abnormal herniation of the uterus, bladder, or rectum through the vagina wall due to weakening of the pelvic floor muscles (eg, levator ani muscle complex), ligaments, and nerves caused by chronic, increased intraabdominal pressure (eg, pregnancy, obesity) and pelvic floor injury or obstetric trauma (eg, forceps-assisted vaginal delivery),
The levator ani muscle complex forms most of the pelvic floor and functions to hold the pelvic organs in a stable position. When this complex is damaged there is increased pelvic floor laxity, resulting in decreased pelvic organ support.
| Definitions | • Cystocele - bladder • Rectocele - rectum • Enterocele - small intestine • Procidentia- uterus, anterior and posterior wall of the vagina • Apical prolapse - uterus, vaginal vault | | --- | --- | | Risk factors | • Weakened pelvic support and increased intraabdominal pressure • Obesity • Multiparity (MCC & strongest risk factor) • Hysterectomy • Postmenopausal age | | Clinical presentation | • Asymptomatic • Pelvic pressure • Obstructed voiding ( difficulty intiating stream) • Urinary retention • Urinary incontinence • Constipation (posterior prolapse) • Fecal urgency, incontinence (posterior prolapse) • Splinting→having to reduce the herniated mass to void or defecate • Sexual dysfunction • Physical exam→bulging mass that increase with Valsalva. | | Management | • Weight loss • Pelvic floor exercises • Vaginal pessary • Surgical repair |
MCC risk factor is multiparity because pregnancy causes increased intraabdominal pressure with subsequent pelvic floor weakening and laxity; vaginal deliveries, even if uncomplicated can cause additional microinjury to the pelvic floor muscles and nerves.
Advancing age is associated with a progressive increase in the rate of pelvic organ prolapse (POP) because age-related changes (e.g., connective tissue degeneration, muscle weakness) result in weakness of the pelvic floor. Age is not, however, the greatest risk factor for POP.
Complete procidentia is a severe form of POP that includes herniation of the entire anterior, posterior, and apical vaginal compartments through the introitus, such that that the patient has a degree of cystocele (bladder prolapse), rectocele (rectal prolapse), and enterocele (intestinal prolapse) caused by the descent of the pelvic organs. Additionally, all or a portion of the cervix and uterus may be visible externally at the introitus in complete procidentia.
These pelvic organ herniations can result in urinary, defecatory, and sexual dysfunction. Depending on the extent of herniation, other symptoms can include an external mass that may show ulceration and bleeding, as found in this patient.
Diagnosis is made with a complete physical examination. Treatment includes pelvic floor exercises, vaginal pessaries, and surgical correction.
Examination also stages the extent of individual organ descent and guides management.
Management of POP is based on symptoms or complications:
Asymptomatic patients and no complications (eg, no urinary retention or hydronephrosis on ultrasound), do not require treatment and can be managed with reassurance and observation only.
In contrast, symptomatic patients (eg, pelvic pressure) or those with complications could benefit from treatment. Pelvic floor muscle (ie, Kegel) exercises are recommended in these patients. Nonsurgical treatment is with pessary placement, which helps restore pelvic anatomy and reduces the severity of symptoms. Surgical management (eg, anterior vaginal wall repair) can be offered to patients whose condition does not improve or those who decline nonsurgical treatment
<aside> 💡 Both surgical or nonsurgical management are equally efficacious. Therefore, treatment strategy is dependent on patient preference and surgical risk assessment.
Ex→poor surgical candidate due to her age, obesity, class III heart failure, and poorly controlled diabetes mellitus. Therefore, she would be better managed with the nonsurgical option of a pessary fitting, which helps support the prolapsing pelvic organs and restore normal anatomy.
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<aside> 💡 The majority of patients using a pessary have resolution of prolapse and bowel and bladder symptoms.
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Cervical conization does not cause weakening of the pelvic floor muscles associated with POP.