Pelvic Organ Prolapse

Definition/Description

Pelvic organ prolapse is the descent of a pelvic organ into or outside of the vaginal canal or anus. It mainly results from pelvic floor dysfunction1. There are several types:

- Cystocele: prolapse of the bladder into the vagina5 - Urethrocele: prolapse of the urethra - Uterine prolapse5 - Vaginal vault prolapse: prolapse of the vagina4 - Enterocele: small bowel prolapse - Rectocele: rectum prolapse5

Clinically Relevant Anatomy

Please see this page for a detailed overview of pelvic floor anatomy http://www.physio-pedia.com/Pelvic_Floor_Anatomy

Etiology

Pelvic organ prolapse has a multifactorial etiology. It is likely caused by a combination of physiological, anatomical, reproductive, genetic, and lifestyle factors that interact and contribute to dysfunction of the pelvic floor4.

Symptoms

A variety of symptoms may be present, including: - Vaginal bulging2 - Feeling of pelvic pressure or heaviness2 - Pelvic pain2 - Urinary or fecal incontinence or obstruction2 - Altered daily activities, sexual function, and quality of life2

Risk Factors

The factors causing pelvic organ prolapse are different between patients4. Risk factors include the following:

Primary Pelvic Organ Prolapse - Pregnancy & labour5 - Obesity/BMI1,4 - Respiratory problems involving a chronic, long-term cough5 - Cancer of the pelvic organs5 - Hysterectomy (surgical removal of the uterus)5 - Genetics (possibly) (due to weaker connective tissues)5 - History of vaginal delivery increases the risk4 5.56 times1 - Hypertension and Diabetes Mellitus combined increase the risk by 1.9 times1 - Increased birth weight1 - Age4 - Parity4 (i.e. the number of times a woman has given birth to a fetus with a gestational age of greater than or equal to 24 weeks, alive or stillborn)3

Pelvic Organ Prolapse Recurrence (after native tissue repair) - Preoperative stage 3 or 4 pelvic organ prolapse (i.e. a more severe prolapse)4

Treatment/Management

Treatment for pelvic organ prolapse usually involves either conservative management (for mild prolapse or women who are not good surgical candidates), or surgery. Conservative treatments include pelvic floor muscle training and the use of devices (pessaries)2.

In a study by Panman et al. in 2016, examining the 2-year effects of pelvic floor muscle retraining, it was demonstrated that in women aged 55 and greater with symptomatic mild pelvic organ prolapse, pelvic floor muscle retraining results in a significant decrease in pelvic floor symptoms when compared to watchful waiting (note: statistically significant but below the minimal clinically important difference). Additionally, it was found that pelvic floor muscle retraining was more effective in women who experienced increased pelvic floor symptom distress at baseline2. Conversely, the same study found no difference in sexual functioning, quality of life, function of the pelvic floor muscles, or degree of prolapse2.

Pelvic floor muscle retraining included: - Explanation and description of the pelvic floor2 - Instruction regarding how to contract and relax pelvic floor muscles2 o If unable to perform this task:  Feedback through digital palpation2 o If insufficient control demonstrated:  Myofeedback or electrical stimulation2 - General exercise program provided, subsequently modified for individual needs2 - Taught correct technique for contracting pelvic floor muscles before and during increases in abdominal pressure2 - Received information about washroom habits and lifestyle2 - If pelvic floor muscles were overactive, focus was on relaxation rather than contraction2 - Face-to-face contact with physiotherapist as well as encouragement to maintain practice at home 3-5 times per week, 2-3 times per day2