Pelvic organ prolapse

Background

• Definition: herniation of pelvic organs to or beyond vaginal walls

Risk Factors

• Advancing Age
• Multiparity
• Obesity
• Race: Latina + Caucasian Women higher risk than African American Women
• Constipation
• Connective Tissue Disorders
• Chronic Cough

Clinical Features

• Severity may be related to position
  • Less noticeable in AM and supine
  • Worse as day progresses, upright, and active
• Vaginal Bulge/Fullness
• Vaginal Pressure
• Urinary Dysfunction
  • Overactive bladder symptoms
  • Urgency
  • Urinary incontinence
  • Enuresis
    
• 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

Differential Diagnosis

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

Evaluation

• Clinical diagnosis

Management

Emergency Room

• 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

Outpatient

Treatment includes:

• Expectant management
• Conservative (vaginal pessary, pelvic floor muscle exercises)
• Surgical

Disposition

• Discharge with outpatient Gynecology referral

See Also

• Rectal Prolapse

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