PELVIC FLOOR DISORDERS
PELVIC ORGAN PROLAPSE
Pelvic organ prolapse (POP) is a condition caused by an extreme weakening of the pelvic floor muscles, leading to a dropping down of the pelvic organs, which are no longer properly supported by the muscles surrounding them. In some cases, the dropped organs may be felt as a protruding bulge (hernia) in the vagina. Prolapse of the pelvic organs is more common in older women (after menopause), after pregnancy, or after pelvic surgery (e.g. a total or partial hysterectomy). There are different types of POP, depending on the location of the prolapse, and the type of organ bulging into the vaginal space. For instance, a cystocele (anterior vaginal prolapse) occurs when the the front wall of the vagina is weakened, causing the bladder to drop into the vaginal canal. Similarly, a rectocele (posterior vaginal prolapse) occurs when the back wall of the vagina gives way to a protrusion of the rectum. In vaginal vault prolapse, the upper wall of the vagina (just below the cervix) collapse into the lower spaces of the vagina.
Risk Factors
The most important risk factors contributing to pelvic organ prolapse are age, hormone levels (after menopause, decreased estrogen levels can lead to a weakening of the muscles), number of pregnancies (especially vaginal births), and prior pelvic surgeries (such as hysterectomy, which also destabilize the pelvic area). Further, obesity and unhealthy lifestyle choices, such as lack of exercise (or excessive strain on the pelvic area such as from heavy lifting), unhealthy diet (leading to frequent constipation and strong pressing during bowel movements) or smoking can also increase the risk of pelvic organ prolapse.
Symptoms
Symptoms of pelvic organ prolapse include but are not limited to a noticeable bulge (hernia) in the vagina. Other common symptoms are pelvic pain and discomfort, a feeling of fullness (crowding) in the pelvis, difficulty with bowel movement and/or bladder control (constipation or incontinence), and painful urination.
Diagnosis
Thee are several ways to diagnose pelvic organ prolapse. These include discussing patient and family history with a healthcare provider (to check for any risk factors and symptoms) and performing a physical and/or vaginal exam. Moreover, imaging such as Magnetic Resonance Imaging (MRI) and ultrasound can be used to visualize and confirm any suspected vaginal protrusion. There are also external electrical tests, in which surface electrodes are placed on the skin overlying the pelvis to measure the strength (electrical conductivity) of the underlying pelvic muscles. In addition, more invasive tests such as anorectal manometry (insertion of a balloon catheter in the anus) and a urodynamic testing (a battery of different test methods, including catheterization, video and imaging techniques to determine bladder muscle contraction) can measure the strength of bladder and anal sphincter muscles.
Treatments
Depending on the degree of the pelvic organ prolapse, treatments can include a combination of conservative and/or surgical approaches. Non-surgical, conservative interventions usually involve both medications, such as hormone replacement therapy (in post-menopausal women) and laxatives (stool softeners), and physical therapy, such as Kegel exercises (to strengthen sphincter and other pelvic muscles). Additionally, a pessary (a ring shaped soft silicon device, which can be inserted in and removed from the vagina manually) may be used to lend support to the vaginal walls and push back protruding organs. In rare cases, local injections of muscle relaxants and numbing medication may help (e.g. Botox). If there is an extensive hernia (protrusion), surgery may be necessary to close the hole or weakening in the vaginal wall (cystocele or rectocele repair) and lift the protruding organ back into its original position. Sometimes, a tissue grafts or mesh (such as a urethral sling) may be necessary to reinforce support of the vaginal walls. These procedures can often be performed without creating excessive external scars, by accessing the area of interest via the vagina, or with laparoscopic or robotic (minimally invasive) techniques.