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Pelvic Organ Prolapse

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Pelvic organ prolapse is an uncomfortable condition that typically afflicts women after childbirth and menopause. It occurs when weakened pelvic muscles allow the bladder, uterus or rectum to “fall” or sink into the vagina.

Patients may experience pressure, pain and the sensation of something falling out of their vagina or rectum. In extreme cases, people may see or feel their pelvic organs bulge out of their body. When prolapse causes pain, patients should see a doctor.

Traditional treatment for prolapse included surgery, in which a specialist used a patient’s own tissues to provide support for the prolapsed organ. Starting in the early 2000s, surgeons began using transvaginal mesh implants to support prolapsed organs.

While drug companies claim that vaginal mesh is superior for treating prolapse, the FDA (U.S. Food and Drug Administration) says there is no evidence to support those claims. Moreover, after receiving thousands of complaints that the products can perforate organs and erode through tissues, the FDA has begun investigating the safety of transvaginal mesh products.

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Causes of Pelvic Organ Prolapse

Medical studies estimate that half  of women who deliver one or more babies through vaginal childbirth will experience prolapse. After two vaginal births, a woman is eight times more at risk of prolapse than a woman who hasn’t given birth vaginally. And after four vaginal births, a woman is 12 times more likely to suffer from prolapse. Women who deliver babies who are heavier than nine pounds are also at an increased risk.

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.

Connective tissue in the pelvis can also weaken and cause prolapse when the uterus or cervix are 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.

Rectal prolapse occurs in men as they age and their tissue loses its elasticity.

The following conditions also can contribute to prolapse:
Multiple sclerosis Obesity
Spinal cord injury and paralysis Smoking
Muscular dystrophy Chronic cough
Genetic weakness of connective tissue

Symptoms of Pelvic Organ Prolapse

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 (dyspareunia) is a common symptom of prolapse in women. Recurring urinary tract infections may also indicate prolapse.

Both women and men suffering from prolapse may experience pain during bowel movements or urination. Lifting objects, standing and jumping worsen prolapse symptoms; lying down alleviates them.

Painful and embarrassing symptoms — and a poor quality of life — may drive women with prolapse to see their doctor.

Other Symptoms of Pelvic Organ Prolapse:

  • Pulling and stretching sensation in groin
  • Feeling bloated in the lower belly
  • Lower backache
  • Spotting or bleeding
  • Constipation

 Diagnosing Pelvic Organ Prolapse

People usually seek medical attention for prolapse when it causes them pain and discomfort. A doctor can diagnose prolapse with a cotton swab test, a bladder function test or a pelvic-floor strength test. To diagnose rectal prolapse, doctors use a physical exam or a colonoscopy.

If the prolapse is at an early stage, an MRI, X-ray, ultrasound, colonoscopy or cystoscopy can detect it. In cystoscopies and colonoscopies, a small camera is inserted through the urethra or the rectum.

Physical exam:

Cotton swab test:

With a cotton swab test, a small cotton applicator is fed through a woman’s urethra. The patient is then asked to strain or cough, which indicates the position of the bladder.

Bladder function test:

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. A catheter also may be inserted through the urethra to fill the bladder with sterile liquid. The pressure and volume of the bladder are recorded and allow the doctor to diagnose the bladder’s condition.

Pelvic floor strength test:

In a pelvic floor strength test, potential muscle weakness is measured as the patient uses his or her pelvic floor and sphincter muscles.

Staging of Pelvic Organ Prolapse

The Pelvic Organ Prolapse Quantification system (POPQ) is the standard method for classifying how far organs have prolapsed in women. There are five stages of prolapse. At stage 0, organs are in their normal position, and at stage IV, organs protrude out of the body. The POPQ measures six areas in the vagina to document how many centimeters the organs have fallen past the top of the vagina (the hymen). Doctors may use a long Q-tip as a ruler.

Centimeters above the hymen are negative points (less prolapse), and centimeters below are positive (more serious prolapse). Doctors total the points from each area to find the stage of the prolapse.

Treating Pelvic Organ Prolapse

After diagnosis, a doctor will use treatment intended to slow the organs descent — such as Kegel exercises — while they continue to monitor symptoms. When the prolapse causes discomfort, the doctor can then move to surgical methods. If advanced prolapse is left untreated, organs will eventually bulge into the vagina or possibly hang out of the body when standing or walking.

One medical study showed 75 percent of doctors use conservative treatment as the first therapy for prolapse. Conservative treatment has the advantage of being safer, less expensive and less damaging to a patient’s body than aggressive surgery. When patients chose surgery as their first option it is usually because they are looking for a more permanent option than some of the conservative treatments, which can be temporary or less effective against prolapse.

Surgical Treatment

Traditionally, doctors have turned to a surgical procedure known as a colporrhaphy to repair prolapse in women. In a colporrhaphy, doctors use stitches and the patient’s own tissues to repair the weakened muscles.

When a patient is looking for a permanent solution to prolapse, doctors will recommend surgery. Traditionally, doctors performed a colporrhaphy — also known as anterior or posterior colporrhaphy, or simply A&P repair to correct POP. This involves cutting and suturing the patient’s own tissues to create more pelvic floor support. Doctors may perform a laparoscopic colporrhaphy or may cut open the abdomen for the surgery.

Because prolapse can return after a colporrhaphy, about a decade ago doctors began using surgical mesh to reinforce the pelvic floor muscles. A small piece of mesh — known as transvaginal mesh — is inserted through the vagina and sewn in to pelvic floor ligaments and vaginal tissue.

Medical device manufacturers such as Johnson & Johnson, Boston Scientific Corp., C.R. Bard Inc. and American Medical Systems began making transvaginal mesh kits to assist surgeons in the operation.

Today, however, doctors are returning to colporrhaphy because complications with transvaginal mesh are increasingly common. The mesh can erode through vaginal walls and into other organs. It can also cause organ perforation. Many women have to undergo multiple revision surgeries to repair problems caused by transvaginal mesh.

The FDA has ordered 44 mesh manufacturers to perform safety studies on their transvaginal mesh products. Women filed lawsuits against the several mesh manufacturers, including: Johnson & Johnson’s Ehticon unit, C.R. Bard, American Medical Systems, Boston Scientific, Cook Medical, Coloplast and Neomedic saying they were never told of the dangers of the mesh implants. In total, about 75,000 lawsuits are pending in federal courts. Thousands more await trial in states courts across the country.

Conservative Treatment

Women can slow or prevent prolapse naturally by exercising their pelvic floor Kegel muscles. These are the muscles that control urination. Exercising them strengthens the pelvic area and supports the pelvic organs.

Doctors often prescribe low-dose estrogen cream to strengthen pelvic connective tissue and slow the movement of prolapsed organs. Estrogen creams are applied vaginally once a day for the first two weeks of treatment and three times a week thereafter.

Another conservative treatment involves a device called a pessary that is inserted into the vagina. This rubber ring provides support to organs. Estrogen cream can be used with this device to lower the risk of side effects such as odor, vaginal discharge, infection, ulcers, irritation and bleeding. The pessary must be cleaned regularly and removed before sexual intercourse.