Pelvic Organ Prolapse
Pelvic organ prolapse is an uncomfortable condition that can occur in women after childbirth and menopause. It happens when weakened pelvic muscles allow the bladder, uterus or rectum to fall or sink into the vagina. Mild cases can improve on their own, but severe cases may require surgery.
Pelvic organ prolapse is a type of hernia, which is a condition that occurs when an organ bulges through the muscle or tissue that surrounds it.
Muscles, ligaments and fibers that attach to bone support the bladder, uterus and rectum. When the muscles weaken because of childbirth or other factors, the pelvic organs can fall into the vagina.
Nearly 3 percent of women in the United States suffer from POP, according to the Food and Drug Administration’s Office of Women’s Health. Roughly 25% of adult women in the U.S. report a pelvic floor disorder, which includes POP. Experts expect the rates to increase 50% by 2050, according to a September 2022 article by the University of Alabama at Birmingham.
And surgeons perform roughly 200,000 surgeries to treat prolapse each year in the United States, according to an article by Dr. J. Eric Jelovsek in UpToDate.
POP is usually classified as asymptomatic or symptomatic. Asymptomatic means the organs drop but do not extend beyond the vaginal opening. Symptomatic means the organs or tissue extend beyond the vaginal opening.
- Vaginal Vault Prolapse:
- The top of the vagina falls
- The uterus descends into the vagina
- The bladder protrudes into the vagina
- The small intestine protrudes into the vagina
- The rectum protrudes into the vagina
Patients experience pressure, pain or the sensation of something falling out of their vagina or rectum. In extreme cases, women may see or feel their pelvic organs bulge out of their body. When prolapse causes pain, patients should see a doctor.
Prolapse Causes and Prevention
Weakened or stretched pelvic muscles cause pelvic organ prolapse. Childbirth is the most common cause because it increases pressure on internal organs. That pressure can force the organs into the pelvis, leading to prolapse. Women who deliver larger babies are at an increased risk.
Studies indicate that:
- One in three women who gave birth has prolapse
- A woman who has two vaginal births is 8.4 times more likely to experience prolapse than a woman who hasn’t given birth vaginally
- White women have a higher risk of prolapse than black, Hispanic or Asian women
Menopause, old age and other factors also contribute to weakened muscles. When women go through menopause, one side effect is a drop in their collagen levels. Collagen is a naturally occurring protein that helps connective tissue repair itself after stretching or tearing.
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Some causes of prolapse can’t be prevented. Injury to the pelvic floor from vaginal labor is unavoidable. Menopause is inevitable. And you can’t change family history that may put you at a higher risk for prolapse.
However, women can take steps to avoid certain factors that increase the risk of pelvic organ prolapse. These risk factors include smoking, obesity, heavy lifting, and intense activities, such as CrossFit.
Connective tissue in the pelvis can also weaken and cause prolapse when the uterus or cervix is removed during a hysterectomy. The risk of prolapse following a hysterectomy can be reduced if the doctor attaches the top of the vagina to ligaments in the pelvis during the procedure. This provides extra support to the pelvic organs.
Symptoms Develop Gradually As Muscles Weaken
Symptoms of prolapse develop gradually as pelvic floor muscles weaken. Women will often feel pressure as the uterus, bladder or rectum press on the vaginal wall.
Pain during sexual intercourse, known as dyspareunia, is a common symptom of prolapse in women. Recurring urinary tract infections and pain during bowel movements or urination may also indicate prolapse.
Other symptoms of pelvic organ prolapse include:
- Pulling and stretching sensation in the groin
- Feeling bloated in the lower belly
- Lower back pain
- Spotting or bleeding
Lifting objects, standing and jumping may worsen prolapse symptoms. Lying down can help alleviate symptoms.
People who experience multiple symptoms should see their primary doctor or OB-GYN. Doctors can run several tests to diagnose pelvic organ prolapse.
People usually seek medical attention for prolapse when it causes pain and discomfort. A doctor can diagnose prolapse with a cotton swab test, a bladder function test or a pelvic-floor strength test. Primary care doctors or OB-GYNs may refer patients to a pelvic floor specialist called a urogynecologist for diagnosis and treatment.
During a cotton swab test, health care providers feed a small cotton applicator through a woman’s urethra. The patient must then strain or cough. This indicates the position of the bladder.
A bladder function test uses a funnel to record a patient’s urine flow. If the bladder is under pressure from prolapse, the urine will flow at a certain rate. Doctors may insert a catheter through the urethra to fill the bladder with sterile liquid. The doctor will assess the bladder’s condition by measuring the pressure and volume of the bladder.
In a pelvic floor strength test, the patient uses his or her pelvic floor and sphincter muscles, and a health care provider measures muscle weakness.
If the prolapse is in an early stage, an MRI, X-ray, ultrasound, colonoscopy or cystoscopy can detect it. In cystoscopies and colonoscopies, doctors insert a small camera through the urethra or the rectum.
Stages of Pelvic Organ Prolapse
The Pelvic Organ Prolapse Quantification system provides a standardized method for classifying how far organs have prolapsed in women, according to a 2011 article in the Journal of Medicine and Life.
Organs are in their normal position
An organ extends more than one centimeter above the hymen
An organ is less than one centimeter from the hymen
An organ extends more than one centimeter but less than two centimeters below the hymen
The organ protrudes into the vagina
The POP-Q system measures six areas in the vagina to document how many centimeters the organs have fallen past the hymen. Doctors may use a long Q-tip as a ruler.
Centimeters above the hymen are negative points, which indicate less prolapse. Centimeters below the hymen are positive points, which signify more serious prolapse. Doctors total the points from each area to find the stage of the prolapse.
Treatment Options With and Without Vaginal Mesh
Pelvic organ prolapse can be a serious condition that lowers quality of life. Patients should talk to their doctors about all treatment options.
Depending on the stage of the prolapse, doctors may start by recommending treatment that slows the descent of the organs, such as Kegel exercises. Such conservative, non-surgical treatment options may provide relief from symptoms and help patients avoid surgery.
Doctors continue to monitor symptoms until prolapse causes pain or discomfort. When prolapse causes pain or discomfort, doctors may move to surgical methods.
If advanced prolapse is left untreated, organs can eventually bulge into the vagina or hang out of the body when standing or walking.
Overall, treatment options for pelvic organ prolapse are limited and long-term success rates are inconsistent. Some doctors refer to pelvic organ prolapse as a chronic disease because many women experience a recurrence of symptoms after treatment.
Conservative treatment is the first line of therapy for treating POP, according to Jelovsek. Conservative treatment has the advantage of being safer, less expensive and less damaging to a patient’s body than surgery.
Women can slow or prevent prolapse naturally by exercising their pelvic floor Kegel muscles. Kegel muscles control urination. Exercising them strengthens the pelvic area and supports the pelvic organs.
Low-Dose Estrogen Cream
Doctors often prescribe low-dose estrogen cream to strengthen pelvic connective tissue and slow the movement of prolapsed organs. Patients can apply estrogen creams vaginally once a day for the first two weeks of treatment and three times a week thereafter.
Another conservative treatment involves inserting a device called a pessary into the vagina. This rubber ring provides support to organs. To lower the risk of side effects such as odor, vaginal discharge, infection, ulcers, irritation and bleeding, patients can apply estrogen cream with the device. Clean the pessary regularly and remove it before sexual intercourse.
Many women may have POP but not suffer symptoms. There is no need for surgery in those cases. But women who are symptomatic — or asymptomatic with stage 3 or 4 prolapse — might be candidates for surgery.
Surgery can either be obliterative or reconstructive. Obliterative surgery narrows or closes off the vagina. It provides support for prolapsed organs, but women who undergo this procedure will no longer be able to have sex.
There are multiple types of reconstructive surgery. These procedures are intended to restore the pelvic floor and return organs to their original position. They can be done through an incision in the vagina or abdomen, or laparoscopically.
Sacrocolpopexy, which uses surgical mesh to treat vaginal vault prolapse and small intestine prolapse, and sacrohysteropexy, which uses surgical mesh to repair uterine prolapse, are done through an incision in the abdomen or with laparoscopy.
To repair prolapse through the vagina, doctors have traditionally turned to a surgical procedure known as colporrhaphy. During this procedure, a surgeon uses stitches and the patient’s own tissue to repair weakened muscles and create more pelvic floor support.
But because prolapse can return after colporrhaphy, gynecologists began using surgical mesh for transvaginal repair of POP in the 1990s. The FDA cleared the first surgical mesh product specifically for use in POP in 2002.
Medical device companies claimed that vaginal mesh was superior for treating prolapse, but the FDA has said there is no evidence to support those claims.
Because the FDA found that complications with transvaginal mesh are not rare, the agency asked for more safety data from manufacturers. Several companies simply stopped making POP mesh rather than doing the studies.
Lack of safety and efficacy data led the FDA to order manufacturers to stop selling mesh intended for transvaginal repair of POP in April 2019. There are currently no meshes for this use on the market in the United States.
POP Surgery and Pudendal Neuralgia
Pelvic pain is one of the most common complications of surgical POP repair with mesh. One of the causes of pain is pudendal nerve entrapment, or pudendal neuralgia. This happens when the pudendal nerve is compressed or damaged by the mesh or during surgery.
“The surgery for repair of prolapse of pelvic organs is reportedly the most common cause of pudendal neuralgia. The incidence increases if it is a mesh placement surgery that may require mesh removal in cases of chronic persistent pain,” according to Drs. Jasmeen Kaur and Paramvir Singh.
Pudendal neuralgia may be diagnosed as interstitial cystitis, a painful bladder condition. A common treatment for IC is an oral drug called Elmiron. Most Elmiron side effects are mild, but some recent studies have linked long-term use of Elmiron to potentially permanent vision loss.
Patients diagnosed with IC after surgery for POP whose pain didn’t improve after IC treatment should ask their doctors about pudendal nerve entrapment.
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