Uterine and Pelvic Organ Prolapse
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- Symptomatic descent of one or more of (1,2)
- The anterior vaginal wall (bladder or cystocele)
- The posterior vaginal wall (rectum or rectocele)
- The apex of the vagina (uterine cervix descent and prolapse)
- The vault (cuff) after hysterectomy (vault prolapse)
- Prolapses above or to the hymen are not symptomatic (2).
- Associated symptoms (2)
- Feeling of vaginal or pelvic pressure
- Bowel or bladder symptoms
- Cost associated with treatment is >$1 billion annually (~200,000 surgeries/year) (2).
Pelvic organ prolapse (POP) is common but not always symptomatic. It does not always progress with time. In a 3-year prospective cohort study of 249 women, prolapse increased by at least 2 cm in 11% and regressed by 2 cm in 3% (2).
- 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 2.9%.
- The prevalence of lower urinary tract symptoms is as high as 50% in parous women. 11% of all women have surgery for POP or lower urinary tract symptoms by 80 years old.
- 3–6% of women who present for gynecologic care have a prolapse beyond hymen (2).
Etiology and Pathophysiology
- Insidious process begins long before symptoms develop.
- There is a complex interaction between the pelvic floor musculature, connective tissue, and the vaginal wall, which provides support from the perineum to the sacrum (2). Integrity of levator ani is essential to this support system by providing a platform on which the pelvic organs rest (2).
- Symptomatic women typically have multiple defects, including laxity of supporting tissue and damage to the levator ani (2).
- Half of anterior prolapse can be attributed to apical descent of the vagina (2).
- Vaginal childbirth (2): Women who have delivered two children vaginally have a relative risk of 8.4 and every additional child (up to five deliveries) increases the risk of prolapse by 10–20% (2).
- Age: Every 10 years of age increases the risk of prolapse by 40% (2). POP will become more prevalent, as the elderly population is expected to double by 2030 (3).
- Obesity: BMI >25 may increase the risk of developing prolapse (2).
- Constipation: independent risk factor in a survey of >2,000 women (2)
- Race: White and Hispanic women may be at higher risk than black or Asian women (2).
- Occupation (heavy lifting): variable support in the literature (2)
- Hysterectomy: variable support in the literature (2)
- Obstetric factors (operative delivery, infant weight, length of pushing in second stage of labor): variable support in the literature (2)
There is some evidence that pelvic floor muscle training (“Kegel exercises”) may decrease the risk of symptomatic POP (4)[B]. Weight loss and proper management of conditions that cause increase in intra-abdominal pressure may help prevent the problem.
Commonly Associated Conditions
- Urinary incontinence
- Other urinary symptoms