Pelvic organ prolapse

Pelvic organ prolapse
Other names: Genital prolapse
Anatomy of the female pelvic showing commonly prolapsed organs
SpecialtyGynecology
SymptomsPressure in the vagina, bulging out the vagina, urinary incontinence[1]
Usual onsetOlder age[1]
TypesCystocele, rectocele, uterine prolapse, enterocele[1]
Diagnostic methodBased on smptoms and examination[1]
TreatmentHigh fiber diet, pelvic floor exercises, pessary, surgery[1]
Frequency108 million women (2.8% as of 2017)[2]

Pelvic organ prolapse (POP) is when one or more pelvic organs decent from their normal positions.[1] In women this generally occurs into the vagina.[1] Many women have no symptoms.[3] When symptoms occur these may include a feeling of pressure in the vagina, bulging coming out the vagina, or urinary incontinence.[1] It is a type of pelvic floor disorder.[1]

Risk factors include vaginal childbirth, obesity, chronic cough, constipation, menopause, and a family history of the condition.[1] The underlying mechanism involves weakness or damage to the pelvic floor.[1] Types include cystocele (bladder), rectocele (rectum), uterine prolapse (uterus), and enterocele (small bowel).[1] Diagnosis is based on symptoms and examination.[1]

Treatment may involve a high fiber diet, pelvic floor exercises, a removable device placed in the vagina known as a pessary, or surgery.[1] Surgery is generally only recommended if the prolapse is causing significant problems.[4] Pelvic organ prolapse affected about 108 million women in 2017 (2.8% of women).[2] Older women are more commonly affected, particularly those in their 70s.[1][3] Men are very rarely affected.[5]

Signs and symptoms

Many women have no symptoms.[3] When symptoms occur these may include a feeling of pressure in the vagina, bulging coming out the vagina, or urinary incontinence.[1]

Risk factors

Risk factors include vaginal childbirth, obesity, chronic cough, constipation, menopause, and a family history of the condition.[1]

Diagnosis

Diagnosis is based on symptoms and examination.[1]

Types

Grading

Pelvic organ prolapses are graded either via the Baden–Walker System, Shaw's System, or the Pelvic Organ Prolapse Quantification (POP-Q) System.[7]

Shaw's System

Anterior wall

  • Upper 2/3 cystocele
  • Lower 1/3 urethrocele

Posterior wall

  • Upper 1/3 enterocele
  • Middle 1/3 rectocele
  • Lower 1/3 deficient perenium

Uterine prolapse

  • Grade 0 Normal position
  • Grade 1 descent into vagina not reaching introitus
  • Grade 2 descent up to the introitus
  • Grade 3 descent outside the introitus
  • Grade 4 Procidentia

Baden–Walker

Baden–Walker System[8] for the Evaluation of Pelvic Organ Prolapse on Physical Examination
GradePosterior urethral descent, lowest part other sites
0normal position for each respective site
1descent halfway to the hymen
2descent to the hymen
3descent halfway past the hymen
4maximum possible descent for each site

POP-Q

Main article: Pelvic Organ Prolapse Quantification System
POP-Q points
Pelvic Organ Prolapse Quantification System (POP-Q)
StageDescription
0No prolapse anterior and posterior points are all −3 cm, and C or D is between −TVL and −(TVL−2) cm.
1The criteria for stage 0 are not met, and the most distal prolapse is more than 1 cm above the level of the hymen (less than −1 cm).
2The most distal prolapse is between 1 cm above and 1 cm below the hymen (at least one point is −1, 0, or +1).
3The most distal prolapse is more than 1 cm below the hymen but no further than 2 cm less than TVL.
4Represents complete procidentia or vault eversion; the most distal prolapse protrudes to at least (TVL−2) cm.

Management

Vaginal prolapses are treated according to the severity of symptoms.

Conservative

Conservative measures such as changes in diet and fitness, Kegel exercises, and pelvic floor physical therapy may be useful.[9]

A pessary, a rubber or silicone rubber device fitted to the patient which is inserted into the vagina and may be retained for up to several months. Pessaries are a good choice of treatment for women who wish to maintain fertility, are poor surgical candidates, or who may not be able to attend physical therapy.[10] Pessaries require a provider to fit the device, but most can be removed, cleaned, and replaced by the woman herself. Pessaries should be offered to women considering surgery as a non-surgical alternative.

Surgery

With surgery (for example native tissue repair, biological graft repair, absorbable and non-absorbable mesh repair, colpopexy, colpocleisis). Surgery is used to treat symptoms such as bowel or urinary problems, pain, or a prolapse sensation.

A 2016 Cochrane review concluded that evidence does not support the use of transvaginal surgical mesh compared with native tissue repair for anterior compartment prolapse owing to increased morbidity.[11] Safety and efficacy of many newer meshes is unknown.[11] The use of a transvaginal mesh in treating vaginal prolapses is associated with side effects including pain, infection, and organ perforation and serious complications are "not rare."[12] A number of class action lawsuits have been filed and settled against several manufacturers of transvaginal mesh. Transvaginal permanent mesh may reduce a women's perception of vaginal prolapse and probably the risk of recurrent prolapse and of having repeat surgery for prolapse. On the other hand, transvaginal mesh probably has a greater risk of bladder injury and of needing repeat surgery for stress urinary incontinence or mesh exposure.[13]

Epidemiology

Genital prolapse occurs in about 316 million women worldwide as of 2010 (9.3% of all females).[14]

Research

To study POP, various animal models are employed: non-human primates, sheep,[15][16] pigs, rats, and others.[17][18]

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 "Pelvic organ prolapse". womenshealth.gov. 3 May 2017. Archived from the original on 7 May 2019. Retrieved 27 October 2020.
  2. 1 2 GBD 2017 Disease and Injury Incidence and Prevalence, Collaborators. (10 November 2018). "Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017". Lancet (London, England). 392 (10159): 1789–1858. doi:10.1016/S0140-6736(18)32279-7. PMID 30496104.
  3. 1 2 3 American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology and American Urogynecologic, Society. (November 2019). "Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214". Obstetrics and gynecology. 134 (5): e126–e142. doi:10.1097/AOG.0000000000003519. PMID 31651832.
  4. ↑ Health, Center for Devices and Radiological (16 April 2019). "Pelvic Organ Prolapse (POP)". FDA. Archived from the original on 27 October 2020. Retrieved 27 October 2020.
  5. ↑ Laycock, J.; Haslam, J. (2013). Therapeutic Management of Incontinence and Pelvic Pain: Pelvic Organ Disorders. Springer Science & Business Media. p. 14. ISBN 978-1-4471-3715-3. Archived from the original on 2021-08-28. Retrieved 2020-10-27.
  6. ↑ Donita D (2015-02-10). Health & physical assessment in nursing. Barbarito, Colleen (3rd ed.). Boston. p. 665. ISBN 978-0-13-387640-6. OCLC 894626609.
  7. ↑ ACOG Committee on Practice Bulletins—Gynecology (September 2007). "ACOG Practice Bulletin No. 85: Pelvic organ prolapse". Obstetrics and Gynecology. 110 (3): 717–729. doi:10.1097/01.AOG.0000263925.97887.72. PMID 17766624.
  8. ↑ Beckley I, Harris N (2013-03-26). "Pelvic organ prolapse: a urology perspective". Journal of Clinical Urology. 6 (2): 68–76. doi:10.1177/2051415812472675.
  9. ↑ "Kegel Exercises | NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases. Archived from the original on 2018-04-22. Retrieved 2017-12-02.
  10. ↑ Tulikangas P, et al. (Committee on Practice Bulletins—Gynecology and the American Urogynecologic Society) (April 2017). "Practice Bulletin No. 176: Pelvic Organ Prolapse". Obstetrics and Gynecology. 129 (4): e56–e72. doi:10.1097/aog.0000000000002016. PMID 28333818.
  11. 1 2 Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Brown J (November 2016). "Surgery for women with anterior compartment prolapse". The Cochrane Database of Systematic Reviews. 11: CD004014. doi:10.1002/14651858.CD004014.pub6. PMC 6464975. PMID 27901278.
  12. ↑ "UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse: FDA Safety Communication". U.S. Food and Drug Administration. 13 July 2011. Archived from the original on 22 July 2017. Retrieved 23 June 2015.
  13. ↑ Maher, C; Feiner, B; Baessler, K; Christmann-Schmid, C; Haya, N; Marjoribanks, J (9 February 2016). "Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse". The Cochrane Database of Systematic Reviews. 2: CD012079. doi:10.1002/14651858.CD012079. PMC 6489145. PMID 26858090.
  14. ↑ Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. (December 2012). "Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010". Lancet. 380 (9859): 2163–2196. doi:10.1016/S0140-6736(12)61729-2. PMC 6350784. PMID 23245607.
  15. ↑ Patnaik SS, Brazile B, Dandolu V, Damaser M, van der Vaart CH, Liao J. "Sheep as an animal model for pelvic organ prolapse and urogynecological research" (PDF). ASB 2015 Annual Conference 2015. Archived from the original (PDF) on 2019-03-27. Retrieved 2019-03-26.
  16. ↑ Patnaik SS (2015). Investigation of sheep reproductive tract as an animal model for pelvic organ prolapse and urogyencological research. Mississippi State University. Archived from the original on 2021-08-28. Retrieved 2019-03-26.
  17. ↑ Couri BM, Lenis AT, Borazjani A, Paraiso MF, Damaser MS (May 2012). "Animal models of female pelvic organ prolapse: lessons learned". Expert Review of Obstetrics & Gynecology. 7 (3): 249–260. doi:10.1586/eog.12.24. PMC 3374602. PMID 22707980.
  18. ↑ Patnaik SS (2016). Chapter Six - Pelvic Floor Biomechanics From Animal Models. Academic Press. pp. 131–148. doi:10.1016/B978-0-12-803228-2.00006-4.
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