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Pelvic organ prolapse - a common problem

A common problem

Approximately 30%-40% of women develop some presentation of vaginal prolapse in their lifetime, usually following menopause, childbirth, or a hysterectomy. Most women who develop this condition are older than 40 years of age. Many women who develop symptoms of a vaginal prolapse do not seek medical help because of embarrassment or other reasons. Some women who develop a vaginal prolapse do not experience symptoms.

The network of muscles, ligaments, and skin in and around a woman's vagina acts as a complex support structure that holds pelvic organs, and tissues in place. This support network includes the skin and muscles of the vagina walls (a network of tissues called the fascia). Various parts of this support system may eventually weaken or break, causing a common condition called vaginal prolapse.

A vaginal prolapse is a condition in which structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself may begin to prolapse, or fall out of their normal positions. Without medical treatment or surgery, these structures may eventually prolapse farther and farther into the vagina or even through the vaginal opening if their supports weaken enough.

The symptoms that result from vaginal prolapse commonly affect sexual function as well as bodily functions such as urination and defecation. Pelvic pressure and discomfort are also common symptoms.

Types of pelvic organ prolapse

Healthy Pelvic Area Before Prolapse

Normal healthy pelvic anatomy
Typical Pelvic Anatomy

Rectocele (prolapse of the rectum)

This type of vaginal prolapse involves a prolapse of the back wall of the vagina (rectovaginal fascia). When this wall weakens, the rectal wall pushes against the vaginal wall, creating a bulge. This bulge may become especially noticeable during bowel movements.

Prolapse rectocele

Cystocele (prolapse of the bladder, bladder drop)

This can occur when the front wall of the vagina (pubocervical fascia) prolapses. As a result, the bladder may prolapse into the vagina. When this condition occurs, the urethra usually prolapses as well. A urethral prolapse is also called a urethrocele. When both the bladder and urethra prolapse, this condition is known as a cystourethrocele. Urinary stress incontinence (urine leakage during coughing, sneezing, exercise, etc) is a common symptom of this condition.

Prolapse cystocele

Enterocele (herniated small bowel)

The weakening of the upper vaginal supports can cause this type of vaginal prolapse. This condition primarily occurs following a hysterectomy. An enterocele results when the front and back walls of the vagina separate, allowing the intestines to push against the vaginal skin.

Prolapse enterocele

Prolapsed uterus (womb)

This involves a weakening of a group of ligaments called the uterosacral ligaments at the top of the vagina. This causes the uterus to fall, which commonly causes both the front and back walls of the vagina to weaken as well.

uterine-prolapse

Vaginal vault prolapse

A vaginal vault prolapse occurs when the upper part of the vagina falls into the vaginal canal.

vaginal-vault-prolapse

The stages of uterine prolapse:

  • First-degree prolapse - The uterus droops into the upper portion of the vagina.
  • Second-degree prolapse - The uterus falls into the lower part of the vagina.
  • Third-degree prolapse - The cervix, which is located at the bottom of the uterus, sags to the vaginal opening and may protrude outside the body. This condition is also called procidentia, or complete prolapse.
  • Fourth-degree prolapse - The entire uterus protrudes entirely outside the vagina. This condition is also called procidentia, or complete prolapse.
  • Vaginal vault prolapse - This type of prolapse may occur following a hysterectomy, which involves the removal of the uterus. Because the uterus provides support for the top of the vagina, this condition is common after a hysterectomy, with upwards of 10% of women developing a vaginal vault prolapse after undergoing a hysterectomy. In vaginal vault prolapse, the top of the vagina gradually falls toward the vaginal opening. This may cause the walls of the vagina to weaken as well. Eventually, the top of the vagina may protrude out of the body through the vaginal opening, effectively turning the vagina inside out. A vaginal vault prolapse often accompanies an enterocele.

Causes of vaginal prolapse

A network of muscles provides the main support for the pelvic viscera (the vagina and the surrounding tissues and organs within the pelvis). This network of muscles, which is located below most of the pelvic viscera and supports the viscera's weight, is called the levator ani. Pelvic ligaments provide additional stabilizing support.

When parts of this support network are weakened or damaged, the vagina and surrounding structures may lose some or all of the support that holds them in place. Collectively, this condition is called pelvic floor relaxation. A vaginal prolapse occurs when the weight-bearing or stabilizing structures that keep the vagina in place weaken or deteriorate. This may cause the supports for the rectum, bladder, uterus, small bladder, urethra, or a combination of them to become less stable.

Common factors that may cause a vaginal prolapse include the following:

  • Childbirth (especially multiple births) - Childbirth is stressful to the tissues, muscles, and ligaments in and around the vagina. Long, difficult labors and large babies are especially stressful to these structures. Childbirth is the risk factor most commonly associated with cystoceles, in which the bladder prolapses into the vagina. A cystocele is usually accompanied by a urethrocele, in which the urethra becomes displaced and prolapses. A cystocele and urethrocele together are called a cystourethrocele.
  • Menopause - Estrogen is a hormone that helps to keep the muscles and tissues of the pelvic support structure strong. After menopause, the estrogen level decreases; this means that the support structures may weaken.
  • Hysterectomy - The uterus is an important part of the support structure at the top of the vagina. A hysterectomy involves removing the uterus. Without the uterus, the top of the vagina may gradually fall toward the vaginal opening. This condition is called a vaginal vault prolapse. As the top of the vagina droops, added stress is placed on other ligaments. Hysterectomy is also commonly associated with an enterocele, in which the small bladder herniates near the top of the vagina.

Other risk factors of a vaginal prolapse include the following:

  • Advanced age
  • Obesity
  • Dysfunction of the nerves and tissues
  • Abnormalities of the connective tissue
  • Strenuous physical activity
  • Prior pelvic surgery

Vaginal Prolapse Symptoms

The symptoms associated with a vaginal prolapse depend on the type of vaginal prolapse present. The most common symptom of all types of vaginal prolapse is the sensation that tissues or structures in the vagina are out of place. Some women describe the feeling as "something coming down" or as a dragging sensation. This may involve a protrusion or pressure in the area of the sensation. Generally, the more advanced the prolapse, the more severe the symptoms.

The following are general symptoms of all types of vaginal prolapse:

  • Pressure in the vagina or pelvis
  • Painful intercourse (dyspareunia)
  • A lump at the opening of the vagina
  • A decrease in pain or pressure when the woman lies down
  • Recurrent urinary tract infections

The following are symptoms that are specific to certain types of vaginal prolapse:

  • Difficulty emptying bowel - This may be indicative of an enterocele, vaginal vault prolapse, or prolapsed uterus. A woman with difficulty emptying her bowel may find that she needs to place her fingers on the back wall of the vagina to help evacuate her bowel completely. This is referred to as splinting.
  • Difficulty emptying bladder - This may be indicative of a cystocele, urethrocele, enterocele, vaginal vault prolapse, or prolapsed uterus.
  • Constipation - This is the most common symptom of a rectocele.
  • Urinary stress incontinence - This is a common symptom of a cystocele.
  • Pain that increases during long periods of standing - This may be indicative of an enterocele, vaginal vault prolapse, or prolapsed uterus.
  • Protrusion of tissue at the back wall of the vagina - This is a common symptom of a rectocele.
  • Protrusion of tissue at the front wall of the vagina - This is a common symptom of a cystocele or urethrocele.
  • Enlarged, wide, and gaping vaginal opening - This is a common symptom of a vaginal vault prolapse.

Some women who develop a vaginal prolapse do not experience symptoms.

Vaginal Prolapse Treatment

Most vaginal prolapses gradually worsen and can only be fully corrected with surgery. However, the type of treatment that is appropriate to treat a vaginal prolapse depends on factors such as the cause and severity of the prolapse, whether the woman is sexually active, and the woman's treatment preference.

Nonsurgical options may be most appropriate for women who are not sexually active, cannot undergo surgery because of medical reasons, or experience few or no symptoms associated with the condition.

Surgical repair is the treatment option that most sexually active women who develop a vaginal prolapse choose because the procedure is usually effective.

Self-care treatment for Vaginal Prolapse

Treatments at home for vaginal prolapse include one or a combination of the following:

Activity modification - For a vaginal prolapse that causes minor or no symptoms, the doctor may recommend activity modification such as avoiding heavy lifting or straining.

Kegel (pelvic floor) exercises - These are exercises used to tighten the muscles of the pelvic floor. Kegel exercises might be used to treat mild-to-moderate cases of vaginal prolapse or to supplement other treatments for prolapses that are more serious.

Pessary - A pessary is a small device, usually made of vinyl, that is placed within the vagina for support. Pessaries come in several varieties. This nonsurgical treatment option may be the most appropriate for women who are not sexually active, cannot have surgery, or plan to have surgery but need a temporary nonsurgical option until surgery can be performed (for example, women who are pregnant or in poor health). Pessaries must be removed and cleaned at regular intervals to prevent infection. Some pessaries are designed to allow the woman to do this herself. A doctor must remove and clean other types. Estrogen cream is commonly used along with a pessary to help prevent infection and vaginal wall erosion. Some women find that pessaries are uncomfortable or that they easily fall out.

Vaginal Prolapse Medications

Oestrogen replacement therapy may be used to help the body strengthen the muscles in and around the vagina. Oestrogen replacement therapy may be contraindicated (such as in a people with certain types of cancer) and has been associated with certain health risks including increased risk of blood clots and stroke, particularly in older postmenopausal women. Women's bodies stop creating oestrogen naturally after menopause, and the muscles of the vagina may weaken as a result. In mild cases of vaginal prolapse, oestrogen may be prescribed in an attempt to reverse vaginal prolapse symptoms, such as vaginal weakening and incontinence. For more severe prolapses, oestrogen replacement therapy may be used along with other types of treatment.

Vaginal Prolapse Surgery

A generalized weakness of the vaginal muscles and ligaments is much more likely to develop than are isolated defects. If a woman develops symptoms of one type of vaginal prolapse, she is likely to have or develop other types as well. Therefore, a thorough physical examination is necessary for the surgeon to detail what surgical steps are necessary to correct the vaginal prolapse completely. The typical surgical strategy is to correct all vaginal weaknesses at once.

Surgery is usually performed while the woman is under general anaesthesia. Some women receive a spinal epidural. The type of anaesthesia given usually depends on how invasive and lengthy the surgery is expected to be.

Acknowledgement: emedicinehealth.com and pelvichealthsource.com

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