Uterine and Pelvic Organ Prolapse

BASICS

DESCRIPTION

Symptomatic descent of one or more of (1,2)
- The anterior vaginal wall (bladder or cystocele)
- The posterior vaginal wall (rectum or rectocele)
- The apex of the vagina (uterine cervix descent and prolapse)
- The vault (cuff) after hysterectomy (vault prolapse)
Prolapses above or to the hymen are not symptomatic (2).
Associated symptoms (2)
- Feeling of vaginal or pelvic pressure
- Heaviness
- Bulging
- Bowel or bladder symptoms
Cost associated with treatment is more than $1 billion annually (~200,000 surgeries/year) (2).

EPIDEMIOLOGY

Incidence
Pelvic organ prolapse (POP) is common but not always symptomatic. It does not always progress with time. In a 3-year prospective cohort study of 249 women, prolapse increased by at least 2 cm in 11% and regressed by 2 cm in 3% (2).
Prevalence

A national survey of 7,924 women (over 20 years of age) found a prevalence of 25% for one or more pelvic floor disorders (including urinary incontinence, fecal incontinence, and POP). Prevalence of POP was 2.9% (3).
The prevalence of lower urinary tract symptoms is as high as 50% in parous women. 11% of all women have surgery for POP or lower urinary tract symptoms by 80 years old (4).
3 " 6% of women who present for gynecologic care have a prolapse beyond hymen (2).

ETIOLOGY AND PATHOPHYSIOLOGY

Insidious process begins long before symptoms develop.
There is a complex interaction between the pelvic floor musculature, connective tissue, and the vaginal wall, which provides support from the perineum to the sacrum (2). Integrity of levator ani is essential to this support system by providing a platform on which the pelvic organs rest (2).
Symptomatic women typically have multiple defects, including laxity of supporting tissue and damage to the levator ani (2).
Half of anterior prolapse can be attributed to apical descent of the vagina (2).

RISK FACTORS

Vaginal childbirth (2): Women who have delivered two children vaginally have a relative risk of 8.4 and every additional child (up to five deliveries) increases the risk of prolapse by 10 " 20% (2).
Age: Every 10 years of age increases the risk of prolapse by 40% (2). POP will become more prevalent, as the elderly population is expected to double by 2030 (5).
Obesity: BMI >25 may increase the risk of developing prolapse (2).
Constipation: independent risk factor in a survey of more than 2,000 women (2)
Race: White and Hispanic women may be at higher risk than black or Asian women (2).
Occupation (heavy lifting): variable support in the literature (2)
Hysterectomy: variable support in the literature (2)
Obstetric factors (operative delivery, infant weight, length of pushing in second stage of labor): variable support in the literature (2)

GENERAL PREVENTION

There is some evidence that pelvic floor muscle training ( "Kegel exercises " ) may decrease the risk of symptomatic POP (6)[B]. Weight loss and proper management of conditions that cause increase in intra-abdominal pressure may help prevent the problem.

COMMONLY ASSOCIATED CONDITIONS

Urinary incontinence
Other urinary symptoms (4)
- Urgency
- Frequency

DIAGNOSIS

HISTORY

Less than half of women discuss symptoms with PCP. Only 10 " 12% seek medical attention. Barriers include embarrassment, social stigma, ability to cope, belief that POP is part of the aging process, belief that treatment options are limited, and fear of surgery (4).
Common symptoms include the following:
- Feeling a bulge in vagina
- Something "falling out " of vagina
- Pelvic pressure
- Difficulty with voiding or defecation
- Urgency
- Frequency
- Incontinence (urinary or fecal)
- Constipation
Document the presence, duration, and severity of urinary, bowel, or prolapse symptom. Assess impact on sexual function and quality of life with validated questionnaires (PISQ 9 OR 12) (1,7).
Assess past medical history.
- Gravity and parity/obstetric history
- History of ascites
- Chronic constipation
- Document physical impairment (mobility, dexterity, or visual acuity), as this may affect management (1).
- Document the patient 's desire, goals, and expectation (1).

PHYSICAL EXAM

Abdominal examination to document any distention or masses
Complete pelvic and rectal examination. Have patient cough or strain, particularly in an upright (standing) position while examining the distal vagina.
The GOLD STANDARD is to measure vaginal descent using the Pelvic Organ Prolapse Quantification (POPQ) scale, which is a scale that describes the prolapse in relationship to the vaginal hymen (2). The validated simplified version has four measurements with classification in four stages. Patient is supine with the head of the bed at 45 degrees, performing Valsalva.
- Stage 1: prolapse in which the distal point is superior or equal to 1 cm above hymen
- Stage 2: prolapse in which the distal point is between 1 cm above and 1 cm below hymen
- Stage 3: prolapse in which the distal point is superior or equal to 1 cm below the hymen, but some vaginal mucosa is not everted
- Stage 4: complete vaginal vault eversion ( "procidentia " ). Entire vaginal mucosa everted (2)
A split speculum can be used to observe anterior, posterior, and apical parts of the vagina successively.
Patient should be standing for maximum descent (2).

DIFFERENTIAL DIAGNOSIS

Rectal prolapse
Hemorrhoids
Bartholin cyst
Cervical elongation

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Urinalysis if symptomatic POP (1)
Renal function (serum creatinine) if urinary incontinence and probability of renal impairment (1)
Imaging: not routinely recommended (1)

Follow-Up Tests & Special Considerations

Postvoid residual if patient has urinary incontinence
Urodynamic testing prior to invasive treatment or after treatment failure to plan further therapy (1)
Imaging of upper urinary tract if hematuria or back pain (1)
Cystoscopy recommended if patient has hematuria, pain, or discomfort suggesting bladder lesion (1)
Colonoscopy or sigmoidoscopy if patient has fecal incontinence (1)
Colonoscopy, air contrast barium enema, and/or computed tomography if change in bowel habits or rectal bleeding (1)

TREATMENT

GENERAL MEASURES

Treatment should take into account type and severity of symptoms, patient 's age, other comorbid conditions, sexual function, infertility, and risk of recurrence.
Treatment for asymptomatic patients:
- Stage 1 or 2: clinical observation (2)
- Stage 3 or 4: regular follow-up and evaluation (every 6 to 12 months) (2)
Treatment is indicated when there is urinary/bowel obstruction or hydronephrosis regardless of the degree of prolapse (2).
A vaginal pessary should be considered in all women presenting with symptomatic prolapse (8)[B].
- There are more than 13 types of silicone devices that may be inserted into the vagina to support the pelvic organs.
- The most commonly used pessaries are the ring pessary and Gellhorn (8).
- They may prevent prolapse progression and may prove to be an appropriate prevention strategy in the future because the surgical failure rate is around 30% (2).
- Most women can be successfully fitted with a pessary (8)[B].
- Satisfaction rate for patients using pessaries is very high (8)[B].
Complications may be seen with neglected pessaries, such as erosions, abrasions, ulcerations, and vaginal bleeding. Minor complications such as vaginal discharge and odor can be treated without discontinuing pessary use (8)[B]. Vaginal erosion can be treated by removal of pessary and optional vaginal estrogen supplementation.

MEDICATION

First Line

Treatment of vaginal atrophy with topical estrogens may be beneficial for symptomatic POP (9)[B] if there are no contraindications. Suggested to use in conjunction with pelvic floor muscle training (9)
Vaginal creams
- Estradiol cream 0.01% (Estrace)
- Conjugated estrogens 0.625 mg/day (Premarin)
Vaginal tablet
- Estradiol 10 ¼g (Vagifem)
Vaginal ring
- Estradiol 2 mg (Estring)

ISSUES FOR REFERRAL

Referral when pessary or surgery is necessary

ADDITIONAL THERAPIES

Pelvic floor muscle training: may reduce the symptoms of POP (1). Pelvic floor muscle training does not affect the degree of prolapse, only the symptoms (1).

SURGERY/OTHER PROCEDURES

Reconstructive procedures are done with the goal of restoration of vaginal anatomy.
Reconstructive surgery is associated with a high rate of failure (1 in 3 lifetime risk of repeat surgery). New procedures, using surgical mesh and graft material, have higher success rates but limited follow-up or comparative data (2).
Abdominal procedures such as sacral colpopexy using graft material have a higher success rate but a longer operating time, longer time to return to normal activity levels, and an increased cost (10)[B]. There may be resulting problems with sexual function and bladder/bowel complaints (2).

ONGOING CARE

PATIENT EDUCATION

Patients should be educated about pessary complications and possible symptoms of POP if they are still asymptomatic.
Limit caffeine product and bladder irritants if urinary symptoms.
Using insoluble fibers may help patients with bowel complaints such as constipation.

COMPLICATIONS

There is a risk of vaginal mesh extrusion, erosions, dyspareunia, and pelvic pain after surgical repair (11).
Delays in diagnosis (4)[B]
- 61% reported POP symptoms to a physician.
- 65.9% blamed themselves for the delay (fear of surgery, embarrassment).
- 1/3 of women blame their physician for the delay in diagnosis.

REFERENCES

11 Abrams P, Andersson KE, Birder L, et al. 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 " 240.22 Abed H, Rogers RG. Urinary incontinence and pelvic organ prolapse: diagnosis and treatment for the primary care physician. Med Clin North Am. 2008;92(5):1273 " 1293.33 Wu JM, Vaughan CP, Goode PS, et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. women. Obstet Gynecol. 2014;123(1):141 " 148.44 Krissi H, Eitan R, Peled Y. The role of primary physicians in the diagnostic delay of lower urinary tract and pelvic organ prolapse symptoms. Eur J Obstet Gynecol Reprod Biol. 2012;161(1):102 " 104.55 Chow D, Rodr guez LV. Epidemiology and prevalence of pelvic organ prolapse. Curr Opin Urol. 2013;23(4):293 " 298.66 Hagen S, Stark D. Conservative prevention and management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2011;(12):CD003882.77 Aschkenazi S, Rogers R, Beaumont J, et al. The modified short pelvic organ prolapse/urinary incontinence sexual questionnaire, the PISQ-9, for use in a general female population. http://www.ics.org/Abstracts/Publish/46/000201.pdf. Accessed 2014.88 Robert M, Schulz JA, Harvey MA, et al. Technical update on pessary use. J Obstet Gynaecol Can. 2013;35(7):664 " 674.99 Ismail SI, Bain C, Hagen S. Oestrogens for treatment or prevention of pelvic organ prolapse in postmenopausal women. Cochrane Database Syst Rev. 2010;(9):CD007063.1010 Maher C, Feiner B, Baessler K, et al. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013;(4):CD004014.1111 Chermansky CJ, Winters JC. Complications of vaginal mesh surgery. Curr Opin Urol. 2012;22(4):287 " 291.

CODES

ICD10

N81.9 Female genital prolapse, unspecified
N81.10 Cystocele, unspecified
N99.3 Prolapse of vaginal vault after hysterectomy
N81.4 Uterovaginal prolapse, unspecified
N81.6 Rectocele

ICD9

618.9 Unspecified genital prolapse
618.00 Unspecified prolapse of vaginal walls
618.5 Prolapse of vaginal vault after hysterectomy
618.4 Uterovaginal prolapse, unspecified
618.01 Cystocele, midline
618.1 Uterine prolapse without mention of vaginal wall prolapse

SNOMED

73998008 Prolapse of female genital organs (disorder)
413941004 Cystocele with unspecified uterine prolapse (disorder)
42116007 Prolapse of vaginal vault after hysterectomy (disorder)
24976005 uterine prolapse (disorder)
248879001 Anterior vaginal wall prolapse (disorder)
248880003 Posterior vaginal wall prolapse (disorder)

CLINICAL PEARLS

Many women do not discuss POP with their doctor " ask routinely.
Vaginal pessary should be considered in all patients with symptomatic prolapse.
Traditional surgical treatment has a high long-term failure rate (1 in 3).

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