Description

• Symptomatic descent of one or more of (1),(2)
  • The anterior vaginal wall (bladder or cystocele)
  • The posterior vaginal wall (rectum or rectocele)
  • The uterus and cervix
  • The vaginal apex (vault or cuff scar after hysterectomy)
• Prolapses above or to the level of the hymen are generally not symptomatic (2).
• Associated symptoms (2)
  • Feeling of vaginal or pelvic pressure
  • Heaviness
  • Bulging
  • Bowel or bladder symptoms
• Cost associated with treatment is >$1 billion annually (~200,000 surgeries per year) (2).

Epidemiology

Incidence

• The incidence of pelvic organ prolapse (POP) ranges from 1.5 to 1.8 per 1,000 woman-years and peaks in women aged 60 to 69 years (3).
• In the United States, there are approximately 300,000 surgeries for POP each year (3), and a woman’s lifetime risk of undergoing surgery for pelvic floor prolapse ranges from 6% to 18% (3).

Prevalence

• A national survey of 7,924 women (>20 years of age) found a prevalence of 25% for one or more pelvic floor disorders (including urinary incontinence, fecal incontinence, and POP). Prevalence of POP was 3–6% (4).
• POP is common but not always symptomatic. It does not always progress. It is estimated that 50% of women will develop prolapse, but only 10–20% of those will seek care for their condition (3).

Etiology and Pathophysiology

• Pelvic organs are supported by attachments between pelvic floor muscles, connective tissue, and the bony pelvis. Defects in this support can lead to prolapse in one or multiple compartments (5).
• Symptomatic women typically have defects in more than one compartment as well as damage to the levator ani and its attachments to the pelvis (5).
• Gradual process that begins long before symptoms develop

Risk Factors

• Vaginal childbirth: Each additional vaginal birth increases risk (2),(4).
• Age
• Family history (2)
• Race: White and Hispanic women may be at higher risk than black or Asian women (1),(2).
• Obesity BMI >30 kg/m² (2),(4)
• Chronic straining (constipation, chronic cough from pulmonary disease, repeated heavy lifting) (2)
• History of hysterectomy (2),(4)

General Prevention

There is some evidence that pelvic floor muscle training (“Kegel exercises”) may decrease the risk of symptomatic POP (5)[B]. Weight loss and proper management of conditions that cause increase in intra-abdominal pressure such as constipation may help prevent prolapse (5)[C]. Elective caesarean delivery has not been shown to prevent prolapse.

Commonly Associated Conditions

• Constipation
• Fecal incontinence
• Urinary incontinence or retention
• Other urinary symptoms
  • Urgency
  • Frequency