Pelvic Organ Prolapse

WHAT IS PROLAPSE?

Pelvic organ prolapse is a very common condition, particularly among older women. It's estimated that half of women who have children will experience some form of prolapse in later life, but because many women don't seek help from their doctor the actual number of women affected by prolapse is unknown Prolapse may also be called uterine prolapse, genital prolapse, uterovaginal prolapse, pelvic relaxation, pelvic floor dysfunction, urogenital prolapse or vaginal wall prolapse.

In prolapse of the uterus (procidentia), the uterus drops down into the vagina. It usually results from weakening of the connective tissue and ligaments supporting the uterus. The uterus may bulge only into the upper part of the vagina, into the middle part, or all the way through the opening of the vagina, causing total uterine prolapse. Prolapse of the uterus may cause pain in the lower back or over the tailbone, although many women have no symptoms. Total uterine prolapse, which is obvious, can cause pain during walking. Sores may develop on the protruding cervix and cause bleeding, a discharge, and infection. Prolapse of the uterus may cause a kink in the urethra. A kink may hide urinary incontinence if present or make urinating difficult. Women with total uterine prolapse may also have difficulty having a bowel movement.

In prolapse of the vagina, the upper part of the vagina drops down into the lower part, so that the vagina turns inside out. The upper part may drop part way through the vagina or all the way through, protruding outside the body and causing total vaginal prolapse. Prolapse of the vagina occurs only in women who have had a hysterectomy. Total vaginal prolapse may cause pain while sitting or walking. Sores may develop on the protruding vagina and cause bleeding and a discharge. Prolapse of the vagina may cause a compelling or frequent need to urinate. Or it may cause a kink in the urethra. A kink may hide urinary incontinence if present or make urinating difficult. Having a bowel movement may also be difficult.

DIAGNOSIS

Doctors can usually diagnose pelvic floor disorders by performing a pelvic examination, using a speculum (an instrument that spreads the walls of the vagina apart). A doctor may insert one finger in the vagina and one finger in the rectum to determine how severe a rectocele is.

A woman may be asked to bear down (as when having a bowel movement) or to cough while standing. She may be examined while standing. The resulting pressure in the pelvis may make a pelvic floor disorder more obvious.

Procedures to determine how well the bladder and rectum are functioning, such as urine tests, may be performed. These procedures help doctors determine whether drugs or surgery is the best treatment. If a woman has a problem with the passage of urine or urinary incontinence, doctors may use a flexible viewing tube to view the inside of the bladder (a procedure called cystoscopy) or the urethra (a procedure called urethroscopy). Also, the amount of urine that the bladder can hold without leakage and the rate of urine flow may be measured. Doctors may determine whether prolapse of the uterus is preventing the diagnosis of urinary incontinence.

TREATMENT

If prolapse is mild, performing Kegel exercises can help by strengthening the pelvic floor muscles. Kegel exercises target the muscles around the vagina, urethra, and rectum-the muscles used to stop a stream of urine. These muscles are tightly squeezed, held tight for about 10 seconds, then relaxed for about 10 seconds. The exercise is repeated 10 to 20 times in a row. Performing the exercises several times a day is recommended. Women can do Kegel exercises when sitting, standing, or lying down.

If prolapse is severe, a pessary may be used to support the pelvic organs. A pessary may be shaped like a diaphragm, cube, or doughnut. Pessaries are especially useful for women who are waiting for surgery or who cannot have surgery. A doctor fits the pessary to the woman by inserting and removing different sizes until the right one is found. A pessary can be worn for many weeks before it needs to be removed and cleaned with soap and water. Women are taught how to insert and remove the pessary. If they prefer, they may go to the doctor's office periodically to have the pessary cleaned. Evaluation of vaginal skin by physician is recommended periodically. -Vaginal irritation may be prevented by using estrogen cream and vaginal odor may be lessened by an antimicrobial cream. As long as no other problems occur, these women may continue to use the pessary, removing it for cleaning each month. These women should also see their doctor every 6 to 12 months.

Estrogen vaginal suppositories or cream should be used. These preparations can help keep vaginal tissues healthy and can prevent sores from forming.

Surgery is often needed but is usually performed only after a woman has decided not to have any more children. Surgery usually involves inserting instruments into the vagina. The weakened area is located, and the tissues around it are built up to prevent the organ from dropping through the weakened area.

For severe prolapse of the uterus or vagina, the surgery may require an incision in the abdomen. The upper part of the vagina is attached with stitches to a nearby bone in the pelvis. Often, a catheter is inserted to drain the urine for 1 to 2 days. If urinary incontinence is a problem or would occur after prolapse of the uterus is repaired, surgery to correct incontinence can usually be performed at the same time. In such cases, the catheter may be left in place longer. Heavy lifting, straining, and standing for a long time should be avoided for at least 8 weeks after surgery.

If prolapse of the rectum makes having a bowel movement difficult, surgery may be necessary.