been shown to be prolonged after delivery, although this recovers over time.
  • Connective tissue disordersEhlers " “Danlos, Marfan syndrome
  • Pelvic neuropathyChronic constipation, straining, and vaginal childbirth may cause chronic stretching and injury to pudendal nerve.
  • Congenital disordersSpina bifidaBladder exstrophy
  • Postoperative effectsPelvic surgery may disrupt innervation to pelvic supportive tissues.
  • Obesity
  • Chronic cough
  • Smoking
  • Labor and delivery may result in direct damage to connective tissue supports and muscles (disruption).
  • Indirect damage may result in injury to nerves and muscles (ischemia, compression, stretching).Pudendal nerve latency has been shown to be prolonged after delivery, although this recovers over time.
  • Pudendal nerve latency has been shown to be prolonged after delivery, although this recovers over time.
  • Ehlers " “Danlos, Marfan syndrome
  • Chronic constipation, straining, and vaginal childbirth may cause chronic stretching and injury to pudendal nerve.
  • Spina bifida
  • Bladder exstrophy
  • Pelvic surgery may disrupt innervation to pelvic supportive tissues.

Associated Conditions

  • Urinary incontinence
  • Fecal incontinence
  • Depression

Diagnosis

History

  • Review of systems including (1)[C]:Presence, severity, duration, and bother of prolapse symptomsConcurrent urinary, bowel, neurologic, or sexual function concernsPoor stream, hesitance, straining to void, incomplete emptying, recurrent urinary tract infection (UTI), splinting (need to reduce prolapse to urinate/defecate)
  • Past medical history including (1)[C]:Prior conservative medical treatmentPessary trialPhysical therapy, Kegel exercisesCoexisting diseases (as listed under "Risk Factors " ) such as constipationPhysical impairmentPatients with limited mobility, dexterity, or vision may have different needs.
  • Past surgical history including (1)[C]:Previous prolapse or anti-incontinence surgery, pelvic surgery
  • Patient medication (1)[C]
  • Obstetric and menstrual history (1)[C]
  • Social history (1)[C]:Smoking, exercise
  • Other:Patient goals and expectations (1)[C]Support symptoms/care-givers (1)[C]Cognitive function (1)[C]
  • Presence, severity, duration, and bother of prolapse symptoms
  • Concurrent urinary, bowel, neurologic, or sexual function concernsPoor stream, hesitance, straining to void, incomplete emptying, recurrent urinary tract infection (UTI), splinting (need to reduce prolapse to urinate/defecate)
  • Poor stream, hesitance, straining to void, incomplete emptying, recurrent urinary tract infection (UTI), splinting (need to reduce prolapse to urinate/defecate)
  • Prior conservative medical treatmentPessary trialPhysical therapy, Kegel exercises
  • Coexisting diseases (as listed under "Risk Factors " ) such as constipation
  • Physical impairmentPatients with limited mobility, dexterity, or vision may have different needs.
  • Pessary trial
  • Physical therapy, Kegel exercises
  • Patients with limited mobility, dexterity, or vision may have different needs.
  • Previous prolapse or anti-incontinence surgery, pelvic surgery
  • Smoking, exercise
  • Patient goals and expectations (1)[C]
  • Support symptoms/care-givers (1)[C]
  • Cognitive function (1)[C]

Physical Exam

  • Pelvic examination should:Define severity of maximum anatomic support defect (1)[C]Assess pelvic muscle function (1)[C]Determine if epithelial or mucosal ulceration is present (1 " “2)[C]Examination of pelvic support and all vaginal areas should be done with patient resting and with patient straining with Valsalva maneuver (2 " “4)[C].Examination of each compartment with split speculum on straining (2 " “3)[C]Cervix or vaginal cuffAnterior vaginal wallPosterior vaginal wallGenital hiatus (length of vaginal opening)Perineal bodyVulvar or vaginal atrophy (1)[C]Cough stress test to rule out stress incontinence (2)[C]Bimanual exam (2)[C]Recto-vaginal exam (2)[C]Poor sphincter toneAnal sphincter defect
  • Neurologic examinationAnal wink reflex (1)[C]Pelvic muscle strength (2)[C]Sensation (1)[C]
  • Define severity of maximum anatomic support defect (1)[C]
  • Assess pelvic muscle function (1)[C]
  • Determine if epithelial or mucosal ulceration is present (1 " “2)[C]
  • Examination of pelvic support and all vaginal areas should be done with patient resting and with patient straining with Valsalva maneuver (2 " “4)[C].
  • Examination of each compartment with split speculum on straining (2 " “3)[C]Cervix or vaginal cuffAnterior vaginal wallPosterior vaginal wallGenital hiatus (length of vaginal opening)Perineal body
  • Vulvar or vaginal atrophy (1)[C]
  • Cough stress test to rule out stress incontinence (2)[C]
  • Bimanual exam (2)[C]
  • Recto-vaginal exam (2)[C]Poor sphincter toneAnal sphincter defect
  • Cervix or vaginal cuff
  • Anterior vaginal wall
  • Posterior vaginal wall
  • Genital hiatus (length of vaginal opening)
  • Perineal body
  • Poor sphincter tone
  • Anal sphincter defect
  • Anal wink reflex (1)[C]
  • Pelvic muscle strength (2)[C]
  • Sensation (1)[C]

Tests

  • Usually not necessary (1 " “3)[C]
  • Consider upper urinary tract imaging if prolapse is beyond the hymen and the patient declines pessary or surgery (1)[C]Anal manometry or defecography may be considered for women with defecatory symptoms (3)[C].
  • Anal manometry or defecography may be considered for women with defecatory symptoms (3)[C].
  • Reduce prolapse to evaluate occult (masked, latent, potential) stress incontinence; urodynamic evaluation or cough stress test may be used (2 " “4)[C]
  • Post-void residual (1 " “3)[C]

Differential Diagnosis

  • Rectal prolapse
  • Pelvic mass

Treatment

Additional Treatment

  • Many patients with prolapse are asymptomatic and seek only reassurance (4)[C].
  • Treatment goal is to minimize the impact of condition or achieve a cure (2)[C].
  • Treatment strategy depends on the severity of the symptoms, associated pelvic floor conditions, prior surgery, as well as the patient 's general health, activity level, and informed decision (2)[C].
  • Patients with mild asymptomatic prolapse may be monitored with annual exams (3 " “4)[C].
  • Asymptomatic patients with severe prolapse should be examined every 3 months to reassess the risks and benefits of observation (2)[C].
  • Asymptomatic patients with obstructed urination/defecation, unresponsive vaginal erosions, or hydronephrosis from ureteral kinking should be treated (3)[C].
  • Pelvic floor muscle trainingReduce the symptoms of prolapse (1)[B]Prevent or slow deterioration of anterior prolapse (1)[B]
  • PessaryShould be discussed with all symptomatic women (4)[B]Can be fitted in most women regardless of prolapse stage (4)[A]Successful fitting less likely with vaginal length less than 7 cm, or vaginal introitus wider than 4 finger-breadthsProtrusion symptoms may improve with successful "fit "  (1)[B].Correct fit includes:Symptom resolution (2)[C]Pessary should be comfortable, and stay in place with Valsalva (2)[C].Patients should be able to void with the pessary in place prior to leaving clinic (3)[C].No clear consensus on frequency of follow-upInitial follow-up 2 " “3 weeks (2)[C]Patients able to remove/replace pessary need less frequent follow-up than those who cannot (2 " “3)[C].Follow-up recommendations range from 1 to 6 months, but regular follow-up is mandatory (1 " “3)[C].At follow-up visits:Pessary is removed and inspected (2)[C].Vaginal walls are inspected for evidence of abrasions or ulcerations from pessary (may need a different size) (2)[C].Vaginal atrophy or erosions treated with topical estrogen cream (1 " “3)[C]Patients who will not follow up are not candidates for pessaries as prolonged neglect may result in the pessary becoming impacted in the vagina or erosion of pessary into bladder or rectum (2 " “3)[C].
  • Reduce the symptoms of prolapse (1)[B]
  • Prevent or slow deterioration of anterior prolapse (1)[B]
  • Should be discussed with all symptomatic women (4)[B]
  • Can be fitted in most women regardless of prolapse stage (4)[A]Successful fitting less likely with vaginal length less than 7 cm, or vaginal introitus wider than 4 finger-breadths
  • Protrusion symptoms may improve with successful "fit "  (1)[B].
  • Correct fit includes:Symptom resolution (2)[C]Pessary should be comfortable, and stay in place with Valsalva (2)[C].Patients should be able to void with the pessary in place prior to leaving clinic (3)[C].
  • No clear consensus on frequency of follow-upInitial follow-up 2 " “3 weeks (2)[C]Patients able to remove/replace pessary need less frequent follow-up than those who cannot (2 " “3)[C].Follow-up recommendations range from 1 to 6 months, but regular follow-up is mandatory (1 " “3)[C].
  • At follow-up visits:Pessary is removed and inspected (2)[C].Vaginal walls are inspected for evidence of abrasions or ulcerations from pessary (may need a different size) (2)[C].Vaginal atrophy or erosions treated with topical estrogen cream (1 " “3)[C]
  • Patients who will not follow up are not candidates for pessaries as prolonged neglect may result in the pessary becoming impacted in the vagina or erosion of pessary into bladder or rectum (2 " “3)[C].
  • Successful fitting less likely with vaginal length less than 7 cm, or vaginal introitus wider than 4 finger-breadths
  • Symptom resolution (2)[C]
  • Pessary should be comfortable, and stay in place with Valsalva (2)[C].
  • Patients should be able to void with the pessary in place prior to leaving clinic (3)[C].
  • Initial follow-up 2 " “3 weeks (2)[C]
  • Patients able to remove/replace pessary need less frequent follow-up than those who cannot (2 " “3)[C].
  • Follow-up recommendations range from 1 to 6 months, but regular follow-up is mandatory (1 " “3)[C].
  • Pessary is removed and inspected (2)[C].
  • Vaginal walls are inspected for evidence of abrasions or ulcerations from pessary (may need a different size) (2)[C].
  • Vaginal atrophy or erosions treated with topical estrogen cream (1 " “3)[C]
  • Unsuccessful conservative management
  • Visible prolapse (beyond hymen)
  • Significant symptoms
  • Recurrent UTIs

Surgery

  • Type and extent of repair will depend on precise defects, patient 's desires and expectations, associated pelvic floor disorders (incontinence), and the patient 's age, medical status, and comorbidities.The only symptom specific to prolapse is vaginal bulge or protrusion. Other symptoms may or may not be related to prolapse (4)[A].
  • Obliterative (closure of vagina)Reserved for women who do not desire future vaginal intercourse (1)[B]Elderly, medically compromised (3)[C]Shorter operative time, decreased perioperative morbidity, low risk of recurrence (3)[C]
  • ReconstructiveVaginal prolapse repair should be performed with compartment-specific repairs depending on what is prolapsed and symptomatic (2)[C].Apical prolapse requires re-suspending the vaginal apex to nearby ligaments.Apical prolapse may be repaired via a vaginal, abdominal, laparoscopic, or robotic approach.Round ligament suspension is not effective for uterine or vaginal prolapse (4)[B].Anterior vaginal prolapse can be repaired with either a vaginal approach (cystocele repair) or abdominal/laparoscopic repair (paravaginal) (2)[C].Posterior vaginal prolapse (rectocele) repair should be performed via a transvaginal and not a transanal approach (4)[B].Vaginal mesh should be used with caution because of potential complications such as erosion, infection, pain, and dyspareunia (3)[C].
  • The only symptom specific to prolapse is vaginal bulge or protrusion. Other symptoms may or may not be related to prolapse (4)[A].
  • Reserved for women who do not desire future vaginal intercourse (1)[B]Elderly, medically compromised (3)[C]Shorter operative time, decreased perioperative morbidity, low risk of recurrence (3)[C]
  • Elderly, medically compromised (3)[C]
  • Shorter operative time, decreased perioperative morbidity, low risk of recurrence (3)[C]
  • Vaginal prolapse repair should be performed with compartment-specific repairs depending on what is prolapsed and symptomatic (2)[C].Apical prolapse requires re-suspending the vaginal apex to nearby ligaments.Apical prolapse may be repaired via a vaginal, abdominal, laparoscopic, or robotic approach.Round ligament suspension is not effective for uterine or vaginal prolapse (4)[B].
  • Anterior vaginal prolapse can be repaired with either a vaginal approach (cystocele repair) or abdominal/laparoscopic repair (paravaginal) (2)[C].
  • Posterior vaginal prolapse (rectocele) repair should be performed via a transvaginal and not a transanal approach (4)[B].
  • Vaginal mesh should be used with caution because of potential complications such as erosion, infection, pain, and dyspareunia (3)[C].
  • Apical prolapse requires re-suspending the vaginal apex to nearby ligaments.
  • Apical prolapse may be repaired via a vaginal, abdominal, laparoscopic, or robotic approach.
  • Round ligament suspension is not effective for uterine or vaginal prolapse (4)[B].
  • FDA safety communication issued in 2011 for transvaginal mesh use for pelvic organ prolapse.
  • Clinicians should discuss the risks and benefits of concurrent anti-incontinence procedures for asymptomatic women (4)[C].Continent patients identified with stress urinary incontinence preoperatively during prolapse correction are at increased risk of postoperative incontinence if uncorrected (4)[A].
  • Continent patients identified with stress urinary incontinence preoperatively during prolapse correction are at increased risk of postoperative incontinence if uncorrected (4)[A].

Ongoing Care

Prognosis

Complications

References

Additional Reading

Codes

ICD9

  • 618.2 Uterovaginal prolapse, incomplete
  • 618.3 Uterovaginal prolapse, complete
  • 618.4 Uterovaginal prolapse, unspecified
  • 599.5 Prolapsed urethral mucosa
  • 618.6 Vaginal enterocele, congenital or acquired
  • 618.04 Rectocele
  • 618.5 Prolapse of vaginal vault after hysterectomy

ICD10

  • N81.2 Incomplete uterovaginal prolapse
  • N81.3 Complete uterovaginal prolapse
  • N81.4 Uterovaginal prolapse, unspecified
  • N81.0 Urethrocele
  • N81.5 Vaginal enterocele
  • N81.6 Rectocele
  • N99.3 Prolapse of vaginal vault after hysterectomy

SNOMED

  • 18973006 uterovaginal prolapse (disorder)
  • 24976005 uterine prolapse (disorder)
  • 198268002 uterovaginal prolapse, incomplete (disorder)
  • 12068006 prolapse of urethra (disorder)
  • 398061002 vaginal enterocele (disorder)
  • 62730001 female proctocele without uterine prolapse (disorder)
  • 398022005 vaginal wall prolapse (disorder)
  • 42116007 prolapse of vaginal vault after hysterectomy (disorder)

Clinical Pearls

  • Pelvic organ prolapse is a common, distressing, and disabling condition affecting up to 34% of women of all ages.
  • Pelvic organ prolapse may have a significant impact on a patient 's quality of life and body image.