Pelvic Organ Prolapse

2024/05/31

What is Pelvic Organ Prolapse

Pelvic organ prolapse occurs when the uterus or part of the vaginal canal becomes lax and protrude out of its original position. Please refer to the photo of a normal vagina and uterus without POP on the left.

Severity of Prolapse

Mild or 1st degree prolapse: When the prolapse is still within the vagina
Moderate or 2nd degree prolapse: When the prolapse is just outside the vagina
Severe or 3rd and 4th degree prolapse: When the prolapse is completely outside the vagina

Types of Prolapse

You may present with one or more types of prolapse.

Cystocoele: When the top of the vagina supporting the bladder prolapses downwards into and outwards outside the vagina.
Rectocoele / Enterocoele: When the bottom of the vagina supporting the rectum / small intestines respectively prolapses upwards into and outside the vagina.
Uterine prolapse: When the back of the vagina supporting the uterus prolapses into and outside the vagina.
Procidentia: When there is prolapse of the uterus and vagina including the bladder completely outside the vagina.
Vault prolapse: When the back of the vagina prolapse into and outside the vagina after a previous hysterectomy.

What are the causes?

The prolapse is due to the progressive weakening of the supporting tissues of the uterus and the vagina in situations such as pregnancy and childbirth, especially difficult and prolonged labour.

The supporting tissues become even weaker when you enter the menopause and as you grow older. If you are involve in strenuous physical work, or suffer from chronic cough and constipation, you have an increased tendency to develop pelvic organ prolapse.

Other causes include congenital weakness of the pelvic floor muscles, ligaments and fascia and collagen deficiency.

Symptoms

Some of the symptoms are listed below. These symptoms are not listed in descending order of frequency or presentation, but may be related to the severity/degree of the prolapse:

A dragging sensation in the lower abdomen and pelvis
A swelling sensation in the vagina
Backache that progresses through the day
A lump outside the vagina
Vaginal bleeding and discharge
Difficulty in walking, sitting
Difficulty in passing urine and motion
Difficulty or inability to have sex
Anxiety, depression because of feeling less feminine secondary to the lump below and inability to have sex
Fear that lump below may be a growth or cancer

Therapeutic options

You are advised to see your gynaecologist or urogynaecologist to receive a complete evaluation of your condition.

A complete management programme may involve lifestyle changes, pelvic floor rehabilitation, use of topical (local) oestrogen cream and/or vaginal tablets to improve post-menopausal vaginal dryness and thinning, vaginal pessaries to support your prolapse and urodynamics investigations before surgical intervention.

Surgery for POP

Surgery for POP would depend on the severity and type of prolapse. The commonly performed vaginal operations include:

Anterior repair or anterior colporrhaphy for repair of cystocoele (bladder prolapse).
Posterior repair or posterior colpoperineorrhaphy for repair of rectocoele and enterocoele repair, as required
-aginal hysterectomy* to remove the uterus (womb) from the vaginal route; and repair of the back of the vagina to the uterosacral ligaments (strong ligaments between the back of your womb to your sacrum [back of your pelvic bone]). Both Fallopian tubes and ovaries may also be removed, especially if you are post-menopausal, just as in abdominal (open) or laparoscopic (key hole) hysterectomy. This would also depend on the condition of your ovaries from a pelvic ultrasound scan performed before your operation and on inspection of your ovaries during surgery, your personal preference, the severity of your prolapse.
Vault prolapse surgery by supporting your vaginal vault to the Sacrospinous ligament, a strong ligament situated at the side wall of your pelvis to the side of your sacrum. This operation is known as Sacrospinous ligament fixation.

Advantages of vaginal surgery

The advantages of vaginal surgery are:

Natural orifice surgery
No abdominal (tummy) incisions (cuts), wounds or scars
Less pain
Fewer complications
Shorter surgery
Shorter hospitalisation
Cost effectiveness
Quicker recovery
Faster return to normal activities and work

*All the above advantages hold true for vaginal hysterectomy when compared to abdominal (open) and laparoscopic (key hole) hysterectomy.