Pelvic organ prolapse
| Pelvic organ prolapse | |
|---|---|
| Other names | Female genital prolapse |
 | |
| A 40 year old woman with uterine prolapse, which is visible only in standing position, with the cervix protruding through the vulva. | |
| Specialty | Gynecology |
| Frequency | 316 million women (9.3% as of 2010)[1] |
Pelvic organ prolapse (POP) is the descent of pelvic organs from their normal positions into or beyond the vaginal canal.[2][3] POP may involve one or more areas including the anterior or posterior vaginal wall, the uterus or cervix, and the top of the vagina.[3] Risk factors include vaginal childbirth, a greater number of births, older age, higher body mass index (BMI), and pelvic floor muscle injury.[4] Treatment can involve dietary and lifestyle changes, physical therapy, or surgery.[5]
Signs and symptoms
[edit]Pelvic organ prolapse can be asymptomatic.[3] When symptoms are present, the most characteristic is a sensation of a vaginal bulge.[6] Pelvic pressure or heaviness may also occur.[7]
Urinary and bowel symptoms and sexual difficulties may coexist with pelvic organ prolapse, but the extent to which prolapse causes or worsens these symptoms is not fully understood.[8]
Types
[edit]
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- Anterior vaginal wall prolapse
- Cystocele (bladder into vagina)
- Urethrocele (urethra into vagina)
- Cystourethrocele (both bladder and urethra)
- Posterior vaginal wall prolapse
- Enterocele (small intestine into vagina)
- Rectocele (rectum into vagina)
- Sigmoidocele
- Apical vaginal prolapse
- Uterine prolapse (uterus into vagina)[9]
- Vaginal vault prolapse (descent of the roof of vagina) – after surgical removal of the uterus hysterectomy[10]
Grading
[edit]Pelvic organ prolapses are graded either via the Baden–Walker System, Shaw's System, or the Pelvic Organ Prolapse Quantification (POP-Q) System.[11]
Shaw's System
[edit]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
[edit]| Grade | Posterior urethral descent, lowest part other sites |
|---|---|
| 0 | normal position for each respective site |
| 1 | descent halfway to the hymen |
| 2 | descent to the hymen |
| 3 | descent halfway past the hymen |
| 4 | maximum possible descent for each site |
POP-Q
[edit]| Stage | Description |
|---|---|
| 0 | No prolapse anterior and posterior points are all −3 cm, and C or D is between −TVL and −(TVL−2) cm. |
| 1 | The criteria for stage 0 are not met, and the most distal prolapse is more than 1 cm above the level of the hymen (less than −1 cm). |
| 2 | The most distal prolapse is between 1 cm above and 1 cm below the hymen (at least one point is −1, 0, or +1). |
| 3 | The most distal prolapse is more than 1 cm below the hymen but no further than 2 cm less than TVL. |
| 4 | Represents complete procidentia or vault eversion; the most distal prolapse protrudes to at least (TVL−2) cm. |
Management
[edit]Vaginal prolapses are treated according to the severity of symptoms.
Non-surgical
[edit]With conservative measures, such as changes in diet and fitness, Kegel exercises, and pelvic floor physical therapy.[13]
A pessary, a rubber or silicone rubber device fitted to the patient is also a non-surgical option, it is inserted into the vagina and may be retained for up to several months. Vaginal pessaries can immediately relieve prolapse and prolapse-related symptoms.[14] Pessaries are a good choice of treatment for women who wish to maintain fertility, are poor surgical candidates, or who may not be able to attend physical therapy.[15] Pessaries require a provider to fit the device, but most can be removed, cleaned, and replaced by the woman herself; however, others have this done for them by a clinician biannually. A trial compared the two approaches and found that, compared with clinic-based care, self-management was associated with a similar quality of life, fewer complications, and was more cost-effective.[16][17] Pessaries should be offered as a non-surgical alternative for women considering surgery.
Surgery
[edit]Surgery (for example native tissue repair, biological graft repair, absorbable and non-absorbable mesh repair, colpopexy, or colpocleisis) is used to treat symptoms such as bowel or urinary problems, pain, or a prolapse sensation. When operating a pelvic organ prolapse, introducing a mid-urethral sling during or after surgery seems to reduce stress urinary incontinence.[18][needs update] Transvaginal repair seems to be more effective than transanal repair in posterior wall prolapse, but adverse effects cannot be excluded.[19] According to the FDA, serious complications are "not rare."[20]
Evidence does not support the use of transvaginal surgical mesh compared with native tissue repair for anterior compartment prolapse owing to increased morbidity.[21] For posterior vaginal repair, the use of mesh or graft material does not seem to provide any benefits.[19]
Compared to native tissue repair, transvaginal permanent mesh likely reduces the perception of vaginal prolapse sensation, the risk of recurrent prolapse, and of having repeat surgery specifically only for prolapse. Transvaginal mesh (TVM) has a greater risk of bladder injury and of needing repeat surgery for stress urinary incontinence or mesh exposure.[22] The use of a TVM in treating vaginal prolapses is associated with severe side effects including organ perforation, infection, and pain.
Safety and efficacy of many newer meshes is unknown.[21] Thousands of class action lawsuits have been filed and settled against several manufacturers of TVM devices.[23]
For surgical treatment of apical vaginal prolapse, going through the abdomen (sacral colpopexy) may have better outcomes than a surgical approach that goes through the vagina.[10]
Epidemiology
[edit]Genital prolapse occurs in about 316 million women worldwide as of 2010 (9.3% of all females).[1]
Research
[edit]To study POP, various animal models are employed: non-human primates, sheep,[24][25] pigs, rats, and others.[26][27]
See also
[edit]References
[edit]- 1 2 Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. (December 2012). "Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010". Lancet. 380 (9859): 2163–2196. doi:10.1016/S0140-6736(12)61729-2. PMC 6350784. PMID 23245607.
- ↑ Padoa A, Braga A, Brecher S, Fligelman T, Mesiano G, Serati M (16 October 2025). "Pelvic Organ Prolapse: Current Challenges and Future Perspectives". Journal of Clinical Medicine. 14 (20): 7313. doi:10.3390/jcm14207313. ISSN 2077-0383. PMC 12565515. PMID 41156187.
- 1 2 3 Collins S, Lewicky-Gaupp C (March 2022). "Pelvic Organ Prolapse". Gastroenterology Clinics of North America. 51 (1): 177–193. doi:10.1016/j.gtc.2021.10.011. ISSN 1558-1942. PMID 35135661.
- ↑ Schulten SF, Claas-Quax MJ, Weemhoff M, van Eijndhoven HW, van Leijsen SA, Vergeldt TF, et al. (August 2022). "Risk factors for primary pelvic organ prolapse and prolapse recurrence: an updated systematic review and meta-analysis". American Journal of Obstetrics and Gynecology. 227 (2): 192–208. doi:10.1016/j.ajog.2022.04.046. PMID 35500611.
- ↑ "Pelvic organ prolapse". womenshealth.gov. 3 May 2017. Retrieved 29 December 2017.
- ↑ Collins SA, O'Shea M, Dykes N, Ramm O, Edenfield A, Shek KL, et al. (August 2021). "International Urogynecological Consultation: clinical definition of pelvic organ prolapse". International Urogynecology Journal. 32 (8): 2011–2019. doi:10.1007/s00192-021-04875-y. ISSN 0937-3462. PMID 34191102.
- ↑ Haylen BT, Maher CF, Barber MD, Camargo S, Dandolu V, Digesu A, et al. (February 2016). "An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP)". International Urogynecology Journal. 27 (2): 165–194. doi:10.1007/s00192-015-2932-1. ISSN 0937-3462. PMID 26755051.
- ↑ Harvey MA, Chih HJ, Geoffrion R, Amir B, Bhide A, Miotla P, et al. (2021). "International Urogynecology Consultation Chapter 1 Committee 5: relationship of pelvic organ prolapse to associated pelvic floor dysfunction symptoms: lower urinary tract, bowel, sexual dysfunction and abdominopelvic pain". International Urogynecology Journal. 32 (10): 2575–2594. doi:10.1007/s00192-021-04941-5. PMID 34338825.
- ↑ Donita D (10 February 2015). Health & physical assessment in nursing. Barbarito, Colleen (3rd ed.). Boston. p. 665. ISBN 978-0-13-387640-6. OCLC 894626609.
{{cite book}}: CS1 maint: location missing publisher (link) - 1 2 Maher C, Yeung E, Haya N, Christmann-Schmid C, Mowat A, Chen Z, et al. (26 July 2023). "Surgery for women with apical vaginal prolapse". The Cochrane Database of Systematic Reviews. 2023 (7) CD012376. doi:10.1002/14651858.CD012376.pub2. ISSN 1469-493X. PMC 10370901. PMID 37493538.
- ↑ ACOG Committee on Practice Bulletins—Gynecology (September 2007). "ACOG Practice Bulletin No. 85: Pelvic organ prolapse". Obstetrics and Gynecology. 110 (3): 717–729. doi:10.1097/01.AOG.0000263925.97887.72. PMID 17766624.
- ↑ Beckley I, Harris N (26 March 2013). "Pelvic organ prolapse: a urology perspective". Journal of Clinical Urology. 6 (2): 68–76. doi:10.1177/2051415812472675. S2CID 75886698.
- ↑ "Kegel Exercises | NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 2 December 2017.
- ↑ Boyd S, Propst K, O'Sullivan D, Tulikangas P (March 2019). "25: Pessary use and severity of pelvic organ prolapse over time: a retrospective study". American Journal of Obstetrics and Gynecology. 220 (3): S723. doi:10.1016/j.ajog.2019.01.055. ISSN 0002-9378. S2CID 86740242.
- ↑ Tulikangas P, et al. (Committee on Practice Bulletins—Gynecology and the American Urogynecologic Society) (April 2017). "Practice Bulletin No. 176: Pelvic Organ Prolapse". Obstetrics and Gynecology. 129 (4): e56–e72. doi:10.1097/aog.0000000000002016. PMID 28333818. S2CID 46882949.
- ↑ Hagen S, Kearney R, Goodman K, Best C, Elders A, Melone L, et al. (December 2023). "Clinical effectiveness of vaginal pessary self-management vs clinic-based care for pelvic organ prolapse (TOPSY): a randomised controlled superiority trial". eClinicalMedicine. 66 102326. doi:10.1016/j.eclinm.2023.102326. ISSN 2589-5370. PMC 10701109. PMID 38078194.
- ↑ "Pelvic organ prolapse: self-management of pessaries can be a good option". NIHR Evidence. 11 April 2024. doi:10.3310/nihrevidence_62718.
- ↑ Baessler K, Christmann-Schmid C, Maher C, Haya N, Crawford TJ, Brown J (19 August 2018). "Surgery for women with pelvic organ prolapse with or without stress urinary incontinence". Cochrane Database Syst Rev. 2018 (8) CD013108. doi:10.1002/14651858.CD013108. PMC 6513383. PMID 30121956.
- 1 2 Mowat A, Maher D, Baessler K, Christmann-Schmid C, Haya N, Maher C (5 March 2018). "Surgery for women with posterior compartment prolapse". Cochrane Database Syst Rev. 2018 (3) CD012975. doi:10.1002/14651858.CD012975. PMC 6494287. PMID 29502352.
- ↑ "UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse: FDA Safety Communication". U.S. Food and Drug Administration. 13 July 2011. Archived from the original on 17 July 2011. Retrieved 23 June 2015.
- 1 2 Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Brown J (November 2016). "Surgery for women with anterior compartment prolapse". The Cochrane Database of Systematic Reviews. 2017 (11) CD004014. doi:10.1002/14651858.CD004014.pub6. PMC 6464975. PMID 27901278.
- ↑ Yeung E, Baessler K, Christmann-Schmid C, Haya N, Chen Z, Wallace SA, et al. (13 March 2024). "Transvaginal mesh or grafts or native tissue repair for vaginal prolapse". The Cochrane Database of Systematic Reviews. 2024 (3) CD012079. doi:10.1002/14651858.CD012079.pub2. ISSN 1469-493X. PMC 10936147. PMID 38477494.
- ↑ Michelle Llamas, BCPA (11 November 2022). "Transvaginal Mesh Lawsuits". drugwatch. Retrieved 16 January 2023.
- ↑ Patnaik SS, Brazile B, Dandolu V, Damaser M, van der Vaart CH, Liao J. "Sheep as an animal model for pelvic organ prolapse and urogynecological research" (PDF). ASB 2015 Annual Conference 2015. Archived from the original (PDF) on 27 March 2019. Retrieved 26 March 2019.
- ↑ Patnaik SS (2015). Investigation of sheep reproductive tract as an animal model for pelvic organ prolapse and urogyencological research. Mississippi State University.
- ↑ Couri BM, Lenis AT, Borazjani A, Paraiso MF, Damaser MS (May 2012). "Animal models of female pelvic organ prolapse: lessons learned". Expert Review of Obstetrics & Gynecology. 7 (3): 249–260. doi:10.1586/eog.12.24. PMC 3374602. PMID 22707980.
- ↑ Patnaik SS (2016). Chapter Six - Pelvic Floor Biomechanics From Animal Models. Academic Press. pp. 131–148. doi:10.1016/B978-0-12-803228-2.00006-4.