Pelvic organ prolapse: Difference between revisions
 
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==Background==
==Background==
[[File:Blausen 0732 PID-Sites.png|thumb|Pelvic anatomy.]]
*Definition: herniation of pelvic organs to or beyond vaginal walls
*Definition: herniation of pelvic organs to or beyond vaginal walls
*First Degree: Lowering of cervix into lower 1/3 of vagina
*Second Degree: Protrusion of cervix through the vaginal introitus
*Third Degree: Complete externalization of the uterus and inversion of the vagina (also called descensus or procidentia)


===Risk Factors===
===Risk Factors===
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* Multiparity
* Multiparity
* Obesity
* Obesity
* Race: Latina + Caucasian Women higher risk than African American Women
* Race (Latina/white women at higher risk than black women)
* [[Constipation]]
* [[Constipation]]
* Connective Tissue Disorders
* [[Connective tissue disorder]]s
* Chronic [[Cough]]
* Chronic [[Cough]]
* Heavy lifting


===Types===
===Types===
*Cystocele
*Cystocele
** Most common form of pelvic organ prolapse
**Most common form of pelvic organ prolapse
** Hernia of anterior vaginal wall + descent of bladder
**Hernia of anterior vaginal wall + descent of bladder
*Rectocele
*Rectocele
** Hernia of posterior vaginal segment + descent of rectum
**Hernia of posterior vaginal segment + descent of rectum
*Enterocele
*Enterocele
** Hernia of intestines to or through vaginal wall
**Hernia of intestines to or through vaginal wall
*Uterine/Vaginal Vault Prolapse
*Uterine/vaginal vault prolapse
** Descent of apex of vagina to lower vagina, hymen, or beyond introitus
**Descent of apex of vagina to lower vagina, hymen, or beyond introitus
** Apex= uterus and cervix, cervix, or vaginal vault
**Apex= uterus and cervix, cervix, or vaginal vault
** Apical prolapse often associated with enterocele
**Apical prolapse often associated with enterocele
*Urethral Prolapse
**Postmenopausal and prepubescent females


==Clinical Features==
==Clinical Features==
[[File:PMC3180421 1752-1947-5-459-2.png|thumb|Total uterine prolapse.]]
[[File:PMC5350386 CRIOG2017-1640614.001.png|thumb|Uterine prolapse.]]
*Severity may be related to position
*Severity may be related to position
** Less noticeable in AM and supine
**Less noticeable in AM and supine
** Worse as day progresses, upright, and active
**Worse as day progresses, upright, and active
*Vaginal Bulge/Fullness
*Vaginal bulge/fullness, pressure
*Vaginal Pressure
*Urinary dysfunction
*Urinary Dysfunction
**Overactive bladder symptoms  
**Overactive bladder symptoms  
**Urgency
**Urgency
**Urinary incontinence
**[[Urinary incontinence]]
**Enuresis<br>
**Enuresis
*Defecatory Dysfunction
*Defecatory dysfunction
**[[Constipation]]
**[[Constipation]]
**Incomplete emptying
**Incomplete emptying
**Fecal urgency
**Fecal urgency
**Fecal incontinence
**Fecal incontinence
**Obstructive symptoms- Straining or need for digital pressure to vagina in order to completely evacuate<br>
**Obstructive symptoms- straining or need for digital pressure to vagina in order to completely evacuate<br>
*Sexual Dysfunction
*Sexual dysfunction
**Reports of adverse effects or orgasm and sexual satisfaction
**Reports of adverse effects or orgasm and sexual satisfaction
**Dyspareunia
**Dyspareunia
**Avoidance of sexual activity due to fear of discomfort or embarrassment
**Avoidance of sexual activity due to fear of discomfort or embarrassment
*Urethral prolapse
**pain with unination
**blood in diaper or underwear
**tenderness while wiping


==Differential Diagnosis==
==Differential Diagnosis==
{{Postmenopausal Pelvic Pain DDX}}
{{Postmenopausal Pelvic Pain DDX}}
{{Prepubescent Urethral Prolapse}}


==Evaluation==
==Evaluation==
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==Management==
==Management==
===Emergency Room===
===Emergency Department===
*Look for signs of infection or skin breakdown if prolonged prolapse
*Look for signs of infection or skin breakdown if prolonged prolapse
*Reduction may be as simple as pushing organ back inside
*Reduction may be as simple as pushing organ back inside
*If difficult reduction due to edema
*If difficult reduction due to edema:
** Provide analgesia, and place copious granulated sugar
**Provide [[analgesia]], and place copious granulated sugar
** Wait 15 minutes for edema to subside and re-attempt reduction
**Wait 15 minutes for edema to subside and re-attempt reduction
** If reduction fails, consult Gynecology
**If reduction fails, consult gynecology
**Saline-soaked gauze applied to prolapsed organs could provide both comfort and protection of exposed mucosa
*For urethral prolapse:
**Topical estrogen twice daily (0.01%)
**Sitz baths
**Consult urology if concern for necrosis of tissue


===Outpatient===
===Outpatient===
Treatment includes:
Treatment includes:
* Expectant management
*Expectant management
* Conservative (vaginal pessary, pelvic floor muscle exercises)
*Conservative (vaginal pessary, pelvic floor muscle exercises)
* Surgical
*Estrogen creams and Sitz baths (Urethral Prolapse)
*Surgical


==Disposition==
==Disposition==
*Discharge with outpatient Gynecology referral
*Discharge with outpatient Gynecology or Urology referral


==See Also==
==See Also==

Latest revision as of 17:43, 28 April 2024

Background

Pelvic anatomy.
  • Definition: herniation of pelvic organs to or beyond vaginal walls
  • First Degree: Lowering of cervix into lower 1/3 of vagina
  • Second Degree: Protrusion of cervix through the vaginal introitus
  • Third Degree: Complete externalization of the uterus and inversion of the vagina (also called descensus or procidentia)

Risk Factors

Types

  • Cystocele
    • Most common form of pelvic organ prolapse
    • Hernia of anterior vaginal wall + descent of bladder
  • Rectocele
    • Hernia of posterior vaginal segment + descent of rectum
  • Enterocele
    • Hernia of intestines to or through vaginal wall
  • Uterine/vaginal vault prolapse
    • Descent of apex of vagina to lower vagina, hymen, or beyond introitus
    • Apex= uterus and cervix, cervix, or vaginal vault
    • Apical prolapse often associated with enterocele
  • Urethral Prolapse
    • Postmenopausal and prepubescent females

Clinical Features

Total uterine prolapse.
Uterine prolapse.
  • Severity may be related to position
    • Less noticeable in AM and supine
    • Worse as day progresses, upright, and active
  • Vaginal bulge/fullness, pressure
  • Urinary dysfunction
  • Defecatory dysfunction
    • Constipation
    • Incomplete emptying
    • Fecal urgency
    • Fecal incontinence
    • Obstructive symptoms- straining or need for digital pressure to vagina in order to completely evacuate
  • Sexual dysfunction
    • Reports of adverse effects or orgasm and sexual satisfaction
    • Dyspareunia
    • Avoidance of sexual activity due to fear of discomfort or embarrassment
  • Urethral prolapse
    • pain with unination
    • blood in diaper or underwear
    • tenderness while wiping

Differential Diagnosis

Postmenopausal Pelvic Pain

Gynecologic

Gastrointestinal

Urologic

Prepubescent-Urethral prolapse

Urologic

  • Sarcoma botryoides
  • sarcoma botryoides

Evaluation

  • Clinical diagnosis

Management

Emergency Department

  • Look for signs of infection or skin breakdown if prolonged prolapse
  • Reduction may be as simple as pushing organ back inside
  • If difficult reduction due to edema:
    • Provide analgesia, and place copious granulated sugar
    • Wait 15 minutes for edema to subside and re-attempt reduction
    • If reduction fails, consult gynecology
    • Saline-soaked gauze applied to prolapsed organs could provide both comfort and protection of exposed mucosa
  • For urethral prolapse:
    • Topical estrogen twice daily (0.01%)
    • Sitz baths
    • Consult urology if concern for necrosis of tissue

Outpatient

Treatment includes:

  • Expectant management
  • Conservative (vaginal pessary, pelvic floor muscle exercises)
  • Estrogen creams and Sitz baths (Urethral Prolapse)
  • Surgical

Disposition

  • Discharge with outpatient Gynecology or Urology referral

See Also

References

  • Rogers, RG, Fashokun, TB. Pelvic organ prolapse in women: Epidemiology, risk factors, clinical manifestations, and management. In: Post T, ed. UpToDate; Waltham, MA.: UpToDate; 2020. www.uptodate.com. Accessed June 16, 2020
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