Prolapse; pelvic organ prolapse

Pelvic organ prolapse or POP is a condition in which one or more of the organs in your pelvic cavity -- uterus, vagina, bladder and rectum - has fallen below its natural position in the pelvis. These organs are normally held in place by a web of muscles and connective tissues that act like a hammock. However, when these muscles and tissues become weakened or damaged, one or more of the pelvic organs shift out of normal position and literally "fall" into the vagina.

Causes
Pelvic muscles may be weakened or stretched by giving birth vaginally, especially if you had a difficult labor and delivery, multiple vaginal deliveries and/or large babies. Being overweight, loss of muscle tone with aging, or having a hysterectomy or other abdominal surgery are additional reasons why these muscles may be weakened.

• The risk of prolapse increases nearly 20 percent with each additional vaginal delivery up to five births.

Heredity may play a role in determining who is predisposed toward POP and who is not, because statistics suggest that POP occurs more often in women of Northern European and Hispanic descent than in women of African or Asian descent.

Prevalence
Few studies have been conducted to find out how many women have experienced POP. However, some statistics are available.

• In the Women's Health Initiative, a study involving more than 27,000 women, 40% of women aged 50-79 years were found to have some form of POP.
• In the Pelvic Organ Support Study of 1,004 women between the ages of 18 and 83, 38% had mild prolapse and 35% had moderate prolapse, while 2% had more severe prolapse.

Despite the fact that POP is a relatively common condition, affecting at least half of all women who have had children, it is believed to be under reported, under diagnosed and under treated. Many women are embarrassed to discuss their symptoms with their physician, and physicians themselves rarely raise the topic with their patients. There is a general lack of education about POP: 4 out of 5 women have never even heard of it. When they have, it is most often from their mother or other family member. Historically, women were told POP is a fact of aging they just have to accept.

Symptoms
There are many degrees of prolapse. Women with very mild cases may have no symptoms at all. In fact, an estimated 80-90% of women with mild prolapse are asymptomatic. Women who have mild to moderate degrees of prolapse may experience a feeling of pressure or heaviness in the pelvic area after being on their feet for a long time or after physical exercise. In more severe cases, prolapse has an impact on a woman’s quality of life through such symptoms as:

• difficulty in completely emptying the bladder
• bowel problems are not common
• pain or discomfort during intercourse
• pressure or pain in the pelvic area and lower back
• urinary incontinence, in which urine is leaked during activities such as laughing, coughing or exercising
• a bulge or lump in the vagina
• a feeling that something is falling out of the vagina, like a tampon that is half in and half out

Diagnosis
To diagnose POP your health care professional will take a detailed medical history, then perform a pelvic exam to determine the kind and degree of POP you have. A standing exam is best, because the weight of your organs will push down and make it easier to assess the prolapse.

There are several different types of POP.

• In uterine prolapse, the uterus drops down into the vagina. This has been happening to women since humankind began and was one of the first gynecological conditions to be described. It used to be called "falling of the womb," and in earlier times women felt they just had to live with it. Today, however, excellent treatment options exist.
   
• Women who have had a hysterectomy can develop vaginal vault prolapse, where the top of the vagina protrudes into the lower vagina.
   
• A cystocele is prolapse of the bladder into the front vaginal wall.
   
• A rectocele is prolapse of the rectum, pressing into the back vaginal wall.
   
• An enterocele is protrusion of the small bowel pressing against the front of the vagina.

It is possible to have more than one type of prolapse at the same time. Your doctor will measure the position of your uterus and other organs to determine the degree of prolapse and will discuss various treatment options with you.

Treatment options
A variety of POP treatments are available, both non-surgical and surgical. The right choice for a particular woman will depend on the type and degree of prolapse, the symptoms she is experiencing, and other general medical factors.

Many women with mild to moderate symptoms respond well to non-surgical approaches. For a woman who feels her condition impairs her quality of life, pelvic repair surgery may be a good choice. Today, minimally invasive techniques can correct the problem without the lengthy recovery, pain and increased risk of infection that are associated with open abdominal surgery.  Some gynecologists specialize in "pelvic floor" repair. 

References
 

1. Barber MD. Symptoms and outcome measures of pelvic organ prolapse. Clin Obstet Gynecol. 2005;48(3):648-61.
2. Jelovsek JE, et al. Pelvic organ prolapse. Lancet. 2007;369(9566):1027-38.
3. Hendrix SL et al. Pelvic organ prolapse in the Women’s Health Initiative: gravity and gravidity. Am J Obstet Gynecol. 2002;186(6):1160-66.
4. Lewin Group, Inc. Prevalence and treatment patterns of pelvic health disorders among U.S. women. National Women's Health Resource Center 2007. www.healthywomen.org.
5. National Women's Health Resource Center, Inc. Your Guide to Uterine Health. 2003; www.healthywomen.org.
6. Swift S, et al. Pelvic Organ Support Study (POSST): the distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol. 2005;192(3):795-806.
7. What's Happening Down There? Let's Talk About Prolapse. www.BeatProlapse.com

Reviewed:  January 2008.