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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Keywords:© 2014 American Academy of Physician Assistants.
pelvic organs; prolapse; uterus; pessary; herniation; pregnancy