Vaginal prolapse

Summary

Pelvic organ prolapse (POP) is the downward displacement of pelvic organs due to weakened pelvic floor support, often from childbirth, aging, or chronic strain. Symptoms include vaginal bulge, pelvic pressure, and urinary or bowel issues. Diagnosis is clinical using the POP-Q system. Management includes pelvic floor exercises, pessaries, or surgery, depending on severity. Complications may involve incontinence, infections, and sexual dysfunction.

Definition

Pelvic organ prolapse (POP) is defined as the descent or herniation of pelvic organs (such as the bladder, uterus, rectum, or vaginal apex) through or beyond the vaginal walls due to weakening of the pelvic floor muscles, fascia, and ligaments. This condition ranges from partial prolapse, where organs remain within the vagina, to total prolapse (procidentia), where the uterus and vaginal walls protrude outside the vaginal introitus.

Anatomy and Pathophysiology

The pelvic floor comprises muscles (e.g., levator ani), ligaments (e.g., uterosacral and cardinal ligaments), and fascia (e.g., pubocervical and rectovaginal fascia) that support the pelvic viscera. Damage or weakening of these structures, often related to childbirth or chronic strain, leads to prolapse.

Common Prolapse Types:

Etiology and Risk Factors

The primary etiology is pelvic floor insufficiency from muscular or connective tissue injury. Risk factors include:

• Vaginal childbirth (especially high parity or traumatic delivery)

• Advanced age and menopause

• Hypoestrogenism

• Obesity, chronic cough, constipation

• Prior pelvic surgery (e.g., hysterectomy)

• Genetic connective tissue disorders (e.g., Ehlers-Danlos syndrome)

• Diabetes mellitus

Clinical Presentation

Patients may present with:

• Pelvic pressure or a sensation of vaginal fullness

• Visible or palpable vaginal bulge

• Urinary symptoms: frequency, urgency, incontinence, retention

• Bowel symptoms: constipation, incomplete evacuation

• Sexual dysfunction: dyspareunia

• Lower back or pelvic pain, worsened with prolonged standing

Diagnosis

POP is diagnosed clinically via pelvic examination:

• Inspection and Valsalva maneuver to assess for bulging

• Speculum exam: assess anterior/posterior walls and vaginal apex

• Bimanual exam: evaluate pelvic floor strength

• Staging (POP-Q system):
  

Management

Conservative Management (first-line, especially for mild/asymptomatic cases):

• Pelvic floor muscle training (e.g., Kegel exercises)

• Lifestyle changes: weight loss, smoking cessation, manage constipation

• Vaginal estrogen for postmenopausal women

• Vaginal pessaries: silicone/latex devices that support pelvic organs

• Requires regular cleaning

• Contraindicated in dementia, pelvic pain, or poor follow-up compliance

Surgical Management (for symptomatic or refractory cases):

• Uterine-preserving options: uterine suspension (hysteropexy)

• Obliterative procedures: colpocleisis (for non-sexually active women)

• Mesh repair is now discouraged due to risk of erosion, infection, and pain

Complications

• Urinary: incontinence (including "unmasked" post-repair), retention, infections

• Bowel: fecal incontinence, obstructive defecation

• Local: pressure ulcers, mucosal breakdown, bleeding

• Sexual: dyspareunia

• Infections: cystitis, pyelonephritis, endometritis, salpingitis