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Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is a condition characterised by the descent of pelvic organs from their normal positions into the vagina. It predominantly affects women and is usually associated with the collapse of the pelvic floor following gynaecological cancer treatment, childbirth, or heavy lifting. The injury to fascia membranes and other connective structures can result in cystocele, rectocele, or both. Treatment options include dietary and lifestyle changes, physical therapy, or surgery.

Types

POP can be classified into several types based on the affected area. These include:

  • Anterior vaginal wall prolapse
    • Cystocele: Bladder into vagina
    • Urethrocele: Urethra into vagina
    • Cystourethrocele: Both bladder and urethra
A cystocele protruding through the vagina in a 73 year old woman.
A cystocele protruding through the vagina in a 73 year old woman.
  • Posterior vaginal wall prolapse
    • Enterocele: Small intestine into vagina
    • Rectocele: Rectum into vagina
    • Sigmoidocele: Sigmoid colon into vagina
Large rectocele.
Large rectocele.
  • Apical vaginal prolapse
    • Uterine prolapse: Uterus into vagina
    • Vaginal vault prolapse: Descent of the roof of the vagina, often after hysterectomy
Uterine prolapse in a 71 year old woman, with the cervix visible in the vaginal orifice.
Uterine prolapse in a 71 year old woman, with the cervix visible in the vaginal orifice.

Grading

Pelvic organ prolapses are graded using systems such as 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 System

  • Grade 0: Normal position for each respective site
  • Grade 1: Descent halfway to the hymen
  • Grade 2: Descent to the hymen
  • Grade 3: Descent halfway past the hymen
  • Grade 4: Maximum possible descent for each site

POP-Q System

  • Stage 0: No prolapse, anterior and posterior points are all −3 cm
  • Stage 1: Most distal prolapse more than 1 cm above the level of the hymen
  • Stage 2: Most distal prolapse between 1 cm above and 1 cm below the hymen
  • Stage 3: Most distal prolapse more than 1 cm below the hymen but no further than 2 cm less than TVL
  • Stage 4: Complete procidentia or vault eversion

Management

Non-surgical

Non-surgical measures include changes in diet and fitness, Kegel exercises, and pelvic floor physical therapy. A pessary, a rubber or silicone device fitted to the patient, can be inserted into the vagina and may be retained for several months. Pessaries can relieve prolapse and prolapse-related symptoms and are especially suitable for women who wish to maintain fertility, are poor surgical candidates, or cannot attend physical therapy.

Surgical

Surgical options include native tissue repair, biological graft repair, absorbable and non-absorbable mesh repair, colpopexy, or colpocleisis. Surgery is recommended for symptoms such as bowel or urinary problems, pain, or a prolapse sensation. Introducing a mid-urethral sling during or after surgery can reduce stress urinary incontinence. Transvaginal repair is generally more effective than transanal repair for posterior wall prolapse, although it carries risks of complications.

A 40 year old woman with uterine prolapse, which is visible only in standing position, with the cervix protruding through the vulva.
A 40 year old woman with uterine prolapse, which is visible only in standing position, with the cervix protruding through the vulva.

Epidemiology

Genital prolapse affects about 9.3% of all females worldwide, equating to approximately 316 million women as of 2010.

Research

Various animal models, including non-human primates, sheep, pigs, and rats, are used to study pelvic organ prolapse.


Self-assessment MCQs (single best answer)

What is pelvic organ prolapse (POP) characterised by?



Which of the following is NOT a type of anterior vaginal wall prolapse?



Which grading system uses the terms "Grade 0" to "Grade 4" to classify uterine prolapse?



Which of the following is a non-surgical management option for pelvic organ prolapse?



In the POP-Q System, what is indicated by Stage 4?



What is the prevalence of genital prolapse among females worldwide?



Which of the following is a posterior vaginal wall prolapse involving the small intestine?



Which system grades the descent halfway to the hymen as "Grade 1"?



What type of surgery might be considered for a woman with pelvic organ prolapse who experiences symptoms like bowel or urinary problems?



Which of the following animal models is used to study pelvic organ prolapse?



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