21 May 2021 Author : Isabel Grilo Pelvic organ prolapse is the descent of the uterus, bladder, vagina, rectum or intestines from their normal position . The organs force the walls of the vagina that are bulged and, in the most severe cases, can reach outside the vaginal opening. Depending on the affected organ and vaginal wall region, the pelvic organ prolapse may have different names: Anterior compartment prolapse, in which there is a bulging of the anterior vaginal wall. It is more often associated with bladder descent and in this case is called cystocele ; Posterior compartment prolapse, in which there is a bulging of the posterior vaginal wall. It is more frequently associated with descent of the rectum and in this case is called the rectocele ; Apical compartment prolapse, which is due to the descent of the cervix or the vaginal dome. Sometimes it is due to the descent of the intestines and in this case it is called the enterocele . Causes and risk factors Pelvic organ prolapse is due to the weakening of the pelvic floor , that is, the structures that support the pelvic organs and keep them in their correct anatomical position. Several circumstances contribute to the weakening of the pelvic floor: The normal aging process and menopause; Weight overload during pregnancy and vaginal deliveries especially when babies are large and deliveries are instrumented. Prolapse can manifest several years after delivery and affects 1-3 women who have had one or more pregnancies. The probability of prolapse occurring increases with the number of deliveries; Obesity; Situations that increase abdominal pressure, such as chronic cough, constipation, repeated efforts, weight load; Some connective tissue disorders such as Ehlers-Danlos syndrome and Marfan syndrome. Symptoms of pelvic organ prolapse The pelvic organ prolapse can be mild and without any symptoms. When symptoms are present, they have a variable severity and can interfere with the quality of life , either in the usual daily activities, limiting the practice of physical activity or compromising sexual activity. Symptoms may include: Sensation of pressure in the pelvic area or in the vagina; Perception of a mass inside the vagina or a lump coming out of the vagina; Urinary symptoms such as difficulty in emptying the bladder completely, frequent urinary infections, involuntary leakage of urine, urgency to urinate; Intestinal symptoms: difficulty in evacuating, sometimes needing to press the vaginal wall to make possible a complete evacuation; Discomfort during sexual intercourse. Treatment of pelvic organ prolapse The treatment options for pelvic organ prolapse can be divided into surgical and non-surgical . The severity of the prolapse, the symptoms and their interference with quality of life, age, general health, and personal preferences of each patient are the main factors to consider when deciding on the treatment to be performed. Non-surgical treatment Non-surgical treatment is preferred if it is intended to preserve the woman reproductive capacity and allows the definitive surgical treatment to be postponed. Life habits Adopting habits that reduce the risk of worsening prolapse is the first measure to implement: Avoid constipation, preferring foods that promote a good intestinal functioning, drink adequate water and seek medical attention if it is necessary to identify and treat causes of recurrent constipation; Control chronic cough problems; Maintain a body weight within healthy limits; Avoid weight loads, repeated efforts and other activities that require abdominal strength. Pelvic floor strengthening and rehabilitation exercises The strengthening of the pelvic floor muscles prevents the worsening of the prolapse and decreases the frequency and severity of the symptoms present , especially in the early stages of the prolapse. Pelvic floor rehabilitation exercises involve repeating sequences of contracting, maintaining and relaxing the pelvic muscles, without using the abdominal, buttock or thigh muscles. It is very important that they are done correctly, and it is sometimes difficult to learn it alone. This learning can be done in physiotherapy. Pelvic floor physiotherapy also involves other techniques that can be useful, such as biofeedback or electrostimulation. In addition, physiotherapists are also the appropriate professionals to supervise and evaluate the results of these treatments. Vaginal pessary Vaginal pessary is a silicone device that is placed in the vagina to support the prolapsed organs and thus relieve the symptoms. There are pessaries with different shapes and sizes. Main indications for placing a pessary are a high surgical risk due to health problems, the preference for non-surgical treatment and the desire of future pregnancy. Vaginal pessaries can also be a temporary option until prolapse correction surgery is performed. Surgical treatment Pelvic organ prolapse surgery is intended to : Eliminate symptoms; Correct anatomical changes; Restore normal function. There are several possible surgical techniques, which are divided into two groups: Reconstructive; Obliteratives. The decision on the technique to be performed depends mainly on: Age and general health status; Location and degree of prolapse; History of abdominal surgery; Patient preference and expectations; Surgeon experience. Reconstructive surgery In reconstructive surgery, the prolapsed organs are repositioned in their correct position . Some techniques are performed vaginally, others are performed abdominally. Vaginal surgery Vaginal surgery does not leave visible external scars . It involves an incision in the wall of the vagina and the placement of organs using the tissues and sutures, meshes or specific prostheses. It can be used to: Correction of the anterior compartment or cystocele correction; Correction of the posterior compartment or rectocele correction; Suspension of the cervix or vaginal dome to the sacred or sacrospinous uterus ligaments; Vaginal hysterectomy with fixation of the vaginal dome to the uterosacral ligaments, which is the most common option when uterine prolapse is already present and there is no desire to maintain fertility. Corrections are often performed in several compartments as the prolapse can reach several pelvic structures simultaneously. Abdominal surgery Open abdominal surgery is done through an incision in the abdomen. Abdominal surgery can also be performed by minimally invasive surgery - laparoscopic or robotic - which is associated with faster recovery and less visible scars and allows for similar corrections. Abdominal surgeries are associated with a longer operative time, a longer recovery time and a higher cost than the vaginal approach. Sacrocolpopexy is the most frequent technique and consists of suspending the prolapsed vaginal dome to the sacrum region using a synthetic mesh. Obliterative surgery Obliterative procedures, such as colpocleisis , are an option for women who, for health reasons, cannot perform more extensive or time-consuming surgeries and who do not wish to have vaginal intercourse afterwards. Surgery results Prolapse-related symptoms are resolved in the long term in about 70% -80% of women who have undergone vaginal surgery and 90% of women who have undergone abdominal surgery. Recurrence cases are generally due to the maintenance of risk factors. Sources International Urogynecologial Association . Pelvic floor prolapse. Jelovsek EL. Pelvic organ prolapse in women: Choosing a primary surgical procedure. www.uptodate.com Rogers RG, Fashokun TB. Pelvic organ prolapse in women: Epidemiology, risk factors, clinical manifestations, and management www.uptodate.com Meet the obstetrics-gynecolcogy team from Hospital da Luz network. The content published in the Health Guide is intended for the general public and is provided for informational and educational purposes only. It does not replace individual medical assessment, diagnosis, or personalized clinical advice from a qualified healthcare professional. The content is produced or reviewed by physicians and other healthcare professionals at Hospital da Luz and is based on the knowledge available at the time of publication or the most recent update, as indicated at the beginning of each item.
