Pelvic organ prolapse

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

• Advancing Age
• Multiparity
• Obesity
• Race (Latina/white women at higher risk than black women)
• Constipation
• Connective tissue disorders
• Chronic Cough
• Heavy lifting

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
  • 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
• Urethral prolapse
  • pain with unination
  • blood in diaper or underwear
  • tenderness while wiping

Differential Diagnosis

Postmenopausal Pelvic Pain

Gynecologic

• Vulvovaginitis
  • Atrophic vaginitis
  • Infectious (STI)
  • Allergic
• Uterine prolapse
  • Cystocele
  • Rectocele
  • Enterocele
  • Uterine/Vaginal Vault Prolapse
• Cervical polyps
• Uterine fibroids
• Endometrial hyperplasia
• Neoplasm
  • Uterine
  • Ovarian

Gastrointestinal

• Rectocele
• Diverticulitis
• Neoplasm
• Appendicitis
• Ischemic Bowel (Mesenteric Ischemia)

Urologic

• Infection
  • Cystitis
  • Urethritis
  • Pyelonephritis
• Cystourethrocele

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

• Rectal Prolapse
• Pelvic pain

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