Uterine and Pelvic Organ Prolapse

Basics

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

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