Pelvic organ prolapse (POP) is characterized by descent of pelvic organs from their normal positions. In women, the condition usually occurs when the

pelvic floor The pelvic floor or pelvic diaphragm is composed of muscle fibers of the levator ani, the coccygeus muscle, and associated connective tissue which span the area underneath the pelvis. The pelvic diaphragm is a muscular partition formed by the lev ...

collapses after gynecological cancer treatment, childbirth or heavy lifting. In men, it may occur after the prostate gland is removed. The injury occurs to fascia membranes and other connective structures that can result in

cystocele A cystocele, also known as a prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms. Others may have trouble starting urination, urinary incontinence, or frequent urination. Complicat ...

rectocele In gynecology, a rectocele ( ) or posterior vaginal wall prolapse results when the rectum bulges ( herniates) into the vagina. Two common causes of this defect are childbirth and hysterectomy. Rectocele also tends to occur with other forms of pel ...

or both. Treatment can involve dietary and lifestyle changes, physical therapy, or surgery.

Types

* Anterior vaginal wall prolapse **

Cystocele A cystocele, also known as a prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms. Others may have trouble starting urination, urinary incontinence, or frequent urination. Complicat ...

(bladder into vagina) **

Urethrocele A urethrocele is the prolapse of the female urethra into the vagina. Weakening of the tissues that hold the urethra in place may cause it to protrude into the vagina. Urethroceles often occur with cystoceles (involving the urinary bladder as well ...

(urethra into vagina) ** Cystourethrocele (both bladder and urethra) * Posterior vaginal wall prolapse **

Enterocele An enterocele is a protrusion of the small intestines and peritoneum into the vaginal canal. It may be treated transvaginally or by laparoscopy. An enterocele may also obstruct the rectum, leading to symptoms of obstructed defecation. Enteroceles ...

(small intestine into vagina) **

Rectocele In gynecology, a rectocele ( ) or posterior vaginal wall prolapse results when the rectum bulges ( herniates) into the vagina. Two common causes of this defect are childbirth and hysterectomy. Rectocele also tends to occur with other forms of pel ...

(rectum into vagina) **

Sigmoidocele Sigmoidocele (also known as Pouch of Douglas descent) refers to a condition where the sigmoid colon descends (prolapses) into the lower pelvic cavity. This can obstruct the rectum and cause symptoms of obstructed defecation. Pathophysiology The ...

* Apical vaginal prolapse **

Uterine prolapse Uterine prolapse is when the uterus descends towards or through the opening of the vagina. Symptoms may include vaginal fullness, pain with sex, trouble urinating, urinary incontinence, and constipation. Often it gets worse over time. Low back pa ...

(uterus into vagina) **

Vaginal vault The vaginal vault is the expanded region of the vaginal canal at the internal end of the vagina. Prolapse The vaginal vault may prolapse after a hysterectomy, as there is no uterus supporting the interior end of the vagina. ''Colposacropexy'' is ...

prolapse (roof of vagina) – after

hysterectomy Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovaries (oophorectomy), Fallopian tubes (salpingectomy), and other surrounding structures. Usually performed by a gynecologist, a hysterectomy may b ...

Grading

Pelvic organ prolapses are graded either via the Baden–Walker System, Shaw's System, or the Pelvic Organ Prolapse Quantification (POP-Q) System.

Shaw's System

Anterior wall * Upper 2/3 cystocele * Lower 1/3 urethrocele Posterior wall * Upper 1/3 enterocele * Middle 1/3 rectocele * Lower 1/3 deficient perineum Uterine prolapse * Grade 0 Normal position * Grade 1 descent into vagina not reaching introitus * Grade 2 descent up to the introitus * Grade 3 descent outside the introitus * Grade 4 Procidentia

Baden–Walker

POP-Q

Pelvic Organ Prolapse Quantification System

Management

Vaginal prolapses are treated according to the severity of symptoms.

Non-surgical

With conservative measures, such as changes in diet and fitness,

Kegel exercise Kegel exercise, also known as pelvic-floor exercise, involves repeatedly contracting and relaxing the muscles that form part of the pelvic floor, now sometimes colloquially referred to as the "Kegel muscles". The exercise can be performed many ti ...

s, and

pelvic floor physical therapy Pelvic floor physical therapy (PFPT) is a specialty area within physical therapy focusing on the rehabilitation of muscles in the pelvic floor after injury or dysfunction. It can be used to address issues such as muscle weakness or tightness post c ...

. With a

pessary A pessary is a prosthetic device inserted into the vagina for structural and pharmaceutical purposes. It is most commonly used to treat Stress incontinence, stress urinary incontinence to stop urinary leakage and to treat pelvic organ prolapse to ...

, a rubber or

silicone rubber Silicone rubber is an elastomer (rubber-like material) composed of silicone—itself a polymer—containing silicon together with carbon, hydrogen, and oxygen. Silicone rubbers are widely used in industry, and there are multiple formulations ...

device fitted to the patient which is inserted into the vagina and may be retained for up to several months. Pessaries are a good choice of treatment for women who wish to maintain fertility, are poor surgical candidates, or who may not be able to attend physical therapy. Pessaries require a provider to fit the device, but most can be removed, cleaned, and replaced by the woman herself. Pessaries should be offered to women considering surgery as a non-surgical alternative.

Surgery

With

surgery Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...

(for example native tissue repair, biological graft repair, absorbable and non-absorbable mesh repair, colpopexy,

colpocleisis Colpocleisis is a procedure involving closure of the vagina. It is used to treat vaginal prolapse. In older women who are no longer sexually active a simple procedure for reducing prolapse is a partial colpocleisis. The procedure was described by ...

). Surgery is used to treat symptoms such as bowel or urinary problems, pain, or a prolapse sensation. Evidence does not support the use of transvaginal surgical mesh compared with native tissue repair for anterior compartment prolapse owing to increased morbidity. For posterior vaginal repair, the use of mesh or graft material does not seem to provide any benefits. Safety and efficacy of many newer meshes is unknown. The use of a transvaginal mesh in treating vaginal prolapses is associated with side effects including

pain Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, ...

infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...

, and

organ perforation Organ perforation is a complete penetration of the wall of a hollow organ in the body, such as the gastrointestinal tract in the case of gastrointestinal perforation. It mainly refers to accidental or pathologic perforation, rather than intentiona ...

. Transvaginal repair seems to be more effective than transanal repair in posterior wall prolapse, but adverse effects cannot be excluded. According to the

FDA The United States Food and Drug Administration (FDA or US FDA) is a federal agency of the Department of Health and Human Services. The FDA is responsible for protecting and promoting public health through the control and supervision of food ...

, serious complications are "not rare." A number of

class action A class action, also known as a class-action lawsuit, class suit, or representative action, is a type of lawsuit where one of the parties is a group of people who are represented collectively by a member or members of that group. The class actio ...

lawsuit - A lawsuit is a proceeding by a party or parties against another in the civil court of law. The archaic term "suit in law" is found in only a small number of laws still in effect today. The term "lawsuit" is used in reference to a civil actio ...

s have been filed and settled against several manufacturers of TVM devices. Compared to native tissue repair, transvaginal permanent mesh probably reduces women's perception of vaginal prolapse sensation and probably reduces the risk of recurrent prolapse and of having repeat surgery for prolapse. On the other hand, transvaginal mesh probably has a greater risk of bladder injury and of needing repeat surgery for stress urinary incontinence or mesh exposure. When operating a pelvic organ prolapse, introducing a mid-urethral sling during or after surgery seems to reduce stress urinary incontinence.

Epidemiology

Genital prolapse occurs in about 316 million women worldwide as of 2010 (9.3% of all females).

Research

To study POP, various animal models are employed: non-human primates, sheep, pigs, rats, and others.

References

External links

{{Diseases of the pelvis, genitals and breasts Noninflammatory disorders of female genital tract Vagina