Pelvic Organ Prolapse

Original Editor - Laura Ritchie, posting on behalf of Lauren Kalvaitis, MPT Class of 2016 at Western University, project for PT9583

Top Contributors - Laura Ritchie, Kim Jackson, Lucinda hampton, Evan Thomas and Vidya Acharya

Introduction

Uterine Prolapse diagram.png

Pelvic floor prolapse is the herniation of the pelvic organs through the perineum. Depending on the pelvic organ involved, pelvic prolapse further categorizes into:

  1. Anterior compartment containing urinary bladder(cystocele)
  2. Middle compartment containing uterine or vaginal prolapse (uterus or vagina)
  3. Posterior compartment containing either the small bowel loops (enterocele) or rectum (rectocele).

Pelvic prolapse is very common among multiparous women over 50 (affects approximately 50% of women over age 50). Symptoms include fecal or urinary incontinence, uterine prolapse, constipation, or incomplete defecation. Pelvic prolapse can negatively impact the patient's body image and sexuality. Pelvic prolapse treatments range from non-surgical approaches like Kegel exercise and pessary to various surgical procedures. Treatments of pelvic prolapse significantly contribute to the healthcare cost in the United States, estimated at approximately $300 million from 2005 to 2006[1].

Definition/Description

Pelvic organ prolapse is the descent of a pelvic organ into or outside of the vaginal canal or anus. It mainly results from pelvic floor dysfunction.[2]
Cystocele.png
There are several types:
  • Cystocele: prolapse of the bladder into the vagina [3]
  • Urethrocele: prolapse of the urethra
  • Uterine prolapse [3]
  • Vaginal vault prolapse: prolapse of the vagina [4]
  • Enterocele: small bowel prolapse
  • Rectocele: rectum prolapse [3]

Clinically Relevant Anatomy

Please see this page for a detailed overview of pelvic floor anatomy.

Etiology

Pelvic organ prolapse has a multifactorial etiology. It is likely caused by a combination of physiological, anatomical, reproductive, genetic and lifestyle factors that interact and contribute to dysfunction of the pelvic floor. [4]

Symptoms

A variety of symptoms may be present including:

  • Vaginal bulging [5]
  • Feeling of pelvic pressure or heaviness [5]
  • Pelvic pain [5]
  • Urinary or fecal incontinence or obstruction [5]
  • Altered daily activities, sexual function and quality of life [5]

Risk Factors

[6]

The factors causing pelvic organ prolapse are different between patients.[4] Risk factors include the following:

Primary Pelvic Organ Prolapse

  • Pregnancy and labour [3]
  • Obesity/BMI [2] [4]
  • Respiratory problems involving a chronic, long-term cough [3]
  • Cancer of the pelvic organs [3]
  • Hysterectomy (surgical removal of the uterus) [3]
  • Genetics (possibly) due to weaker connective tissues [3]
  • History of vaginal delivery increases the risk 5.56 times [4] [2]
  • Hypertension and Diabetes Mellitus combined increase the risk by 1.9 times [2]
  • Increased birth weight [2]
  • Age [4]
  • Parity [4] (i.e. the number of times a woman has given birth to a fetus with a gestational age of greater than or equal to 24 weeks, alive or stillborn) [7]

Pelvic Organ Prolapse Recurrence (after native tissue repair)

  • Preoperative stage 3 or 4 pelvic organ prolapse (i.e. a more severe prolapse) [4]

Treatment/Management

Pelvic floor.png

As prolapse treatment options expand to include more conservative choices, greater awareness and education is needed among women and professionals about these as a first line treatment and preventive measure (alongside a multi-professional team approach)[8].

Women presenting with prolapse symptoms need to be[8]

  • listened to by the health care team,
  • offered information about treatment choices
  • supported to make a decision that is right for them.

Treatment for pelvic organ prolapse usually involves either conservative management (for mild prolapse or women who are not good surgical candidates) or surgery. Conservative treatments include pelvic floor muscle training and the use of devices (pessaries). [5]

Physiotherapy

Physical therapists play a major role in the nonsurgical management of POP. Along with pessary support, pelvic-floor muscle training (PFMT) is cited in highly credible reviews as a main nonsurgical option for women with POP.[9]

For all the information re retraining these muscles see the physiotherapy section of Pelvic Floor Dysfunction and Kegel's Exercises

In a study by Panman et al in 2016, examining the two-year effects of pelvic floor muscle retraining, it was demonstrated that in women aged 55 and greater with symptomatic mild pelvic organ prolapse, pelvic floor muscle retraining results in a significant decrease in pelvic floor symptoms when compared to watchful waiting (note: statistically significant but below the minimal clinically important difference). Additionally, it was found that pelvic floor muscle retraining was more effective in women who experienced increased pelvic floor symptom distress at baseline. Conversely, the same study found no difference in sexual functioning, quality of life, function of the pelvic floor muscles or degree of prolapse.

A randomised control trial[10] compared the effect of intravaginal vibratory stimulation (IVVS) with intravaginal electrical stimulation (IVES) in women with pelvic floor dysfunctions, unable to voluntarily contract the pelvic floor muscles. The results showed improvement with both techniques, with IVVS superior to IVES in improving pelvic floor muscle strength.

11111.png

Pelvic floor muscle retraining included: (Kegel exercises diagram in illustration)

  • Explanation and description of the pelvic floor [5]
  • Instruction regarding how to contract and relax pelvic floor muscles [5]
    • If unable to perform this task, use feedback through digital palpation [5]
    • If insufficient control demonstrated, use myofeedback or electrical stimulation [5]
  • General exercise program provided, subsequently modified for individual needs [5]
  • Taught correct technique for contracting pelvic floor muscles before and during increases in abdominal pressure [5]
  • Received information about washroom habits and lifestyle [5]
  • If pelvic floor muscles were overactive, focus was on relaxation rather than contraction [5]
  • Face-to-face contact with physiotherapist as well as encouragement to maintain practice at home 3-5 times per week, 2-3 times per day [5]

Presentations

http://www.youtube.com/watch?v=w08iCzxnQBUKegel or not.png
Pelvic Physiotherapy - to Kegel or Not?

This presentation was created by Carolyn Vandyken, a physiotherapist who specializes in the treatment of male and female pelvic dysfunction. She also provides education and mentorship to physiotherapists who are similarly interested in treating these dysfunctions. In the presentation, Carolyn reviews pelvic anatomy, the history of Kegel exercises and what the evidence tells us about when Kegels are and aren't appropriate for our patients.

View the presentation

References

  1. Yoon I, Gupta N. Pelvic Prolapse Imaging. InStatPearls [Internet] 2019 Dec 14. StatPearls Publishing.Available from: https://www.ncbi.nlm.nih.gov/books/NBK551513/ (last accessed 11.1.2020)
  2. 2.0 2.1 2.2 2.3 2.4 Isık H, Aynıoglu O, Sahbaz A, Selimoglu R, Timur H, Harma, M. Are hypertension and diabetes mellitus risk factors for pelvic organ prolapse? European Journal of Obstetrics and Gynecology and Reproductive Biology. 2016. 197; 59-62.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 WebMD. (n.d.). What Is Pelvic Organ Prolapse? Retrieved March 30, 2016, from http://www.webmd.com/urinary-incontinence-oab/pelvic-organ-prolapse
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Vergeldt TF, Weemhoff M, Inthout J, and Kluivers KB. Risk factors for pelvic organ prolapse and its recurrence: A systematic review. International Urogynecology Journal Int Urogynecol J. 2015. 26(11); 1559-1573.
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 Panman C, Wiegersma M, Kollen B, Berger M, Leeuwen YL, Vermeulen K, Dekker J. Two-year effects and cost-effectiveness of pelvic floor muscle training in mild pelvic organ prolapse: A randomised controlled trial in primary care. BJOG: Int J Obstet Gy. 2016 Mar 21. doi: 10.1111/1471-0528.13992.
  6. the study spot. Uterine Prolapse and Vaginal Prolapse for USMLE. Available from: http://www.youtube.com/watch?v=YBqUV53_QGU [last accessed 02/09/16]
  7. Patient. (n.d.). Gravidity and Parity Definitions (Implications in Risk Assessment) | Patient. Retrieved March 30, 2016, from http://patient.info/doctor/gravidity-and-parity-definitions-and-their-implications-in-risk-assessment
  8. 8.0 8.1 Abhyankar P, Uny I, Semple K, Wane S, Hagen S, Wilkinson J, Guerrero K, Tincello D, Duncan E, Calveley E, Elders A. Women’s experiences of receiving care for pelvic organ prolapse: a qualitative study. BMC women's health. 2019 Dec;19(1):45. Available from: https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-019-0741-2 (last accessed 11.1.2020)
  9. Saunders K. Recent advances in understanding pelvic-floor tissue of women with and without pelvic organ prolapse: considerations for physical therapists. Physical therapy. 2017 Feb 28;97(4):455-63. Available from:https://academic.oup.com/ptj/article/97/4/455/3057463 (last accessed 11.1.2020)
  10. Rodrigues MP, Barbosa LJ, Paiva LL, Mallmann S, Sanches PR, Ferreira CF, Ramos JG. Effect of intravaginal vibratory versus electric stimulation on the pelvic floor muscles: A randomized clinical trial. European journal of obstetrics & gynecology and reproductive biology: X. 2019 May 12.