What to do about pelvic organ prolapse
Pelvic relaxation is a weakness or laxity in the supporting structures
of the pelvic region. Bladder, rectal, or uterine tissue may then bulge
into the vagina. This is called pelvic organ prolapse.
Once rarely discussed or recognized, this problem has now become a
priority in women’s health. Today, many primary care physicians
and gynecologists routinely screen patients for the symptoms, and the
new surgical specialty of urogynecology has arisen to correct prolapse
conditions and the urinary incontinence that often results. By age 80,
more than 1 in every 10 women will have undergone surgery for prolapse.
Types of pelvic organ prolapse
Different types of pelvic organ prolapse affect different parts of
the vagina (see illustrations):
Cystocele and urethrocele. A cystocele occurs
when the bladder protrudes into the front wall of the vagina. A similar
defect, known as a urethrocele, develops when the urethra presses into
the front vaginal wall.
Rectocele. Part of the rectum bulges into
the back wall of the vagina, sometimes causing difficulty with defecation.
Uterine prolapse. The uterus drops down into
the vagina. In women who have undergone a hysterectomy, a similar condition
known as vaginal vault prolapse can occur: the top of the vagina protrudes
into the lower vagina.
Pelvic organ prolapse conditions
Depending on where weak spots occur, the bladder, urethra,
rectum, or uterus may protrude into the vagina.
What causes pelvic organ prolapse?
Pelvic support comes from pelvic floor muscles, connecting tissue (fascia),
and thickened pieces of fascia that serve as ligaments. When pelvic floor
muscles are weakened, the fascia and ligaments have to bear the brunt
of the weight. Eventually, they may stretch and fail, allowing pelvic
organs to drop and press into the vaginal wall.
Women who have had multiple vaginal births are at greatest risk for
pelvic organ prolapse, particularly after menopause. Other risk factors
include surgery to the pelvic floor, connective tissue disorders, and
What are the symptoms?
Women with mild prolapse discovered during a routine pelvic exam may
have no symptoms at all. But others experience considerable discomfort
and a range of symptoms, including:
Pressure and pain. The most common complaints
are a feeling of pelvic pressure, or bearing down, leg fatigue, and low
Urinary symptoms. Cystocele, urethrocele,
and uterine prolapse can cause stress incontinence and difficulty in
starting to urinate.
Bowel symptoms. A rectocele may cause problems
with defecation by forming a pocket just above the anal sphincter. Stool
can become trapped, causing pain, pressure, and constipation.
Sexual problems. A prolapse can cause irritated
vaginal tissues or pain during intercourse, as well as psychological
If you think you have a pelvic prolapse condition, see your primary
care provider or gynecologist. A traditional pelvic examination is the
only way to diagnose it.
Women with no or very mild symptoms don’t need treatment, although
they should avoid anything that might worsen the prolapse. Losing weight
if necessary, avoiding lifting heavy objects, and quitting smoking all
prevent prolapses from progressing. Prolapse doesn’t necessarily
worsen over time, so there’s no need to seek aggressive treatments,
unless your symptoms are really bothersome.
If you’re experiencing major discomfort or inconvenience, surgery
is the only definitive way to relieve symptoms and improve your quality
of life (see “Surgical treatment,” below). But if your symptoms
are mild or you want to delay or avoid surgery, less invasive treatments
Kegel exercises. A woman with prolapse but
no symptoms may be urged to practice Kegel exercises to reduce the chance
that her condition will progress. Kegel exercises are a series of contractions
that strengthen the pelvic floor. You squeeze two sets of pelvic floor
muscles at the same time: those you would use to prevent yourself from
passing gas and those you would tighten to stop urinating. Avoid contracting
your stomach muscles.
Try to do 30–40 pelvic contractions each day; you may want to
divide them into three or four groups of 10 each, spread throughout the
day. Squeeze and hold the contraction for 3–5 seconds; then rest
for the same length of time. Build up to 10-second contractions, with
10 seconds of rest in between.
Pessary . For women who aren’t good
surgical candidates or want to delay surgery (perhaps if planning to
have more children), one alternative is a vaginal pessary — a device
similar to a diaphragm or cervical cap that’s inserted in the vagina
to help support the pelvic area (see illustration).
Before undergoing surgical repair of a prolapse, you’ll need
to have a thorough pelvic exam, to ensure that all problems have been
identified. Be sure your surgeon has expertise in the field of pelvic
reconstruction, as new procedures and anatomical knowledge have led to
Surgical techniques. Pelvic reconstruction
surgery may be performed through the vagina or abdominally; both procedures
are equally effective. A newer option is laparoscopic surgery, in which
repairs are made with instruments, including a camera, inserted through
a few tiny abdominal incisions. The prolapsed organ will be repositioned
and secured with stitches to the surrounding tissues and ligaments. The
vaginal defect will be repaired, sometimes using a piece of synthetic
material, called a graft. Women can usually leave the hospital within
one to three days.
Complications. Possible complications of pelvic
reconstructive surgery include urinary tract infection, temporary or
permanent incontinence, infection, bleeding, and — rarely — damage
to the urinary tract that requires additional corrective surgery. Some
women may develop chronic irritation or pain during intercourse from
a suture or scar tissue.
There’s also a risk of recurrence, which seems to be highest for
cystocele and lowest for rectocele. Fortunately, recurrence rates are dropping
as surgical techniques and preoperative planning improve. The chance of
recurrence will also be reduced if a woman avoids stress, such as heavy
lifting or straining during a bowel movement, and performs Kegel exercises
regularly before and after surgery.
August 2005 Update
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