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pelvic organ prolapse

Classification: - first degree: extension to the mid vagina - second degree: approaching the hymenal ring - third degree: at the hymenal ring - fourth degree: beyond the hymenal ring Epidemiology: - common in postmenopausal women Physical examination: - pelvic examination - pelvic organ prolapse can only be demonstrated in the supine position if the patient can generate adequate intra-abdominal pressure - examination in the standing position if patient cannot generate adequate intra-abdominal pressure [3] Clinical manifestations: 1) commonly occurs in association with stress urinary incontinence 2) prolapse may wax & wane 3) over a period of 4 years, maximal vaginal descent - increases by >= 2 cm in 11% - decreases by >= 2 cm in 3% 4) increasing body-mass index & history of >= 5 vaginal deliveries increases risk for progression of prolapse 5) lower abdominal or pelvic tenderness, heaviness, pressure may be noted 6) dyspareunia 7) retroflexed uterus Complications: - complications of mesh surgical repair [2] a) most frequent complications 1] erosion through vaginal epithelium 2] infection 3] pain 4] urinary problems 5] recurrence of prolapse and/or incontinence b) other complications 1] bowel, bladder, and blood vessel perforation during insertion 2] vaginal scarring & mesh erosion Management: - pelvic floor muscle training (Kegel exercises) may be useful for mild cases [9] - unclear role in managing uterine prolapse (NEJM) [17] - vaginal pessary [15] a) addition of vaginal pessary more effective than Kegel exercises alone [11] b) other indications - patient does not want surgery - need to delay surgery - patient is poor surgical candidate [3] c) twice weekly vaginal estrogen also recommended [15] d) initial strategy of pessary therapy inferior to surgery for improvement at 24 months [16] - surgical repair - avoid pelvic mesh procedures [2,7,8,10] - failure rate of surgical repair increases over time [4] - not much benefit at 7 years

Specific

cystocele; vesicocele; bladder prolapse; anterior prolapse prolapse of the uterus; cervical incompetence; pudendal hernia rectocele; proctocele; rectal procidentia

General

prolapse; procidentia pelvic floor disorder gynecologic disease

References

  1. Bradley CS, Zimmerman MB, Qi Y, Nygaard IE. Natural history of pelvic organ prolapse in postmenopausal women. Obstet Gynecol. 2007 Apr;109(4):848-54. PMID: 17400845
  2. FDA MedWatch Transvaginal Placement of Surgical Mesh http://www.fda.gov/medwatch/safety/2008/safety08.htm#Mesh - FDA NEWS RELEASE: July 13, 2011 FDA: Surgical placement of mesh to repair pelvic organ prolapse poses risks http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm262752.htm
  3. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  4. Nygaard I et al Long-term Outcomes Following Abdominal Sacrocolpopexy for Pelvic Organ Prolapse. JAMA. 2013;309(19):2016-2024. PMID: 23677313 http://jama.jamanetwork.com/article.aspx?articleid=1687577 - Iglesia CB Pelvic Organ Prolapse Surgery. Long-term Outcomes and Implications for Shared Decision Making. JAMA. 2013;309(19):2045-2046 PMID: 23677317 http://jama.jamanetwork.com/article.aspx?articleid=1687565
  5. Kuncharapu I, Majeroni BA, Johnson DW. Pelvic organ prolapse. Am Fam Physician. 2010 May 1;81(9):1111-7. PMID: 20433127
  6. Miedel A, Tegerstedt G, Morlin B, Hammarstrom M A 5-year prospective follow-up study of vaginal surgery for pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2008 Dec;19(12):1593-601 PMID: 18696002
  7. FDA News Release: April 29, 2014 FDA issues proposals to address risks associated with surgical mesh for transvaginal repair of pelvic organ prolapse. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm395192.htm
  8. Maher CM, Feiner B, Baessler K, Glazener CM. Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review. Int Urogynecol J. 2011 Nov;22(11):1445-57 PMID: 21927941
  9. Wiegersma M et al. Effect of pelvic floor muscle training compared with watchful waiting in older women with symptomatic mild pelvic organ prolapse: Randomised controlled trials in primary care. BMJ 2014 Dec 22; 349:g7378 PMID: 25533442 http://www.bmj.com/content/349/bmj.g7378
  10. FDA News Release. January 4, 2016 FDA strengthens requirements for surgical mesh for the transvaginal repair of pelvic organ prolapse to address safety risks. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm479732.htm
  11. Cheung RY, Lee JH, Lee LL, Chung TK, Chan SS. Vaginal pessary in women with symptomatic pelvic organ prolapse: A randomized controlled trial. Obstet Gynecol 2016 Jun 6 PMID: 27275798
  12. Hagen S et al. Pelvic floor muscle training for secondary prevention of pelvic organ prolapse (PREVPROL): A multicentre randomised controlled trial. Lancet 2016 Dec 20 PMID: 28010994 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32109-2/abstract - Dekker JH. Pelvic organ prolapse: Prevention by training? Lancet 2016 Dec 20 PMID: 28010990 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32108-0/abstract
  13. Glazener CM, Breeman S, Elders A et al. Mesh, graft, or standard repair for women having primary transvaginal anterior or posterior compartment prolapse surgery: Two parallel-group, multicentre, randomised, controlled trials (PROSPECT). Lancet 2016 Dec 20 PMID: 28010989 Free Article http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31596-3/abstract - Brincat C, Brubaker L. Mesh, graft, or standard repair for prolapse surgery? Lancet 2016 Dec 20 PMID: 28010987 Free Article http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32595-8/abstract
  14. Morling JR, McAllister DA, Agur W et al. Adverse events after first, single, mesh and non-mesh surgical procedures for stress urinary incontinence and pelvic organ prolapse in Scotland, 1997-2016: A population- based cohort study. Lancet 2016 Dec 20; PMID: 28010993 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32572-7/abstract - McAchran SE, Goldman HB. Synthetic midurethral slings redeemed. Lancet 2016 Dec 20 PMID: 28010988 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32597-1/abstract
  15. Gold RS, Baruch Y, Amir H et al. A tailored flexible vaginal pessary treatment for pelvic organ prolapse in older women. J Am Geriatr Soc 2021 Sep; 69:2518. PMID: 33979457 https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17223
  16. Thomas A Findings Question Value of Pessary for Pelvic Organ Prolapse. Medscape. January 03, 2023 https://www.medscape.com/viewarticle/986430 - van der Vaart LR, Vollebregt A, Milani AL et al Effect of Pessary vs Surgery on Patient-Reported Improvement in Patients With Symptomatic Pelvic Organ Prolapse. A Randomized Clinical Trial. JAMA. 2022;328(23):2312-2323. PMID: 36538310 https://jamanetwork.com/journals/jama/article-abstract/2799654
  17. NEJM Knowledge+ No authors listed Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214. Obstet Gynecol. 2019 Nov;134(5):e126-e142 PMID: 31651832 - Doshani A, Teo RE, Mayne CJ, Tincello DG. Uterine prolapse. BMJ. 2007 Oct 20;335(7624):819-23. PMID: 17947787 PMCID: PMC2034734 Free PMC article. Review.