Pelvic Organ Prolapse

Clinical description

Pelvic organ prolapse is herniation of pelvic organs to or beyond the vaginal introitus.

Other terms for pelvic organ prolapse include procidentia, anterior or posterior compartment or apical prolapse, cystocoele, rectocoele and enterocoele.

Signs and symptoms

History Vaginal or pelvic pressure, sensation of vaginal bulge or something falling out of the vagina, +/- vaginal discharge, +/- PVB from ulceration, +/- urinary symptoms (ranging from stress or urge type urinary incontinence to urinary retention), +/- defecatory symptoms (ranging from constipation to rectal incontinence), +/- sexual dysfunction Exam/Investigations Pelvic exam using POPQ or Baden Walker system to classify

Treatment

Expectant management If symptoms are tolerable and the patient prefers to avoid treatment, then the prolapse can be observed and evaluated regularly for the development of worsening urinary and/or defecatory symptoms.

Conservative management usually temporary since prolapse is chronic, but can continue as long as patient prefers

• Vaginal pessary (multiple types, multiple sizes)
• Pelvic floor muscle exercises (Kegel's)
• Oestrogen therapy (vaginal cream or pessary) as an adjunct

Surgical treatment Procedure of choice depends on many factors, including age, risk factors for recurrence and technical expertise.

Surgery should only be considered after childbearing is complete or if highly symptomatic and conservative measures have failed.

Prior to reconstructive surgery of apical prolapse, determine whether anatomic correction of the prolapse will result in stress incontinence (occult urinary incontinence) and consider adding a procedure to prevent post-operative incontinence.

• Abdominal (uterosacral suspension or sacrocolpopexy for apical, paravaginal repair for anterior, enterocele

repair) vs

• Vaginal approach: TVH, Uterosacral suspension vs sacrospinous ligament fixation for apical, anterior and

posterior colporrhaphy,

• Reconstructive vs. obliterative procedure (colpocleisis if no longer sexually active)
• +/- Concomitant hysterectomy
• Consider evaluation of ureteral patency with cystoscopy or direct visualization via cystotomy