Pelvic organ prolapse, defined as herniation of the pelvic organs against the vaginal walls and often through the vaginal introitus, is noted in up to 60% of parous women but is symptomatic in fewer than 30% of all women.1,2 Clinical presentation of pelvic organ prolapse is anticipated to almost double with the projected rise in the older female population in coming decades.3 Although the patient herself may be unaware of any changes in her anatomy, or simply describe “a bulge down there,” a clinical assessment and understanding of possible types of pelvic organ prolapse help to guide treatment options and improve patient satisfaction.
Prolapse represents a defect in support of one or more of the vaginal walls, which are held in place by connective tissues and the pelvic musculature.4 Prolapse may be conceptualized as a type of herniation, and the bulge may contain any of the pelvic organs (including the bladder, bowel, or uterus). Incidence increases with parity beyond one pregnancy, advancing age, menopausal status, obesity, chronic straining such as is seen with chronic cough or constipation, heavy lifting, and connective tissue disorders.4–6 Pelvic organ prolapse appears to run in families, although the exact genetic cause is unknown. An ethnic correlation with pelvic organ prolapse has been disputed, but some studies suggest that white and Hispanic women are more likely to develop prolapse than African American and Asian women.7
History Initial evaluation of prolapse should start with a patient-oriented discussion. Ask the patient when she first noticed the bulge, how she discovered it, and how it bothers her. Women who present with pelvic organ prolapse may need reassurance, as they sometimes fear that the mass is cancerous, they are at risk of internal infection, or their pelvic organs are in danger of injury.8 Feelings of isolation and poor self-image also are common.9 Ask the patient about specific symptoms that she associates with the prolapse. Some women must push the prolapsed tissue back into the vagina in order to urinate or defecate, an act termed splinting. Patients often describe low back pain, pelvic heaviness or pressure, vaginal dryness, and/or bleeding of the exposed tissue.10 Women with mild prolapse may report significant discomfort, and women with severe prolapse may report no discomfort. Many women also suspend sexual activity or their partners may avoid intercourse due to fear of worsening the problem.9 This can cause significant relationship stress and decreased quality of life and should be sensitively addressed. Compile a history of the patient's abdominal and pelvic surgeries, especially previous prolapse surgeries. Specific questionnaires are available to aid history-taking. The Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ) are two of the most frequently used tools.11
Physical examination A standardized physical examination for pelvic organ prolapse should include abdominal examination. Encourage the patient to empty her bladder before the examination. She should undress from the waist down and cover her lap with a drape. Before asking a supine patient to move into the dorsal lithotomy position, ask her to plant her feet in the middle of the examination table, bend her knees, and move herself down toward the end of the table before guiding her feet into the stirrups. This method helps to prevent leg cramping.
Initial examination for pelvic organ prolapse includes noting the condition of the labia and introitus. Grossly prolapsed tissue may or may not be apparent at rest. If prolapsed tissue is present, inspect it for ulceration or bleeding, which may occur with chronic rubbing of the delicate and often atrophic genital tissue against clothing. Lesions of the posterior fourchette may occur in the same manner.
The examination of women with pelvic organ prolapse is different from a normal well-woman examination in two respects. In a well-woman examination, the examiner is interested in performing a Pap smear and measuring the uterine size. In an examination for pelvic organ prolapse, the examiner is interested in grading the prolapse and ascertaining the status of pelvic floor strength.
To grade the prolapse, ask the patient to perform a Valsalva maneuver before reducing any visible prolapse. Straining will help display the greatest degree of prolapse and is useful for obtaining Pelvic Organ Prolapse Quantification (POP-Q) measurements, which will be described later in this article.12 After initial POP-Q measurements are taken, the prolapse may be gently reduced and the examination continued with a lubricated speculum. Lubrication is especially important during examination of women with vaginal atrophy, to minimize burning and discomfort. Once the speculum is inserted, the vaginal walls and cervix should be inspected for lesions or other abnormalities. Remaining POP-Q measurements are taken using a half speculum.
To measure pelvic floor strength, an Oxford measurement is recorded by asking the patient to perform a Kegel exercise (squeezing the pelvic floor muscles). A score of 0 denotes no strength, and a score of 5 denotes normal strength.13 The muscles themselves should be examined with one or two digits if possible to evaluate for hypertonicity (Figure 1). A bimanual examination will rule out obvious adnexal masses and tenderness. Finally, perform a rectal examination to check for an obvious weakness of the anterior rectal wall, such as is expected in a patient with a rectocele (Figure 2).14
Several types of prolapse may be identified on pelvic examination, and a patient may have any combination of these types.
- Anterior compartment prolapse, also called cystocele, represents a defect of the anterior compartment, resulting in a bulge created by the bladder moving into the vaginal space. Cystocele is what many patients expect when they think of pelvic organ prolapse, as evidenced by the common statement, “My bladder is falling out.” Cystocele also is the most commonly encountered form of pelvic organ prolapse.15,16
- Posterior compartmentprolapse consists of two subtypes: rectocele, a bulge caused by a defect of the rectum into the vaginal cavity, and enterocele, a bulge caused by the small intestines or even sigmoid colon pressing into the vaginal canal (Figure 3). In enterocele, a careful examiner may feel the peristalsis of bowel during digital rectal examination.
- Apical prolapse occurs when the apex of the vaginal canal descends.
- Procidentia refers to the most advanced stage of uterine prolapse, in which all three compartments-–anterior, posterior, and apical-–prolapse simultaneously. A patient with procidentia is in danger of incarceration of the prolapsed contents: the prolapsed bladder may fill with urine, the bowel may become necrotic, or the uterus may swell to a degree that it cannot return within the pelvic cavity. Any of these scenarios constitutes a surgical emergency (Figure 4).
POP-Q The POP-Q method of describing prolapse creates a numeric map of the location and extent of the defects.12 Points are measured using the vaginal introitus as a reference point designated as 0. Each point in the POP-Q scale represents 1 cm of movement proximal or distal to 0, or 1 cm in length (in the case of points GH and PB). Points GH, PB, Aa, Ba, C, D, Ap, and Bp are all measured with the patient performing a Valsalva maneuver; she should be encouraged beforehand not to guard against vaginal bulging or urinary or fecal incontinence, as these are all relevant findings on examination. The overall stage of the prolapse is based on the most distal edge of the prolapse at maximum Valsalva effort. Stages range from 0 to IV, in ascending degree of severity. These staging designations may help the surgeon determine which levels of DeLancey support may be deficient.17 The levels of support are:
- Level 1 support, provided by the uterosacral and cardinal ligamentous attachments to the sacrum and lateral pelvis. These support the vaginal apex, cervix, and uterus. Uterine descent or apical prolapse may occur when Level 1 support is lost.
- Level 2 support is provided by the pubocervical and rectovaginal attachments to the levator ani fascia and arcus tendineus fascia pelvis. These attachments support the lateral walls of the vagina. A cystocele may occur when Level 2 support is compromised.
- Level 3 support consists of the perineal membrane, perineal body, and superficial and deep perineal muscles, which support the distal third of the vagina. Depending on the location of compromise, loss of Level 3 support may lead to urethral hypermobility (a risk factor for stress urinary incontinence), rectocele, or enterocele.18
During the examination, observe the patient's vulva, urethra, and vagina for lesions. Moderate, steady pressure applied to the vaginal walls with the pads of two fingers should not cause pain.19 If the patient reports pain, she may have underlying muscle spasm that must be treated separately from prolapse. Note that some patients will not verbalize pain; observe for changes in facial expression or ask specifically about discomfort. Occasionally, fasciculations will be palpated and confirm the presence of muscle spasm. Finally, insert a small catheter to check postvoid residual, the amount of urine left in the bladder after a spontaneous void. During rectal examination, hard stool in the rectal vault signifies underlying constipation, a risk factor for pelvic organ prolapse.
During the discussion phase of the visit, use diagrams and pelvic models to help clarify the different types and stages of prolapse. Send the patient home with reliable resources, such as trusted pamphlets and/or websites. If surgical management is planned, bring the patient back to the office to discuss her condition and expectations for treatment. Separating a patient's problems into the categories of prolapse, urinary complaints, and bowel complaints helps to emphasize the independent nature of the issues and underscores the expectation that treating prolapse may not improve urinary leakage, bowel issues, and pain.
A challenging aspect of treating pelvic organ prolapse revolves around understanding what the patient expects to gain from treatment. She may be bothered by bladder, bowel, or bulge symptoms that she attributes to pelvic organ prolapse. Some women, on the other hand, are bothered purely by the knowledge that their genital anatomy has changed and not by any prolapse-related symptoms in particular.8
Practitioners must carefully elicit the patient's expectations for prolapse treatment and address them appropriately. One area of management that deserves special attention is the relationship between low abdominal or pelvic pain and prolapse. Patients and providers alike commonly assume that prolapsed tissue causes pain, and therefore that surgical correction of prolapse will alleviate that pain. This is often not the case.20 Pain is more commonly associated with muscle spasm or strain, vaginal atrophy, or conditions such as chronic low back pain and fibromyalgia. One way to clarify this for the patient is to suggest a short-term trial of a pessary. A pessary allows reversible correction of prolapse that will help the patient appreciate how she is likely to feel after surgery. If pain is not relieved, proceed with workup or referral to address the cause of pain. Similar pessary trials can be applied for constipation and urinary complaints that the patient attributes to prolapse.
Management options for prolapse depend on the patient's goals. If the prolapse is not bothersome to her, she may be assured that it can be safely observed and surgical treatment deferred without risk of harm. The exception to this is in cases of urinary retention, as indicated by elevated postvoid residual and the sensation of poor bladder emptying, caused by kinking of the urethra in the presence of a cystocele. In such cases, the bladder should be lifted by either a pessary or surgical means. Otherwise, the patient will need to learn clean intermittent self-catheterization to avoid potentially damaging vesicoureteral reflux and hydronephrosis.21,22
Another exception is incarceration of the prolapse, as described earlier. Generally prolapse that does not go past the introitus is not bothersome to patients. These prolapses can be observed conservatively if asymptomatic. Prolapses that pass the introitus can be expected to worsen.23 No other reliable predictors for progressive prolapse have been identified.24 Should the patient desire prolapse correction, a variety of conservative and surgical choices are available.
Pessaries and pelvic floor physical therapy constitute the conservative approach. Pessaries are easily fit and managed by PAs, and are discussed in more detail shortly. Physical therapy should be performed by a specially trained pelvic floor physical therapist if possible. The American Physical Therapy Association designates specialized physical therapists as women's health providers and maintains an online directory on its website.25 Interestingly, research indicates that a statistically significant number of women who receive pelvic floor physical therapy experience both subjective and objective improvement in prolapse symptoms and staging, respectively.26,27
Surgical correction of pelvic organ prolapse is not a single procedure, but rather represents an array of choices. Prolapse surgeries are beyond the scope of this article. However, they are generally divided into reconstructive or obliterative repairs, and may involve a hysterectomy in a woman who still has a uterus. The specialty of female pelvic medicine and reconstructive surgery is now the specialist body that provides care for this population. These specialists are called urogynecologists and finish 3 years of Accreditation Council for Graduate Medical Education-accredited fellowship training after completing an obstetrics/gynecology or urology residency.28
The primary care provider may have a small supply of pessaries available (Figure 5). Pessaries are the backbone of conservative therapy for the woman with symptomatic prolapse, and have been used in varying forms for thousands of years.29 Pessary use is generally well-tolerated and relieves prolapse symptoms satisfactorily in most patients who elect for a pessary trial.10 Pessaries can be especially helpful in women who do not want surgery, who are poor surgical candidates, who have not yet completed childbearing, and those who desire symptom relief while awaiting a surgery date. Most pessaries can be autoclaved and reused, so a patient should be allowed to try several pessaries if needed without fear of extra cost.
Pessaries come in many shapes and sizes and are typically made of flexible silicone, which does not cause allergic reactions or absorb odor.29 Generally, providers should try a ring with support model first, in the same size as the patient's GH (see previous section on POP-Q measurements). Several sizes of the ring with support shape should be tried before it is ruled out, as it tends to be the easiest for the patient to manage at home. However, providers may elect to offer a comparably sized pessary of a different design, such as a Gellhorn or doughnut.
When inserted in the vagina, the pessary provides support to the prolapsed tissues and restores them to their original anatomic position. A well-fitting pessary should not be uncomfortable; the patient should hardly be aware the pessary is in place. She also should be able to easily remove the pessary for intercourse and cleaning. If the patient is unable or unwilling to remove and clean her own pessary, establish a regular follow-up schedule, with visits occurring at least every 2 to 3 months. If the pessary is not routinely removed and cleaned, its constant pressure on the vaginal walls can cause mucosal erosions and, in the worst cases, fistulous tracts.
The patient also should be encouraged to tell a trusted family member or friend that she is using a pessary, in the event that she is unable to tell a provider herself. Not every woman will find a comfortable pessary, and even a woman who is well-fitted may decide that she will no longer tolerate the regular maintenance involved. Women with vaginal atrophy may benefit from an initial trial of topical estrogen cream before a pessary fitting.
In summary, if the patient desires surgical correction of her prolapse, she should be referred to a urogynecology practice for consultation. Many patients who read online about prolapse surgery are reasonably concerned about the use of synthetic vaginal mesh during repair, especially in light of lawsuits frequently mentioned in the media.30 A specialist can address these concerns more fully; providers can tell patients that mesh has been used safely for several decades abdominally, laparoscopically, and robotically. A specialist can clarify the patient's goals for prolapse surgery and help her choose the best option considering the risks and benefits unique to the patient's situation.
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