Pelvic organ prolapse

Types

• Anterior vaginal wall prolapse
  • Cystocele (bladder into vagina)
  • Urethrocele (urethra into vagina)
  • Cystourethrocele (both bladder and urethra)
• Posterior vaginal wall prolapse
  • Enterocele (small intestine into vagina)
  • Rectocele (rectum into vagina)
  • Sigmoidocele
• Apical vaginal prolapse
  • Uterine prolapse (uterus into vagina)
  • Vaginal vault prolapse (descent of the roof of vagina) – after surgical removal of the uterus hysterectomy

Grading

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

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 perineum

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

POP-Q

Main article: Pelvic Organ Prolapse Quantification System

Management

Vaginal prolapses are treated according to the severity of symptoms.

Non-surgical

With conservative measures, such as changes in diet and fitness, Kegel exercises, and pelvic floor physical therapy.

A pessary, a rubber or silicone rubber device fitted to the patient is also a non-surgical option, it is inserted into the vagina and may be retained for up to several months. Vaginal pessaries can immediately relieve prolapse and prolapse-related symptoms. 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. Pessaries require a provider to fit the device, but most can be removed, cleaned, and replaced by the woman herself; however, others have this done for them by a clinician biannually. A trial compared the two approaches and found that, compared with clinic-based care, self-management was associated with a similar quality of life, fewer complications, and was more cost-effective. Pessaries should be offered as a non-surgical alternative for women considering surgery.

Surgery

Surgery (for example native tissue repair, biological graft repair, absorbable and non-absorbable mesh repair, colpopexy, or colpocleisis) is used to treat symptoms such as bowel or urinary problems, pain, or a prolapse sensation. When operating a pelvic organ prolapse, introducing a mid-urethral sling during or after surgery seems to reduce stress urinary incontinence. Transvaginal repair seems to be more effective than transanal repair in posterior wall prolapse, but adverse effects cannot be excluded. According to the FDA, serious complications are "not rare."

Evidence does not support the use of transvaginal surgical mesh compared with native tissue repair for anterior compartment prolapse owing to increased morbidity. For posterior vaginal repair, the use of mesh or graft material does not seem to provide any benefits.

Compared to native tissue repair, transvaginal permanent mesh likely reduces the perception of vaginal prolapse sensation, the risk of recurrent prolapse, and of having repeat surgery specifically only for prolapse. Transvaginal mesh (TVM) has a greater risk of bladder injury and of needing repeat surgery for stress urinary incontinence or mesh exposure. The use of a TVM in treating vaginal prolapses is associated with severe side effects including organ perforation, infection, and pain.

Safety and efficacy of many newer meshes is unknown. Thousands of class action lawsuits have been filed and settled against several manufacturers of TVM devices.

For surgical treatment of apical vaginal prolapse, going through the abdomen (sacral colpopexy) may have better outcomes than a surgical approach that goes through the vagina.

Epidemiology

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

Research

To study POP, various animal models are employed: non-human primates, sheep, pigs, rats, and others.

References

References

1. (March 2022). "Pelvic Organ Prolapse". Gastroenterology Clinics of North America.
2. (April 2018). "Pelvic floor disorders in women with gynecologic malignancies: a systematic review". International Urogynecology Journal.
3. (2017-05-03). "Pelvic organ prolapse".
4. Donita, D'Amico. (2015-02-10). "Health & physical assessment in nursing".
5. (2023-07-26). "Surgery for women with apical vaginal prolapse". The Cochrane Database of Systematic Reviews.
6. (September 2007). "ACOG Practice Bulletin No. 85: Pelvic organ prolapse". Obstetrics and Gynecology.
7. (2013-03-26). "Pelvic organ prolapse: a urology perspective". Journal of Clinical Urology.
8. "Kegel Exercises {{!}} NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases.
9. (March 2019). "25: Pessary use and severity of pelvic organ prolapse over time: a retrospective study". American Journal of Obstetrics and Gynecology.
10. (April 2017). "Practice Bulletin No. 176: Pelvic Organ Prolapse". Obstetrics and Gynecology.
11. (December 2023). "Clinical effectiveness of vaginal pessary self-management vs clinic-based care for pelvic organ prolapse (TOPSY): a randomised controlled superiority trial". eClinicalMedicine.
12. (11 April 2024). "Pelvic organ prolapse: self-management of pessaries can be a good option". NIHR Evidence.
13. (19 August 2018). "Surgery for women with pelvic organ prolapse with or without stress urinary incontinence". Cochrane Database Syst Rev.
14. (13 July 2011). "UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse: FDA Safety Communication". U.S. Food and Drug Administration.
15. (November 2016). "Surgery for women with anterior compartment prolapse". The Cochrane Database of Systematic Reviews.
16. (5 March 2018). "Surgery for women with posterior compartment prolapse". Cochrane Database Syst Rev.
17. (2024-03-13). "Transvaginal mesh or grafts or native tissue repair for vaginal prolapse". The Cochrane Database of Systematic Reviews.
18. (2022-11-11). "Transvaginal Mesh Lawsuits".
19. (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.
20. "Sheep as an animal model for pelvic organ prolapse and urogynecological research.". ASB 2015 Annual Conference 2015.
21. (2015). "Investigation of sheep reproductive tract as an animal model for pelvic organ prolapse and urogyencological research". Mississippi State University.
22. (May 2012). "Animal models of female pelvic organ prolapse: lessons learned". Expert Review of Obstetrics & Gynecology.
23. Patnaik, Sourav S.. (2016). "Chapter Six - Pelvic Floor Biomechanics From Animal Models". Academic Press.