Harvey's Garden

Pelvic organ prolapse

2 min read

Herniation of pelvic organs (bladder, uterus, rectum, vaginal apex) into or out of the vagina due to weakened pelvic floor muscles and connective tissue.

Epidemiology

Etiology

  • Etiology: insufficiency of the pelvic floor muscles and the ligamentous supportive structure of the uterus and vagina
  • Risk factors:
    • Multiple vaginal deliveries and/or traumatic births (greatest risk factor)
    • Low estrogen levels (e.g., during menopause)
    • Increased intraabdominal pressure (due to, e.g., obesity, cough related to chronic lung disease and/or smoking, ascites, pelvic tumors, constipation)

Pathophysiology

  • Specific sites
    • Vaginal wall prolapse
      • Anterior vaginal wall prolapse: herniated anterior vaginal wall, which is often associated with a cystocele (descent of the bladder) or urethrocele (descent of the urethra); can be due to weakness of the pubocervical fascia; Most common type.
      • Posterior vaginal wall prolapse: herniated posterior vaginal wall, which is associated with a rectocele (descent of the rectum) or enterocele (herniated section of the intestines); can be due to weakness of the rectovaginal fascia
    • Uterine prolapse: descent of the uterus
    • Vaginal vault prolapse: descent of the apex of the vagina
    • Apical compartment prolapse: herniated uterus, cervix, or vaginal vault
    • Uterine procidentia: protrusion of all vaginal walls or cervix beyond the vaginal introitus

Clinical features

  • Feeling of pressure on or discomfort around the perineum (“sensation of vaginal fullness”)
  • Lower back and pelvic pain (may become worse with prolonged standing or walking)
  • Rectal fullness, constipation, incomplete rectal emptying
  • Prolapse of the anterior (most common) or the posterior vaginal wall
  • Weakened pelvic floor muscle and anal sphincter tone

Diagnostics

Treatment

  • Treatment is guided by symptom severity and patient preference. Asymptomatic prolapse often requires no intervention.
  • Conservative Management (First-line for mild/moderate symptoms):
    • Pelvic floor muscle training (PFMT) / Kegel exercises: Strengthens the levator ani muscles.
    • Vaginal pessary: A removable silicone device inserted into the vagina to provide structural support. Requires periodic cleaning.
    • Vaginal estrogen: Topical creams/rings can improve tissue atrophy, especially in postmenopausal women.
    • Lifestyle modification: Weight loss, treatment of chronic cough/constipation.
  • Surgical Management (For severe, symptomatic prolapse or failure of conservative Tx):
    • Reconstructive procedures: Apical suspension (e.g., sacrocolpopexy, uterosacral ligament suspension) or anterior/posterior colporrhaphy (repair of specific vaginal walls).
    • Obliterative procedures (Colpocleisis): Vagina is surgically closed. Reserved for elderly, non-sexually active patients with significant comorbidities.
    • Hysterectomy may be performed concurrently with prolapse repair.

Graph View