Pelvic Organ Prolapse

The pelvic organs include the uterus, urethra, bladder, rectum and the vagina. These organs are all supported by the muscles of the pelvic floor and connective tissue called fascia.

Prolapse occurs when this support structure is weakened through various factors, like direct muscle trauma, neuropathic injury, disruption or stretching. In most cases, a combination of factors causes this damage.

The descent of one or more pelvic organs results in a protrusion of the uterus and/or vaginal wall, which may manifest as urinary, bowel, sexual or pelvic symptoms.

Most women complain of the sensation of ‘a lump coming down’ or a feeling of discomfort or heaviness within the pelvis. The symptoms tend to worsen with prolonged standing and towards the end of the day.

Other complaints include pain during intercourse and chronic backache. Urinary symptoms like urgency, frequency of urination and a sensation of incomplete emptying may be experienced if the bladder is affected.

If the rectum is involved, women may complain of difficulty in opening the bowels and having to reduce the prolapse manually before passing motion.

How do I prevent pelvic organ prolapse?

Pelvic floor exercises taught and practised early, before menopause, can help in reducing the incidence of prolapse. Other preventive strategies include avoiding factors that will result in chronic increased intra-abdominal pressure such as smoking, constipation and heavy lifting. It is also important to keep within the recommended body mass index to prevent obesity.

Causes of Pelvic Organ Prolapse

• Age. With increasing age, fascial tissues become stiffer and more liable to rupture and damage.
• Pregnancy and childbirth. During pregnancy, the fascia becomes more elastic and the pelvic floor may be damaged during childbirth.
• Hormonal factors. The effects of ageing and oestrogen withdrawal at menopause cause the fascia to be less elastic and more easily damaged.
• Smoking. Chronic chest disease resulting in a chronic cough leads to an increase in the intraabdominal pressure and exposes the pelvic floor to greater strain.
• Constipation. Repetitive straining causes chronically increased intraabdominal pressure.
• Obesity. This also causes increased intra-abdominal pressure.
• Exercise. Frequent heavy lifting and exercises such as weightlifting, high-impact aerobics and longdistance running also increase the risk of urogenital prolapse.

You will be referred to a urogynaecologist who will examine you and grade the degree of pelvic organ prolapse.

Additional tests may be needed, depending on the degree of prolapse and other additional symptoms noted by the patient. These include bladder urodynamics studies, a urethral pressure profile, and an ultrasound of the gynaecological organs or the urinary system.

The different grades of pelvic organ prolapse

The grading of pelvic organ prolapse is as follows:

• First degree: The lowest part of the prolapse lies above the introitus (opening of the vagina).
• Second degree: The lowest part of the prolapse extends to the level of the introitus on straining.
• Third degree: The lowest part of the prolapse extends through the introitus and lies outside the vagina.

Conservative management options include:

• Pelvic floor exercises There is a role for pelvic floor exercises in younger women with mild prolapse who find intravaginal ring pessaries unacceptable and are not yet willing to consider surgery, especially if they have not yet completed their family.
• Intravaginal ring pessaries Ring pessaries vary in size and are fitted to each patient according to her vaginal size. It lies within the vagina and has to be changed every four to six months.

Surgical options vary according to the type and degree of prolapse:

• Pelvic floor repairs
  If the urethra, bladder, rectum or intestines protrude through the vaginal wall, the pelvic floor will be repaired and strengthened with sutures to correct the prolapse and replace the organs back to their original position.
• Vaginal hysterectomy
  This is indicated when the uterus protrudes through the vaginal opening. The uterus is removed via the vaginal route.
• Mesh repair
  This may be indicated in cases of severe prolapse, to enhance the degree of support to the pelvic floor, preventing a future recurrence. A synthetic mesh is placed beneath the vaginal skin after reducing the pelvic organs back to their original position.
• Sacrospinous ligament fixation
  This is done in cases of severe uterine prolapse, to suspend the vaginal vault to the sacrospinous ligament and thus reduce the chance of prolapse recurrence.

There are a myriad of surgical techniques and this list is by no means exhaustive. The specific surgical procedure can only be advised by a urogynaecologist after assessing the patient.