Guest Author - Denise Howard, M.D., M.P.H.
Pelvic organ prolapse is a condition in which the uterus and/or the vaginal walls drop down and some times through the vaginal opening. This typically occurs in post reproductive women. The problem is even more prevalent in older women. It is unclear how many women are affected. One study estimates that 1/11 women will undergo surgery for this problem.
Pelvic organ prolapse includes uterine prolapse, cystocele, rectocele, enterocele and vaginal vault prolapse. When the uterine supports become weak the uterus gradually falls down into the vagina. The cervix can be felt or seen dropping through the vaginal opening. A cystocele occurs when the vaginal wall that rest underneath the bladder starts to drop down. Its supports have also become weak and as this wall drops down and through the vagina the bladder will follow. This occurs because the vaginal wall is part of the support structure of the bladder. A rectocele occurs when the vaginal wall that rest on top of the rectum becomes weak and as a result bulges up into the vaginal lumen and sometimes out through the opening. The rectal wall will subsequently follow since this vaginal wall is part of the support structure for the rectum. An enterocele occurs when a weakness develops in the upper vaginal wall just underneath the cervix. Some loops of intestine can fall down behind the vaginal wall in this area,causing a bulge in the vagina. Vaginal vault prolapse occurs in women who have had a hysterectomy. All of the vaginal walls are poorly supported. As a result the vagina can gradually fall down, essentially “turning inside out” like a sock.
Prolapse occurs when the support structures to the uterus and vagina are damaged. The support structures include the pelvic floor muscles, connective tissue and ligaments all designed to keep the vagina closed and attached to the pelvic side wall, holding the internal organs in place. Vital components to this support are nerves that communicate with the muscles so they can function properly. The major factor contributing to the development of prolapse is vaginal childbirth. During delivery the nerves can be stretched and connective tissue torn. The pelvic muscles can also be damaged either directly or as a result of nerve damage. If the nerves are damaged then they cannot communicate with the muscles. These muscles can then atrophy from disuse. Damage to these support structures can also occur as a result of pelvic surgery, trauma to the pelvis, and other conditions that might affect the lumbar and sacral regions of the spinal cord.
Symptoms of uterine prolapse include feeling a bulge, pelvic pressure, back pain and discomfort or even pain with intercourse. A cystocele can present with a bulge, frequency and urgency of urination, difficulty urinating and recurrent urinary tract infections. Symptoms of a rectocele also include a bulge, difficulty with intercourse and difficulty having bowel movements. Some women may need to press on the vagina to empty their rectum. An enterocele and vaginal vault prolapse usually present with a notable bulge in the vagina, pelvic pressure and pain, and problems with intercourse.
Treatments for prolapse are available and may include pelvic floor muscle rehabilitation, wearing a supportive device called a pessary or surgery. A thorough evaluation is required to make the correct diagnosis and appropriate recommendations for treatment. It is important to be evaluated by an experienced gynecologic surgeon. Urogynecologists are gynecologic surgeons who have special training in this area.
Even though surgery is generally effective, prevention is the key. Research is ongoing to identify better measures to prevent the development of this problem. Advancements in the treatment and prevention of this problem will eventually be limited by the availability of funds for such research.
