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Vaginal Prolapse

Vaginal prolapse or pelvic organ prolapse (POP) with urinary incontinence is common in women worldwide. POP affects other functions as well but for purposes of this article the  association between POP and urinary incontinence remains to be studied more rigorously. For instance, surgery for urinary incontinence may adversely affect POP indicating the need among continence practitioners for knowledge on POP for optimum care of their patients.   


Presentation

Concurrent pelvic symptoms accompany POP in patients [11]. Ellerkmann et al in 2011 reported the following in 237 women: urinary incontinence, 73%; urinary urgency, 86%; urgency and/or frequency, 34 to 62 %; voiding dysfunction and faecal incontinence, 31% [12]. Evaluation of POP requires knowledge of the symptomatology of pelvic floor disorders and their effects on quality of life. Carefully designed psychometric self-administered questionnaires are used to validate the occurrence and and impact of POP symptoms on a patient's sense of well-being and capacity to resume normal activities. 

Research has improved understanding of the association between loss of pelvic organ support and severity of symptoms, the most consistent of which is the presence of a vaginal protrusion that can be seen or felt by patients with advanced POP. The absence of this vaginal bulge after surgery has a significant effect on a patient’s perception of overall improvement more than anatomical success alone. The hymen being an important outcome indicator, women with prolapse beyond the hymen are more likely to have pelvic floor symptoms and vaginal bulge than those with prolapse at or above the hymen.

Constipation
  • Defect-specific colporrhaphy resulted in the resolution of symptoms associated with rectocele, including reduction in splinting, 55%; dyspareunia, 66% and constipation, 84%. Transanal repair alleviated constipation in 22 to 85% of patients.[symptoma.com]
  • The common factors such as frequent lifting of heavy objects, chronic cough, severe constipation, menopause, childbirth, and pregnancy may increase your risk of developing utero-vaginal prolapse.[vashevnik.com.au]
  • These factors include the loss of muscle tone as women age, injury due to childbirth (especially women who have had many babies or large babies), obesity, chronic coughing, chronic constipation and all place added tension on the pelvic muscles.[med.unc.edu]
Anxiety Disorder
  • Exclusion criteria were: any neurological or anxiety disorder, or the need for combined anti-incontinence surgery. METHODS: All patients were given an indwelling catheter directly after surgery, which was removed on the first postoperative day.[ncbi.nlm.nih.gov]
Dyspareunia
  • Dyspareunia was described in 70 studies for a rate of 9.1%, (95% CI, 8.2 - 10.0%; range, 0 - 66.7%; synthetic, 8.9%; biological, 9.6%).[ncbi.nlm.nih.gov]
  • Abstract We present a 33-year-old woman with a history of radical hysterectomy and pelvic radiation who developed a nonreducible high anterior vaginal wall bulge, postoperative pelvic pain, and dyspareunia.[ncbi.nlm.nih.gov]
  • There was no evidence of a difference between the groups in rates of de novo dyspareunia (RR 0.92, 95% CI 0.58 to 1.47, 11 RCTs, n 764, I(2) 21%, low-quality evidence). Effects on quality of life were uncertain due to the very low-quality evidence.[ncbi.nlm.nih.gov]
  • Secondary outcomes assessed included re-operation for prolapse in the same compartment, dyspareunia and mesh-related complications.[ncbi.nlm.nih.gov]
  • Dyspareunia was also more common after vaginal procedures (RR 2.53, 95% CI 1.17 to 5.50; 3 RCTs, n 106, I 2 43%, low-quality evidence). Vaginal surgery with mesh versus without mesh (6 RCTs, n 598, 1-3 year review).[ncbi.nlm.nih.gov]
Vaginal Discharge
  • Side effects Ring pessaries can occasionally cause vaginal discharge, some irritation and possibly bleeding and sores inside your vagina.[everestpharmacy.co.uk]
  • Gentle swimming is fine once all vaginal discharge has settled Prevent constipation – Avoid straining when opening your bowels. If this is a problem increase your fibre and fluid intake (have at least 1-1½ litres of water per day).[agsc.com.au]
  • However most women with significant prolapse may experience some of the followings: Dragging sensation or discomfort in the lower abdomen or pelvis Sensation of swelling or fullness in the vagina Backache Vaginal discharge or bleeding Difficulty in passing[kkh.com.sg]
  • However, if you have a more severe form of prolapse, you may experience: a vaginal lump a visible lump protruding from your vagina which may occur at the end of the day or with strenuous activity vaginal discharge and bleeding difficulties in passing[depend.com.au]
  • discharge Symptoms may be worse when you stand or sit for a long time.[mountsinai.org]

Workup

Routine laboratory examinations:

  • Rule out infections: creatinine, glucose, BUN, and calcium, in patients with polyuria or compromised renal function. 
  • Urinalysis with cytology, for patients with hematuria, to rule out bladder neoplasm.

Imaging Studies:

  • Ultrasonographic imaging of the uterus.
  • Contrast radiology, MRI, and ultrasonography, to identify the support defects.
  • Proctography and proctosigmoidoscopy, for  defecatory dysfunction. 
  • Colonic transit studies, for peristaltic dysfunctions.
  • Dynamic MRI defecography, for defecatory and high-quality soft tissue imaging; however, the test is expensive and inconclusive.

Diagnostic Procedures:

  • Cervical cytology.
  • Ultrasonography or endometrial biopsy, to rule out endometrial pathology, for patients undergoing LeFort colpocleisis. 
  • Urodynamic testing, for urinary incontinence
  • Cystoscopy, for refractory patients with hematuria, bladder pain, or urinary urgency, and polyuria.
  • Cervical cytology, in lieu of cervical screening.  
Hemoglobin Decreased
  • Change in hemoglobin decreased over time (P 0.0005). Exposure rates also decreased over time (17% in 2005 to 12% in 2006, then 5%-8% in 2006-2011) but were not statistically significant (P 0.49).[ncbi.nlm.nih.gov]

Treatment

The overall prevalence of POP is 31%, increasing with age. By age 80, the probability of requiring surgical intervention is approximately 11%; 29 to 40% undergo reoperation within 3 years after traditional surgery using non-augmented vaginal techniques (culdoplasty, colporrhaphy, and apical vault suspensions). As it were, high failure rates prompted the use of grafts, but without standardized techniques, have had varied outcomes [13]. Pelvic floor graft in the form of tension-free vaginal tape and sacral colpopexy have had long-term restorative benefits. Complications from sacral colpopexy may be increased by laparotomy; as an alternative, laparoscopy, may provide comparable success and faster convalescence time.

Various types of grafts may be used: xenografts (porcine dermis, intestinal mucosa), allografts (cadaveric), or synthetic material (polypropylene). Recent developments focus on TVM (transvaginal mesh) systems using polyproplylene graft material and trocars. The methodology aims for durability, minimize invasiveness and patient apprehension, provide regional anaesthesia, and repair anatomical defects  without trimming the vagina or suturing the mesh to the vagina. Selective application of vaginal implants eliminates the need for hysterectomy. Trocars are installed via the obturator membrane or the ischiorectal fossa. 

TVM systems have been shown to be effective but long-term follow-up on safety and longevity has been limited. Side effects (mesh erosion and shrinkage, dyspareunia, pelvic pain, and stress incontinence) were observed in earlier studies. Newer technology has made possible single-incision trocarless TVM systems, minimizing the side effects and shortening operating time. Potential risks and effectiveness  of these procedures remain to be elucidated [14] [15].

Recommendations:

  • Patients should be informed that the TVM systems have been developed from previous uncontrolled short-term studies with considerable success of anatomical cure. Meanwhile further evidence is needed to establish their advantage over other currently used methods.
  • Training on TVM procedures should be instituted. 
  • Patients should be advised on (a) potential side effects of transvaginal mesh repairs; (b) limitations of traditional treatment modalities and more recent procedures; and (c) that the effectiveness of trocarless kits remains to be investigated. 

Prognosis

The success of anterior colporrhaphy depends on the physician's competence in performing the operation; failure rates of 0 to 20% have been reported. Paravaginal repairs via the vaginal route have been successful in 76 to 98% of cases within one year period of observation . However, controlled prospective studies are needed for more conclusive evidence of long-term benefits from this procedure.

At one year follow up, treatment with traditional posterior vaginal repair was successful in 76 to 96% of cases while posterior colporrhaphy benefited 80 to 90% patients. Defect-specific colporrhaphy resulted in the resolution of symptoms associated with rectocele,  including reduction in splinting, 55%; dyspareunia, 66% and constipation, 84% [10].  Transanal repair alleviated constipation in 22 to 85% of patients. A comparative trial of transvaginal and transanal operation showed the transvaginal procedure to be more effective for symptomatic relief, with less likelihood for recurrence and development of postoperative enterocele.

Abdominal sacrocolpopexy surgery resulted in 88 to 100% cure rate of enterocoele at 2-year follow-up. Vaginal sacrospinous ligament fixation was successful in 88% at 6 weeks and 97% after one year postoperation. The rate of recurrence of POP was less after abdominal sacrocolpopexy than with vaginal sacrospinous ligament fixation. However, recovery was faster in the latter and required less intraoperative time and expenses. A matched case control study of iliococcygeus suspension versus sacrospinous colpopexy showed parallel successful outcomes and complication rates. Modified McCall culdoplasty was successful in 88 to 93% of patients within 1-12 years follow up period. High cure rates of 87 to 89% have been reported in uterosacral ligament suspension. 

Etiology

Vaginal childbirth is attended by damage to surrounding tissues; pregnancy per se is a risk factor. Handa et al in 2011 showed that vaginal childbirth increased the risk for POP and urinary incontinence 5 to 10 years after delivery vis-a-vis cesarean section without labor [4].

Exacerbating factors in POP:

  • Neuropathies associated with labor, decreasing muscle tonicity thus, further sagging and stretching of the pelvic floor as seen in multiparous women. 
  • Genital atrophy and hypoestrogenism, although the exact mechanism involved in the pathogenesis of vaginal prolapse is not fully understood.
  • Diabetic neuropathy, pelvic tumors and sacral nerve disorders. 
  • Increased intra-abdominal pressure due to obesity, constipation, COPD  and smoking 
  • Connective tissue (collagen) abnormalities, such as Marfan disease. 

Thorough knowledge of multiple support defects is critical in the treatment of pelvic floor disorders in women [5].

Epidemiology

Fewer epidemiological studies of POP as compared to urinary incontinence presumes that the symptoms are not specific enough for accurate assessment by conventional survey methods  especially during the early stages of the disease. Some studies rely on secondary data from case management, hospital and/or surgery databases instead of physical examination for vaginal prolapse. While more recent studies use standardized examination techniques, one study dealt with the incidence of posthysterectomy vault prolapse using both methodologies.  

The widely divergent prevalence rate of 2 to 48% of prolapse at the juncture  of the hymen is likely due to differences in the study population on age, race, parity and diagnostic techniques. In all four instances, prevalence rates increased with age except in the study of Bland et al in 1999 which had made no reference with regards to age [6]. Earlier, Olsen et al in 1997 calculated the age-specific incidence rate of surgery for POP in a large care managed population in Oregon [7], yet, epidemiological information on POP remains confined to the white population. 

The annual incidence rate of surgery for POP ranged between 0.4 per 10,000 and 34.3 per 10,000 in the 20-29 age group and in the 70-79 age group, respectively. Incidence rate in the latter group increased to 49 per 10,000 from the combined data on POP and POP with continence surgery versus continence surgery alone. A longitudinal study involving more than 17,000 women aged 25-39, enrolled between 1968 and 1974 was followed up for 26 years [8]. Thereupon, the annual incidence rate of hospital admission for prolapse was found to be 20.4 per 10,000 as compared to the annual incidence rate of surgery for prolapse of 16.2 per 10,000. No data is available on women who are treated but without hospitalization and surgery and those who never seek clinical intervention. The incidence and prevalence of POP based only on surgical cases do not truly reflect the magnitude of the problem in the general population. 

Marchionni et al estimated the 13 years incidence rates of prolapse following hysterectomy to be 0.2 to 0.4% whereas the incidence rate based on physical examination in the same population was more than tenfold  greater or 4.4% [9]. From extensive surgical database studies, the annual age-specific surgical incidence rate of POP requiring hysterectomy and pelvic surgery ranged from 10 to 30 per 10,000, the indication for surgery increasing with age. The overall prevalence rate of POP beyond the hymen (> Stage II) is estimated to be between 2 and 4% but probably much higher in the group seeking intensive clinical care. Well-designed population-based studies, with confirmatory physical examination are needed to ascertain the true status of POP in women.

Sex distribution
Age distribution

Pathophysiology

POP involves a dysfunction in which the vagina and associated structures in the pelvis descend towards the vaginal orifice due to loss of support from the pelvic diaphragm. The condition is manifested in varying degrees of severity. At its worst stage the pelvic organs protrude completely through the vaginal canal and entails multiple defects in the various segments of the genital tract. 

Prevention

Evidence of the efficacy of preventive interventions has not been commensurate with knowledge of risk factors in POP. In fact vaginal childbirth is by far the most important predisposing factor in the etiology of POP. Only as a last resort should planned caesarean section (CS) be considered for selected women with a strong likelihood of developing prolapse. CS entails further risk of postoperative complications and financial burden to the patient and the health care system.

Based on research efforts, a scoring system(UR-CHOICE) has been developed to assess the associated risks of pelvic floor dysfunction. These are:  body mass index, ethnicity, urinary incontinence before pregnancy, age of mother at birth of first child, family history (particularly females), baby's weight (<4 kg) and mother's height (<160 cm). In more sophisticated studies, variables such as genetics  and other relevant disease conditions (benign joint hypermobility syndrome, etc.) can be included in the assessment of POP [16].

Certain surgical procedures may or may not prevent recurrence of POP. For example, total hysterectomy, but not abdominal subtotal hysterectomy, is effective. McCall culdoplasty concomitant with vaginal hysterectomy are likewise preventive. Vaginal apical support procedure done during prolapse surgery may reduce the risk of recurrence in the long run.

Pelvic floor muscle training (PFMT) has been considered as an alternative measure. However, a recent study of a nurse-led PFMT with bladder training at 5, 7, and 9 months after delivery compared to standard rehabilitation methods showed no significant differences between groups at 12-year follow-up. An improved PFMT regimen consisting of individualised physiotherapy sessions, Pilates-based maintenance classes and one-on-one yearly check-ups is currently undergoing evaluation for POP prevention for a two-year follow-up period.

Occurrence of POP with urogenital atrophy presumes that hormone treatment with oestrogens, alone or in combination with other measures, may improve the condition of weakened supporting structures or the diaphragm heretofore, preventing prolapse. However, this remains to be confirmed.  Meanwhile, studies on hormone replacement therapy and lower urinary tract symptoms have shown that local oestrogen treatments are more beneficial than systemic administration. Rigorous longitudinal randomised controlled trials are needed to assess oestrogen's  proper place in POP prevention. 

Other POP preventive measures: 

  • Avoidance of straining and intra-abdominal pressure.
  • Treatment of bowel dysfunction and/or chronic constipation.
  • Diet, for weight loss or bariatric surgery. Studies have shown subjective improvement in symptoms following weight reduction; however, no objective change was observed using the pelvic organ prolapse quantification (POP-Q) system.

Summary

Damage to muscle and nerve tissues in the pelvis causes the pelvic diaphragm to loose its capacity to hold the organs thereat in place leading to vaginal prolapse or pelvic organ prolapse (POP). Thereupon, the bladder, urethra, uterus, cervix, part of the small bowel, rectum and the vagina itself protrude towards the vaginal orifice through the vaginal canal, a condition sometimes called "pelvic hernia".

Risk factors in POP:

  • Injury from vaginal delivery, radiation, and fractures 
  • Hysterectomy and other surgical procedures. 
  • Strenuous activities
  • Smoking
  • Obesity, 40 to 75% greater risk of POP.
  • Aging, menopause, nerve, muscle, and connective tissue dysfunctions

The type of POP depends on where the damage occurs e.g., prolapse uteri, rectocele prolapse, bladder prolapse, etc. Multiple foci of prolapse may be present in the same patient [1] [2] [3].

Patient Information

The pelvic floor consists of supporting structures (nerves, muscle, connective tissue and ligaments) that altogether serve as a "hammock"  or diaphragm, holding various organs (uterus, vagina, cervix, bladder, urethra, part of the small intestine and rectum) in place. If any of these supporting structures are damaged, the diaphragm weakens, causing the pelvic organs to descend into the vaginal canal, and all the way to the vaginal orifice in severe cases. This protruding mass can be felt or seen and is sometimes regarded as "hernia" of the pelvic floor. The condition is called pelvic organ prolapse (POP) or simply, vaginal prolapse.

Pelvic floor disorders is common among women worldwide and risk increases with age. One in 11 women are likely to need surgical intervention for POP in their lifetime. The patient may feel discomfort or complain of problems with urination or bowel movements. A thorough examination is done of the pelvic area to expose the abnormalities. Pelvic muscle exercises and pessaries (vaginal suppositories) may help, but surgery may still be needed.

Factors that commonly predispose to POP:

References

Article

  1. Choi, K. H. & Hong, J. Y. (2014). Management of pelvic organ prolapse. Korean J Urol., 55(11), 693-702.
  2. Siddiqui, N. Y, & Edenfield, A. L. (2014). Clinical challenges in the management of vaginal prolapse. Int J Womens Healt., 16(6), 83-94.
  3. Barber, M. D. & Maher, C. (2013). Apical prolapse. Int Urogynecol J., 24(11), 1815-33.
  4. Handa, V. L., Blomquist. J. L., Knoepp, L. R., et al. (2011). Pelvic floor disorders 5-10 years after vaginal and cesarean childbirth. Obstet Gynecol., 118, 777.
  5. Vergeldt, T. F., Weemhoff, M., IntHout, J., & Kluivers, K. B. (2015, May 13). Risk factors for pelvic organ prolapse and its recurrence: a systematic review. Int Urogynecol J. (Abstract).
  6. Bland, D. R., Earle, B. B., Vitolins., M. Z., &Burke, G. (1999). Use of the Pelvic Organ Prolapse Staging System of the International Continence Society, American Urogynecologic Society, and Society of Gynecologic Surgeons in perimenopausal women. Am J Obstet Gynecol., 181(6), 1324-7.
  7. Olsen, A. L., Smith, V. J., Bergstrom, J. O., Colling, J. C., Clark, A. L. (1997). Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol., 89(4), 501-6.
  8. Vessey, M., & Yeates, D. (2009). Some minor female reproductive system disorders: findings in the Oxford-Family Planning Association contraceptive study. J Fam Plann Reprod Health Care., 35(2),105-10.
  9. Marchionni, M.,  Bracco, G. L., Checcucci, V., Carabaneanu, A., Coccia, E. M., Mecacci, F., & Scarselli, G. (1999). True incidence of vaginal vault prolapse. Thirteen years of experience. J Reprod Med., 44(8),679-84.
  10. Dietz, V. & Maher, C . (2013). Pelvic organ prolapse and sexual function. Int Urogynecol J., 24(11), 1853-7.
  11. Pahwa, A. K., Siegelman, E. S., & Arya, L. A. (2015). Physical examination of the female internal and external genitalia with and without pelvic organ prolapse: A review. Clin Anat., 28(3), 305-13.
  12. Ellerkmann, R. M., Cundiff, G. W., Melick, C. F., Nihira, M. A., Leffler, K., & Bent, A.E. (2011). Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol., 185(6),1332-7.
  13. Richter, L. A., Carter, C., & Gutman, R. E. (2014). Current role of mesh in vaginal prolapse surgery. Curr Opin Obstet Gynecol., 26(5), 409-14.
  14. Costantini, E. & Lazzeri, M. (2015). What part does mesh play in urogenital prolapse management today? Curr Opin Urol., 25(4), 300-4.
  15. Galczyński, K., Nowakowski, L., Romanek-Piva, K., & Rechberger, T. (2014). Laparoscopic mesh procedures for the treatment of pelvic organ prolapse--review of the literature. Ginekol Pol., 85(12), 950-4.
  16. Giarenis, I. & Robinson, D. (2014, Sep 4). Prevention and management of pelvic organ prolapse. F1000Prime Rep., 6, 77.

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Last updated: 2018-06-22 08:39