Pelvic Organ Prolapse (POP)

What is POP?
Pelvic organ prolapse (POP) is a condition where the muscles and tissues supporting the pelvic organs weaken or become damaged, causing one or more organs to descend from their normal position and bulge into or outside of the vaginal canal. This condition primarily affects women, especially as they age.

How Common is it?
POP is very common, especially among older women. Around 1 in 10 women over the age of 50 will experience symptoms of pelvic organ prolapse, and by the age of 80, more than 1 in 10 women will have undergone surgery for prolapse.

Causes of POP
The causes of POP can vary but often include factors such as pregnancy, childbirth, aging, hysterectomy, obesity, chronic straining activities like heavy lifting or chronic coughing, connective tissue diseases, and genetic predisposition.

Various Causes of Pelvic Organ Prolapse (POP):

⦁ Pregnancy and childbirth
⦁ Age and menopause: Lowered estrogen levels can weaken pelvic floor muscles
⦁ Hysterectomy
⦁ Overweight
⦁ Chronic straining activities: Chronic coughing, heavy lifting, or constipation
⦁ Connective tissue diseases
⦁ Genetics

Types of Prolapse:

1.Cystocele (Bladder Prolapse)
Bladder descends into the front wall of the vagina, causing bulge or pressure sensation.
⦁ Symptoms: Urinary symptoms such as frequent urination or urinary incontinence may occur.

2.Rectocele (Rectal Prolapse)
Rectum bulges into the back wall of the vagina.
⦁ Symptoms: Bowel movement difficulties, constipation, or discomfort in the rectal area.

3. Womb Prolapse
Uterus descends downward into the vagina, protruding outside the vaginal opening.
⦁ Symptoms: Sensation of heaviness or dragging in the pelvis, urinary or bowel symptoms.

4. Enterocele (Small Bowel Prolapse)
Small bowel protrudes into the space between the back passage and the vagina.
⦁ Symptoms: Feeling of pressure or fullness in the lower belly, discomfort during sexual intercourse or bowel movements.

5. Vaginal Vault Prolapse
Descent of the top of the vagina after hysterectomy.
⦁ Symptoms: Bulge or protrusion in the vaginal area, urinary or bowel symptoms.

Staging of Prolapse:
The POP-Q system includes 8 or 9 different measurements and 5 stages to classify the extent of pelvic organ prolapse. Here’s how it’s conducted:
⦁ Examination Position: The patient is examined lying on her left side or back with a Sims speculum, gently inserted into the vagina to hold it open. The patient is then asked to cough.
⦁ Measurement: Ruler measurements are taken in both positions, with and without the speculum, to assess the extent of the prolapse. Patients are then asked to strain while standing to see how far any prolapse extends.
⦁ Identified Points: Six points are identified in the vagina: Aa and Ba for the front, Ap and Bp for the back, and C and D for the neck of the womb or top of the vagina (if there is no womb).
Staging Criteria:
⦁ Stage 0: No prolapse.
⦁ Stage I: Prolapse more than 1 cm above the level of the hymen.
⦁ Stage II: Prolapse between 1 cm above and 1 cm below the hymen.
⦁ Stage III: Prolapse more than 1 cm below the hymen.
⦁ Stage IV: Complete everted prolapse or eversion within 2 cm of the total vaginal length.

The POP-Q classification system allows healthcare providers to accurately assess and monitor pelvic organ prolapse, guide treatment decisions, and communicate effectively with patients about their condition. It provides a standardized framework for evaluating the severity and extent of prolapse, which is essential for optimal management and outcomes.

Diagnosis of POP:
⦁ Clinical examination including internal examination using a speculum.
⦁ Assessment of pelvic floor muscles strength.
⦁ Validated pelvic floor symptom questionnaire (⦁ PISQ-IR) may be used.
⦁ Imaging tests may not be necessary but could be used if needed.

Treatment Options for Pelvic Organ Prolapse:
Non-Surgical Options:
⦁ No Treatment: Some women may choose not to undergo any treatment.
⦁ Lifestyle Modification: Suggestions include losing weight, avoiding heavy lifting, and managing constipation to alleviate symptoms.
⦁ Topical Estrogen: Vaginal estrogen is considered for women with signs of vaginal dryness and thinning. An estrogen-releasing ring may be an option for those with difficulties using vaginal estrogen creams or pessaries.
IUGA – Pelvic Floor Exercises⦁ Pelvic Floor Muscle Training: A supervised pelvic floor muscle training program is recommended for at least 16 weeks for women with symptomatic pelvic organ prolapse of stage 1 or stage 2 according to POP-Q classification.
⦁ Pessaries: A vaginal pessary, typically made of medical-grade silicone or plastic, is inserted into the vagina by a professional to provide support for pelvic organs.
⦁ Considerations before starting pessary treatment include treating vaginal dryness with topical estrogen, understanding potential complications, and advising removal of the pessary every 6 months.
⦁ Image: Different types of pessaries by Madhero88 • CC BY-SA 3.0 via Wikimedia Commons.
Follow-up Care: We offer women using pessaries appointments in a pessary clinic every 6 months, especially if they are at risk of complications due to physical or cognitive impairments that may affect ongoing pessary care.

Surgical Management:
⦁ Surgery is offered to women whose symptoms persist despite non-surgical treatment or who choose surgery.
⦁ Shared Decision Making:
⦁ Patient decision aid (pdf) (NICE) is used to help women understand treatment options, including risks and benefits.
⦁ Discussions include different treatment options, benefits and risks of each surgical procedure, uncertainties about long-term effects, and the role of intraoperative prolapse assessment.
⦁ Surgery for Uterine Prolapse:
⦁ Surgical options include hysterectomy or procedures that preserve the uterus.
⦁ Links to⦁ ⦁ Vaginal hysterectomy and⦁ ⦁ Operations.
⦁ Surgery for Vault Prolapse:
⦁ Treatment options include vaginal surgery or keyhole surgery with or without mesh.

Decision aid
⦁ Links to⦁ ⦁ Vaginal conservative surgery and⦁ ⦁ Key hole surgery.
⦁ Surgery for Anterior or Bladder Prolapse and Posterior or Bowel Prolapse:
⦁ Surgical operation (anterior or posterior repair) is offered to correct the prolapse without using mesh.
⦁ Links to⦁ ⦁ Anterior repair and⦁ ⦁ Posterior repair.

Recovery after surgery
Risks and Complications of Surgery:
⦁ Common Risks: Bleeding, infection, pain during intercourse, return of the prolapse after surgery, and urinary problems.
⦁ Uncommon Risks: Damage to the bladder or bowel, development of a clot in the legs or lungs, and pelvic abscess.
⦁ Complications of Surgery for Vault Prolapse: Risk of prolapse recurrence, pain during sex, urinary problems, constipation, and mesh-related complications.
⦁ Follow-up after Surgery:
⦁ Follow-up appointment six months later, including an intimate examination and checking for any signs of mesh exposure.
⦁ Recurrence of Prolapse:
⦁ About 25 to 30 out of 100 women who undergo surgery for prolapse may experience another prolapse in the future.
⦁ Surgery for Women with Both Stress Urinary Incontinence and Pelvic Organ Prolapse:
⦁ Combined surgery may be suggested, considering the uncertainty about the long-term effectiveness and risks involved.
⦁ Mesh Surgery:
⦁ Assessment of new symptoms after mesh surgery and discussion of potential complications and treatments.

Symptoms and Diagnosis
Symptoms of POP can include a sensation of pressure or fullness in the lower belly, bulging or protrusion in the vaginal area, discomfort during sexual intercourse, backache, and urinary or bowel symptoms. Diagnosis involves a thorough medical history, physical examination, and possibly a pelvic floor symptom questionnaire.

Risks and Complications
Common risks associated with surgery include bleeding, infection, pain during intercourse, and recurrence of prolapse. Mesh-related complications may occur in some cases, necessitating careful monitoring and management.

Follow-up and Support
Regular follow-up appointments are recommended after surgery to monitor progress and address any complications. Patients are provided with information and support resources to facilitate their recovery and manage any recurrent symptoms.

References
⦁ Royal College of Obstetricians & Gynaecologists (RCOG) – Patient Information Leaflet:⦁ ⦁ Pelvic Organ Prolapse
⦁ National Institute for Health and Care Excellence (NICE) Guideline [NG123]:⦁ ⦁ Urinary incontinence and pelvic organ prolapse in women: management
⦁ POP Q staging taken from the AUGS website
⦁ Information Leaflets from British Society of Urogynaecology (BSUG)
Vaginal Hysterectomy for Uterine Prolapse
Operations to Treat Uterine Prolapse
⦁ SHP BSUG
SSF BSUG
Colpocleisis BSUG
Anterior Repair BSUG
Posterior Repair BSUG
⦁ International Urogynecological Association (IUGA) – Pelvic Floor Exercises Information (⦁ YourPelvicFloor.org)
⦁ Patient Information Leaflets from Patient.info (⦁ Patient.info)
⦁ British Society of Urogynaecology (BSUG) Patient Information Leaflets (⦁ BSUG Patient Information Leaflets)