Pelvic Organ Prolapse
Pelvic Organ Prolapse (POP) is a condition unique to females in which the genitourinary organs descend within the pelvis, distort the vaginal wall and, in some patients, prolapse outside the vagina bulging through the introitus or hymenal ring. Therefore, POP may be considered a type of hernia in which the pelvic organs descend into the vagina but remain entirely covered by the vaginal wall. POP is also known as vaginal prolapse. POP may involve any combination of the organs located within the female pelvis including bladder, cervix, bowel, and rectum.
POP represents a spectrum of disease ranging from asymptomatic mild descent of one segment of the vagina, to complete eversion of the vagina with prolapse of the urinary bladder, urethra, cervix and uterus, small intestine, and rectum. Urethral hypermobility, for example, may be considered a rather minor manifestation of POP whereas uterine procidentia represents a state of complete prolapse of the cervix and uterus outside of the vagina. The degree or severity of prolapse is often but not invariably related to symptoms. Some types of POP may be rather impressive in size with minimal symptomatology whereas in other patients, small degrees of prolapse may result in significant symptoms. The presence or absence of symptoms may depend on factors such as the type of prolapse, and it’s effects on the genitourinary and gastrointestinal tracts.
POP is often but not always accompanied by symptoms of voiding dysfunction. Urinary symptoms in patients with POP include urinary incontinence, obstructive symptoms including hesitancy, straining and decreased force of stream, urgency and frequency of micturition, and urinary retention. Other symptoms unrelated to POP’s effects on the urinary tract may include pelvic pain, back and flank pain, pelvic discomfort, dyspareunia, bowel dysfunction and defecatory symptoms including constipation, diarrhea, and tenesmus.
POP has been associated with many factors. Studies have implicated pregnancy, aging, hormonal status, obesity and weight gain, chronic pulmonary disease and smoking, genetic factors, congenital anatomic factors, connective tissue abnormalities, as well as congenital and acquired neurological abnormalities. However the strongest relationship exists with parity and its effects on the musculofascial structures of the pelvis. In support of this concept, POP is exceedingly rare in nulliparous patients.
Physical Therapy and Rehabilitation
With rigorous physical therapy and intensive pelvic floor rehabilitation some small degrees of POP can be eliminated by strengthening the pelvic floor musculature. The addition of oral or topical estrogens may augment the response to non-surgical therapy in those patients who are poorly estrogenized.
Larger degrees of POP without significant urinary obstruction but large enough to be bothersome to the patient can be reduced and treated with a pessary. The modern pessary refers to a wide range of flexible silicone support devices which, when inserted into the vaginal canal, reduce and support POP. Some types of pessaries have been used to treat stress urinary incontinence as well. Numerous types and sizes of pessaries exist with certain types of pessaries applicable to particular types of POP. Common types of pessaries include: cubes, rings with or without a support diaphragm, donuts, and Gellhorn (mushroom shaped) devices.
Pessaries can be effective therapy in those patients unwilling or unable to undergo definitive surgical correction of POP. Pessaries are inserted transvaginally and require suitable perineal and posterior vaginal wall support for efficacy. Sizing is done on a trial and error basis.
Surgery for the repair of most types of POP can be performed through a transvaginal or transabdominal approach, as well as with the DaVinci robotic surgical system. Each approach has ardent supporters. Often however, the approach is heavily influenced by the experience and training of the surgeon and their familiarity or expertise with one approach over the other as opposed to the individual merits of each case. Modern techniques permit these types of surgeries to be done on an outpatient basis in many cases.