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What is pelvic organ prolapse?

Pelvic organ prolapse (utero-vaginal prolapse) is the abnormal sliding out or herniation of the pelvic organs from their normal pelvic position along the vaginal axis. The prolapse may include the uterus (uterine prolapse), vaginal apex (vault prolapse), anterior vagina (cystocele), or posterior vagina (rectocele and enterocoele). The causes of pelvic organ prolapse may be congenital weakness or structural disruption of the pelvic floor. Most women who had delivered babies vaginally have some degree of prolapse; albeit majority are not bothersome. About a third will have symptoms of a “lump in the vagina”, pelvic and low back pain, difficulty in urinating and passing motion. Utero-vaginal prolapse may be treated with vaginal pessary, pelvic floor exercises and surgical reconstruction. The lifetime risk of having one corrective operation for urinary incontinence or prolapse is estimated at approximately 11%.

What is the pelvic floor and pelvic floor dysfunction?

The pelvic floor is a complex network of muscles, ligaments, fascia, connective tissues and nerves that interlace around the urethra, bladder, vagina and rectum. It supports the pelvic organs appropriately to allow normal functioning. Disruption of the pelvic floor changes the structural relationships of these organs and results in functional disorders and anatomical distortion. Causes of pelvic floor dysfunction include pregnancy and multiple vaginal births, persistent straining at bowel movement, chronic cough, obesity, pelvic surgery and the menopause.

Pelvic floor disorders are not a normal part of aging. Pelvic floor disorders are pelvic organ prolapse, inadequate bladder control and abnormal bowel control. Treatment of pelvic floor dyfunctions combines physical exercises, medication and surgery. Pelvic floor disorders can significantly compromise the quality of your life, which may result in depression, social isolation, and avoidance of physical and sexual activity due to discomfort and embarrassment.

What are the causes of pelvic organ prolapse?

Many factors come together over a period of many years to trigger and propagate the appearance of pelvic organ prolapse.

Pregnancy

Pregnancy alone stretches and breaks the endopelvic fascia and levator muscles of the pelvic floor, especially during the last trimester.

Childbirth

The pelvic organs are commonly torn from the attachment sites during childbirth. Vaginal birth, and more so in assisted/operative vaginal delivery, significantly increases the risk of utero-vaginal prolapse over Caesarean delivery without labor. Labor damages pelvic nerves, leading to partial pudendal and perineal neruopathies, which impair nerve transmission to the pelvic floor muscles. The resultant poor muscle tone encourages further sagging.

Menopause

The low estrogen level of menopause leads to thinning of the pelvic floor muscles and vaginal supporting tissues.

Medical conditions

Prolapse may potentially result from pelvic tumors, sacral nerve disorders, and diabetic neuropathy. Other medical conditions that may result in prolapse are those associated with increases in intra-abdominal pressure (eg, obesity, chronic pulmonary disease, smoking, constipation).

Congenital weakness

Certain rare abnormalities in connective tissue (collagen), such as Marfan disease, have also been linked to genitourinary prolapse.

Normal aging

As a woman ages, her tissue integrity weakens in general.

What are the symptoms of Prolapse?

It is common to observe prolapsed pelvic organs in women, but they are usually asymptomatic. Mild utero-vaginal prolapse generally does not need to be treated. When the pelvic organ slides towards the vaginal opening, the women begin to experience symptoms. They may notice one, few or all of the complaints below.
    Vulvar bulge of “lump in the vaginal”; which may be small or a very large protruding mass
    “Something coming down” discomfort in the vagina
    Difficulty having a bowel movement
    Trouble emptying the bladder
    Pelvic or vaginal pain
    Lower back pain
    Pain during intercourse
    Increased discomfort with prolonged standing
    Less discomfort with lying down

How to diagnose pelvic organ prolapse?

When a woman presents with symptoms suggesting prolapse of pelvic organs, a detail vaginal and pelvic examination would be carried out. The aims are to determine the type of pelvic organ prolapse, the severity and possible causes or aggravating factors promoting the defect.

What are the types of pelvic organ prolapse?

Cystourethrocele: When the wall between the bladder and vagina weakens, the bladder can fall down into the vaginal cavity.

Uterine Prolapse: The uterine wall can also slide down into the vagina.

Rectocele: Sometimes part of the rectal wall may protrude into the vagina.

Enterocele: Small bowel may also herniate into the vaginal wall. This usually occurs in women who have had a hysterectomy.

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