Pelvic Organ Prolapse (POP)
Pelvic Organ Prolapse (POP) is a common condition affecting 1 in 5 women of all ages. It is estimated that up to 50% of women may have mild POP and up to 10% of women may have a severe POP during their lifetime.
Normally, the pelvic organs—that being the bladder, uterus, vagina, and rectum—are supported and held in place by the Pelvic Floor Muscles, ligaments, and fascia of the pelvis. Due to many factors such as age, hormonal changes, pregnancy, birth, sports, and genetics, these muscles, fascia, and tissue may age, stretch and or be damaged over time, causing one or more of the pelvic organs to move downwards and out of their original supported pelvic position. The organ may eventually, if untreated, descend out of the vagina appearing in full sight.
Women with a POP will often describe a sensation of an uncomfortable bulge in the vagina, a feeling of heaviness in the pelvic girdle, a feeling like they want to pick up, support and or lift their crutch area with their hand. Others may describe a feeling of:
pain or pressure in the pelvis, the lower back, or both
urinary problems – Incontinence (bladder or bowel)
Experience a sense of urgency (needing to rush to the toilet) or the inability to full empty their bladder
Constipation
Painful sexual intercourse
The five more commonly described POP are categorised based on the area of the vagina they affect, that being the front, back and upper area of the vaginal wall. Due to the nature of a POP, it is common that a woman may have more than one type of POP.
Types of Prolapse.
Cystocele (bladder prolapse)
When the bladder prolapses, it pushes through the vagina and creates a bulge in the front vaginal wall. A Cystocoele is the most common type of prolapse in women.
Urethrocele (prolapse of the urethra)
This happens when the urethra (the tube that carries urine from the bladder) pushes through the front of the vaginal wall. This usually occurs with a cystocele.
Uterine prolapse (prolapse of the womb) Uterine prolapse occurs when the womb drops down into the vagina. It is the second commonest type of prolapse and is usually classified into four grades depending on how far the womb has fallen.
Grade 1: The uterus has dropped slightly. At this stage, many women may not be aware they have a prolapse. It may not cause any symptoms and is usually diagnosed because of an examination for a separate health issue.
Grade 2: The uterus has dropped further into the vagina and the cervix (neck or tip of the womb) can be seen at or just outside the vaginal opening.
Grade 3: A significant portion of the uterus has fallen through the vaginal opening.
Grade 4: The whole uterus has fallen through the vaginal opening. This is the most severe form and is called a procidentia.
Rectocoele (prolapse of the rectum or large bowel)
This occurs when the end of the large bowel (rectum) loses support and bulges through the back wall of the vagina. It is different from a rectal prolapse (when the rectum falls out of the anus).
Enterocoele (prolapse of the small bowel)
Part of the small intestine in the pelvis may slip down between the rectum and the back wall of the vagina. This often occurs at the same time as a Rectocoele or Uterine prolapse. This is the least common of the POP.
Causes of pelvic organ prolapse.
Several different factors contribute to the weakening of pelvic floor muscles and damage to the ligament and fascia supports over time. The two most significant factors are thought to be pregnancy and ageing.
Pregnancy and childbirth
Pregnancy is believed to contribute significantly to pelvic organ prolapse. The weight of the baby, and the physical trauma of labour and birth damages tissues that never fully regain their strength and elasticity. Large babies, long labour and the use of forceps or vacuum during birth also contribute significantly to prolapse. Women with multiple deliveries are at a higher risk of prolapse.
Ageing and menopause
Ageing further weakens the pelvic floor muscles, and the natural reduction in oestrogen after menopause also reduces muscle elasticity.
Obesity, large fibroids or tumours
Women who are severely overweight, or have large fibroids or pelvic tumours, are at an increased risk of prolapse.
Chronic coughing or straining
Chronic (long-term) coughing from smoking, asthma or bronchitis, or the straining associated with constipation increases a woman's risk of prolapse.
Heavy lifting
Heavy lifting strains and damages pelvic muscles and women in professions that involve regular manual labour or lifting, such as nursing, have an increased risk of prolapse.
Congenital
Women with genetic conditions such as collagen deficiency (Marfan or Ehlers-Danlos syndrome) have an increased risk of prolapse.
Previous pelvic surgery
Pelvic surgery, including hysterectomy or bladder repair procedures may damage nerves and tissues in the pelvic area, thereby increasing a woman's risk of prolapse.
Spinal cord conditions and injury
Spinal cord injury and medical conditions such as muscular dystrophy and multiple sclerosis dramatically increase a woman's risk of prolapse.
Prolapse: symptoms and diagnosis
Women with mild prolapse may have discomfort but are unaware they have a prolapse. When symptoms do occur, they tend to be related to the organ that has prolapsed.
A bladder or urethra prolapse may cause incontinence (involuntary urine leakage), frequent or urgent need to urinate or difficulty in urinating. Some women may need to insert a finger in their vagina and push the bladder back into place to empty their bladder completely.
A prolapse of the small or large bowel (rectum) may cause constipation or difficulty in defecating. Some women may need to insert a finger in their vagina and push the bowel back into place to empty their bowels.
Women with uterine prolapse may feel a dragging sensation or heaviness in their pelvic area, often described as feeling 'like my insides are falling out'. In severe prolapse where the uterus is bulging out of the vagina, the vaginal skin may become irritated, leading to ulceration and infection.
Prevention measures
There are several things you can do to reduce your risk of prolapse or help prevent a mild prolapse from worsening:
The most effective preventive measure is doing regular pelvic floor muscle exercises (Kegel exercises) throughout your adult life, as it helps keep the pelvic muscles toned and strong.
If you are significantly overweight, try to lose weight.
If you smoke, try to cut down or stop.
Avoid lifting heavy objects.
Eat a high fibre diet (fresh fruits, vegetables, bran) to help prevent constipation.
If you are post-menopausal, some doctors may suggest you use hormone therapy to reduce prolapse symptoms or prevent an existing prolapse from becoming worse. However, there is little scientific evidence to support the claim that hormonal therapy prevents prolapse.
Non-surgical treatments
Non-surgical treatments are used when a woman feels her prolapse symptoms are mild, and do not warrant surgery. When there are other medical conditions which do not allow for surgery to be safely performed, or when a woman wants a temporary measure while contemplating surgery, non-surgical treatments can be used. If a woman has not completed her family, non-surgical treatments are ideal. Definitive surgical treatment can be delayed till childbearing is no longer required.
Physiotherapy (pelvic floor muscle exercises)
Pelvic floor exercises should be performed for at least 3 months and should comprise of at least 8 -10 contractions performed 3 times per day. Pelvic floor muscle exercises should combine both slow and fast action muscle contractions. Aiming for 30 repetitions of each a day. If pelvic floor exercise is found to be beneficial, it should be continued for as long as possible to relieve and prevent worsening of symptoms.
Vaginal Pessary
A vaginal pessary is inserted into the vagina to hold the prolapsed organ(s) in place. Pessaries are made of latex or silicone and come in many different shapes and sizes, with ring pessaries being the commonest available.
Pessaries are generally recommended as a temporary treatment for women who are waiting for surgery, women who are pregnant or want to have more children in the future, and women who are unfit or choose not to have surgery.
Surgical Treatments
Most of the surgical treatments for prolapse aim to lift the prolapsed organ(s) back into place. Vaginal hysterectomy (removal of the uterus via the vaginal route for uterine prolapse) may be performed. The choice of surgery depends on the type of prolapse you have, your health, age, whether you want to keep your uterus or have children in the future, whether you are sexually active, and lastly, your personal preference.