Prevalence and Effects of Pelvic Organ Prolapse

The true prevalence of pelvic organ prolapse (POP) is not known, this is partially because POP is an under-reported condition. Barriers to seeking treatment include embarrassment, lack of awareness of effective treatments and feeling that POP is a normal part of ageing and to be accepted [1].

It is estimated that up to half of all women who have had children may be affected by a degree of POP [2–5]. Large, well-designed epidemiological studies have consistently demonstrated the prevalence at rates of around 50% [2–5]. In older parous women (aged over 68 years) up to 97% have been demonstrated to have prolapse on clinical examination [5]. There is, however, a large difference between the number of women objectively demonstrated to have POP on clinical examination and those who experience bothersome symptoms. It have been shown that POP when defined by symptoms may have a prevalence as a low as 6% [6].

The lifetime risk of surgery for prolapse in women was been shown to be around 11–12% [7, 8] and these numbers have been quoted in many studies. However, more recent studies have suggested that by the time women reach their ninth decade, rates of up to 19% in Australia [9] and 20% in the United States have been reported [10]. Despite heterogeneity in these types of studies, including different patient populations, indications for surgery and type of healthcare system, this still makes POP one of the most common indications for surgery in women.

Symptomatic pelvic organ prolapse has been demonstrated to have a significant impact on quality of life [11, 12], as it can impair both physical and social activities, as well as impacting on relationships and sexual function [13, 14].

Women with POP may reduce physical activities as a result of prolapse symptoms, or for fear that such activity may cause the POP to worsen or progress. POP may contribute to social isolation and withdrawal from physical exercise.

The relationship between prolapse and sexual function is now well understood. Both women and their partners have been shown to avoid sexual activity due to POP. Affected women may be aware of ‘something coming down’ or ‘in the way’ during sex as well as reduced sensation and reduced overall satisfaction with sex. A large systematic review showed that sexual function generally improves following prolapse surgery [15].

The relationship between prolapse and body image is a newer area of research. Prolapse has been shown to impact negatively on body image in a number of studies [12, 16–18] and prolapse surgery has been shown to improve body image [19].

Assessments of the impact of prolapse symptoms on quality of life, sexual function and body image are important in the evaluation of women with POP.

Aetiology of Pelvic Organ Prolapse

A simple understanding of functional pelvic anatomy is useful for understanding both the aetiology and pathophysiology of POP.

The principal cause of pelvic organ prolapse is damage to the endopelvic fascia, pelvic floor muscles or ligamentous supports of the uterus. Primary damage usually happens to these support structures during pregnancy and childbirth, both through stretching and distension due to the mass effect of pregnancy and the trauma of delivery. Perineal trauma can result in injury of the endopelvic fascia, levator ani muscles and their insertions. Studies using MRI and 3D ultrasound have helped to establish the relationship between levator ani defects, including avulsion, and pelvic organ prolapse, but this remains an understudied area [21]. Significant perineal trauma including third and fourth degree perineal tears, shoulder dystocia and large birth weight are all shown to be independent risk factors for pelvic organ prolapse [22]. Studies showing that caesarean section is protective against pelvic organ prolapse also support parturition being the leading risk factor for development of pelvic organ prolapse [4].

The other primary cause of POP is connective tissue disorders, including Ehlers-Danlos and Marfan’s syndromes. These conditions affect the strength of the structures involved in pelvic organ support and often lead to development of pelvic organ prolapse at a younger age, or when pregnancy has not occurred. POP in a patient who is nulliparous and has normal connective tissue is, however, unusual.

Following initial damage to the supports of the pelvic organs following childbirth or due to connective tissue disorders, increasing age is the best-evidenced risk factor for POP, which has been shown to approximately double with each decade of life [23].

The mechanism for this is thought to be increased laxity and weakness in the pelvic ligaments and musculature. The hypo-oestrogenic environment of the menopause is also likely to be a risk factor for the development of POP, though evidence is conflicting and hormone replacement therapy has not been shown to be protective against POP [24].

Finally, any condition which causes a continual or regular increase in intra-abdominal pressure may contribute to the development of pelvic organ prolapse. This is due to direct pressure on the pelvic floor exacerbating damage caused by childbirth, connective tissue disease or ageing. Obesity, chronic constipation, heavy lifting and chronic cough are all risk factors. Occupations which require frequent heavy lifting or exercise regimes involving heavy weight lifting are known causes. Further lifestyle risk factors include smoking and low socioeconomic status [22]. It has been shown that regular low-impact physical exercise is protective against pelvic organ prolapse [25].

Anatomical Classification of Pelvic Organ Prolapse

POP can involve the anterior, apical or posterior compartments of the vagina (Table 29.2). Anterior compartment prolapse involves urethra and bladder and is termed cystourethrocoele. The posterior compartment involves the rectum and the small bowel causing a rectoenterocoele (Fig. 29.1). Apical compartment prolapse is the descent of the uterus downwards into the vagina. The uterus may be absent following previous hysterectomy, in which case the vaginal cuff forms the apical portion. When this descends into the vagina this is termed vault prolapse.

Table 29.2

Types of pelvic organ prolapse

Anterior compartment

• Urethrocoele- prolapse of the urethra into the vagina

• Cystocoele- prolapse of the bladder into the vagina

• Cystourethrocoele- prolapse of both urethra and bladder into the vagina

Apical compartment

• Uterine prolapse- descent of the uterus and cervix into the vagina

• Vaginal vault prolapse- following hysterectomy, descent of the vaginal cuff scar into the vagina

Posterior compartment

• Enterocoele- prolapse of the Pouch of Douglas containing small bowel (ileum) into the vagina

• Rectocoele- prolapse of the rectum into the vagina

Anterior compartment prolapse is most common, followed by uterine prolapse and posterior compartment prolapse. In the Women’s Health Initiative study, of the 41% of women aged between 50–79 years who had POP; 34% had a cystocoele, 19% had a rectocoele and there was uterine prolapse in 14% [2].

Symptoms of Pelvic Organ Prolapse

POP is often asymptomatic and may be an incidental finding, for example at smear testing or cystoscopy. Symptoms of POP depend on the anatomical site of the prolapse, with different symptoms for anterior compartment POP (bladder) compared to posterior compartment prolapse (rectum). As POP causes symptoms which are embarrassing or taboo in nature, woman may not readily disclose these symptoms during a consultation [26]. Therefore, the use of patient reported outcome measures to assess patient’s symptoms and concerns is invaluable to helping to accurately ascertain the patient’s symptom profile [27–30].

Examination and Classification of Pelvic Organ Prolapse

If a woman presents to a urologist with lower urinary tract symptoms or haematuria which are through to be related to POP, or if a prolapse is found on clinical examination, the patient should be referred for urogynaecological review.

The purpose of examination in a woman with POP symptoms is to assess for the presence of prolapse, assess which compartment(s) are affected and to assess the stage of the prolapse and the strength of the pelvic floor muscles. All of these findings will, along with the woman’s symptom profile, direct the management strategy.

In order to assess POP, initial examination should be undertaken with the woman supine with legs flexed. Firstly, the perineum should be inspected and signs of oestrogen deficiency, such as thin, dry or inflamed skin noted. In order to demonstrate the prolapse, the woman should be asked to cough hard and to strain or ‘bear down’. Reproducing prolapse in a clinical environment can be challenging and examination may be usefully carried out with the patient standing if an obvious prolapse cannot be demonstrated supine. During this assessment, leakage of urine on coughing/straining may also be noted. Treatment should be aimed at dealing with the symptoms the patient finds to be most bothersome; again, the use of self -completed validated questionnaires may be of value in this context.

Usually the woman is then examined in the left lateral position using a Sims’ speculum to visualise the anterior and posterior vaginal walls separately (Fig. 29.2). It is helpful to have a chaperone to support the patients right leg to aid visualisation of the anterior and posterior vaginal compartments. A Sims’ speculum is used for this. Both metal and single use plastic Sims’ speculums are available. Sim’s speculum is inserted along the posterior wall to assess anterior compartment prolapse and along the anterior wall to assess posterior compartment prolapse. Sponge holding forceps are long round ended forceps, which can be utilised to gently reduce anterior or posterior compartment prolapse to effectively visualise the cervix or vaginal cuff in order to assess descent of the apex (Fig. 29.2). Grasping the cervix or vaginal cuff with a pair of toothed tenaculum forceps is another way to demonstrate prolapse descent, but can cause discomfort and should be undertaken with consent and caution (Fig. 29.2).

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