Pelvic Organ Prolapse: Causes, Symptoms, Treatment, Prevention

Pelvic organ prolapse is a hernia of the pelvic organs to or through the vaginal opening. It is common to talk about prolapse when the upper part of the vaginal wall or the uterus is displaced beyond the vaginal limits. The prolapse of the uterus may be partial (outside of the genital slit is only part of her body) and complete. The term “prolapse of the uterus” implies the displacement of the uterus below the normal level, but the uterus does not extend beyond the genital slit. When the vagina is omitted, the lower third of its anterior (often combined with displacement of the bladder wall) or back (often combined with displacement of the rectal wall) walls are outside the genital slit. Vaginal prolapse is sometimes preceded by prolapse of the uterus.

The location of the pelvic organs is provided by their strong fixation by muscles and ligaments to the bones of the pelvis. Conditionally, we may point out a “funnel”, “hammock” and “plate”, providing a three-level fixation, and the third level “plate” prevents the gaping genital slit, the outlet of the urethra and anus. With the insolvency of the upper levels of fixation, omission occurs, and when the lower level is stretched, prolapse of the pelvic organs occurs.

Epidemiology

According to United Way Pharmacy, the frequency of pelvic prolapses in women varies between 2-28%, but after 40 years it increases to 35% and increases in women after menopause due to the loss of elasticity of the tissues and the accumulation of traumatic factors. In 50% of women who gave birth, there is some violation of the pelvic support. More than 15% of “large” gynecological operations are performed due to the omission and loss of the pelvic organs. There are racial differences in the frequency of this complication, which prevails in the group of women of the white race compared to the black and yellow race.

Risk factors. Relaxation of the pelvis and pelvic prolapses are more likely in the group of patients with a chronic increase in intra-abdominal pressure due to chronic cough, exertion, ascites, obesity, the presence of large pelvic tumors. Long labor with disproportions between the head of the fetus and the mother’s pelvis and injuries to the birth canal are also significant risk factors for prolapse of the genital organs. The age of a woman> 30 years and the postmenopausal period also increases the frequency of this complication.

Etiological factors of pelvic organ prolapse include:

• congenital prolapse;
• congenital cleft of the spine;
• pregnancy;
• trauma during labor (episiotomy, perineal tears);
• previous pelvic surgery (gynecological radical interventions (insufficient connection of cardinal ligaments during hysterectomy), urological operations (hemorrhoidectomy, fistulography);
• menopause;
• chronic increase in intra-abdominal pressure (cough, constipation, bladder neck obstruction, anal stenosis, hard work, ascites, large pelvic tumors);
• fibrosis of genital tissues or collagen deficiency;
• obesity;
• smoking;
• increased physical activity.

Degrees of prolapse

The degree of prolapse is determined by the distance to which the pelvic ptosis occurred:

• I degree – the pelvic structures are within the vagina during tension;
• II degree – pelvic structures descend to the level of the entrance to the vagina at a voltage (to the level of the vulvar ring);
• III degree – pelvic structures descend below the entrance to the vagina at a voltage (below the vulvar ring);
• IV degree – pelvic structures outside the vulvar ring at rest.

Causes and symptoms

• Congenital insufficiency of the pelvic floor muscles due to the violation of their connection with the central nervous system in case of malformations of the spine and spinal cord;
• Relaxation of the abdominal muscles due to asthenia, sharp exhaustion or multiple repeated, especially complicated, pregnancies (polyhydramnios, multiple pregnancies, etc.). The displacement of the uterus downwards is a manifestation of general ptosis of the internal organs;
• Labor complicated by deep perineal tears, especially multiple ones with a narrow pelvis. Use in the delivery of obstetric spikes;
• Elderly and senile age (tissue atrophy occurs);
• Inadequate physical activity (professional activity, implying hard physical labor, carrying weights, especially during puberty, after childbirth and in menopause);
• Sharp weight loss;
• Impaired bowel function, manifested by frequent and prolonged constipation;
• One of the risk factors is obesity, which increases the pressure on the abdominal and pelvic muscles;
• Sometimes a cause of uterine prolapse is a pelvic organ tumor.

Often, genital organ prolapse occurs due to a combination of several causes.

The initial stages of the prolapse of the uterus and / or vagina may be asymptomatic. A slight omission of the uterus and vagina may not cause pain. The menstrual cycle with a prolapse of the uterus is usually not disturbed. Women may feel the first discomfort during an intimate relationship. The weakness of the pelvic floor muscles prevents the onset of an orgasm, both in a woman and in her sexual partner. With the prolapse of the genital organs, there are pulling pains and a foreign body sensation in the vagina, a constant feeling of pressure in the pubic area. Later, the pain spread to the lumbar region and the sacrum. But the biggest problems are caused by weakening of the ligamentous apparatus of the bladder and urinary disorders arising from the prolapse of the uterus. At first, it can be rapid, often the prolapse of the uterus causes stress urinary incontinence (involuntary urination when laughing, coughing, lifting weights, etc.). With a significant displacement of the bladder wall and prolapse of the uterus, urination sometimes becomes possible only after the uterus is reduced. In addition, the presence of residual urine is the cause of cystitis and other inflammatory diseases of the urinary system. Similar problems, difficulty defecation and incomplete emptying of the rectum occur with prolapse of the rectal wall. A woman is forced to take an unusual position or help herself to go to the toilet. Often, inflammatory diseases of the pelvic organs join, as the displacement of the genital organs and the gaping of the genital slit creates favorable conditions for infection and the formation of pressure sores. Trophic ulcers can occur on the prolapsed genital organs (due to blood supply disturbances), swelling of the cervix and vagina, and contact bleeding are possible. Sometimes the uterus that is enlarged due to swelling and inflammation may be affected. Sexual intercourse becomes impossible, social activity is sharply reduced.

Diagnosis

The first step in the diagnosis of prolapse and prolapse of the internal genital organs is the proper gynecological examination. The doctor determines the degree of omission of the walls of the vagina and / or uterus, defects in the urogenital diaphragm and aponeurosis. Additionally, transvaginal ultrasound and combined urodynamic study are usually prescribed.

Modern possibilities of ultrasound diagnostics provide additional information on the state of the adjacent pelvic organs. If abnormalities were found, the scope of the examination can be expanded by using endoscopic diagnostic methods to exclude diseases of the endometrium, the mucous membrane of the bladder and rectum.

Treatment of pelvic organ prolapse

Regardless of the etiology, symptomatic pelvic prolapse is an anatomical problem and requires treatment to restore support for pelvic structures.

Treatment may include hormone replacement therapy to maximize the internal factors that contribute to the elasticity of the tissue and strengthen the pelvic support structures, or physical exercises to train the pelvic muscles. Other treatments include pelvic support rings (pessaries) or reconstructive pelvic surgery.

In postmenopausal women, estrogen replacement therapy (systemic or local) is an important part of treatment, improves tissue tone and remission of atrophic changes in the vaginal mucosa.

With small degrees of pelvic organ prolapse and minor clinical symptoms, United Way Pharmacy recommends physical exercises (Kegel exercises) to strengthen the pelvic muscles. These exercises are to strain and relax the pubic-coccygeal muscles several times a day to train them and increase support for the pelvic floor.

Vaginal pessaries contribute to the mechanical support and restoration of the topographic anatomy of the pelvic organs and reduce the downward force of pressure due to an increase in the area of impact. Pessaries are recommended for patients with severe symptomatic prolapses, but who have contraindications to surgery or refuse surgical treatment.

Pessaries are placed in the vagina, like the diaphragm, and help maintain the normal position of the pelvic organs. The use of vaginal pessaries requires careful monitoring of the patient to prevent vaginal injuries, leukorrhea, secondary infection and necrosis of the direct intestine.

Surgical treatment is indicated for symptomatic pelvic prolapse and unsuccessful conservative therapeutic measures. Typically, reconstructive pelvic prolapse surgery has very good results. Treatment of cystocele and rectocele usually consists of anterior and posterior colporrhaphy, respectively. These procedures restore the fascia defect in the vesicular-vaginal or rectus-vaginal (rectovaginal) septum, through which the hernial protrusion of the pelvic organs occurs.

Perineoplasty restores the defect of the perineal center of the perineal body. In symptomatic uterine prolapse, vaginal or (less commonly) abdominal hysterectomy is usually indicated. Minimally invasive operations using a synthetic loop have gained considerable popularity.

Prolapse of the vaginal stump is corrected by filling the apex of the vagina to fixed pelvic structures (vaginal or laparoscopic colposuspension, etc.). The success of the operation depends on the experience of the surgeon, the degree of pelvic relaxation, age, body weight and lifestyle of the patient.

Colpocleisis is a surgical obliteration of the vagina. This operation is usually performed in case of severe prolapse of the uterus and vaginal walls of aged patients who do not wish to maintain sexual activity. Colpocleisis can be performed under local anesthesia and is indicated for patients with genital prolapse and if there are contraindications to general and regional anesthesia.

Prevention

Basic preventive measures include:

• Careful management of labor (avoid prolonged traumatic labor);
• Treatment of extragenital pathology (diseases leading to an increase in intra-abdominal pressure);
• Layered anatomical restoration of the perineum after childbirth in the presence of tears, episodes or perineotomy;
• The use of hormonal therapy in hypoestrogenic conditions;
• A set of exercises to strengthen the muscles of the pelvic floor.