Abstract
Pelvic organ prolapse is a common condition affecting a large number of women. Incidence increases after the menopause. Age, parity and obesity are the most consistently reported risk factors. Many women can be asymptomatic of prolapse but common symptoms include a sensation of a bulge or fullness in the vagina or urinary, bowel or sexual dysfunction. Management depends upon symptoms and the type and grade of the prolapse as well as any associated medical co-morbidities. Management options include expectant, conservative or surgical approaches. Up to 10% of women having a surgical procedure for prolapse will require a second procedure. It is, therefore, important to consider lifestyle modifications such as weight loss and conservative measures including pelvic floor muscle training, topical estrogens and pessaries as initial management options.
Introduction
Pelvic organ prolapse (POP) is a common condition with prevalence rates of 25–65%. 1 Eleven percent of women undergo surgery for POP by the age of 80 with 30% of these requiring repeat procedures for recurrent symptoms. 2
This article aims to provide an overview of pelvic organ prolapse, its aetiology, presentation, diagnosis and management with particular attention to conservative management.
Aetiology and risk factors
Risk factors for prolapse vary from study to study but those reported consistently are increasing age, parity and obesity. 3 Other possible causes include smoking, chronic increase in intra-abdominal pressure (e.g. constipation and chronic cough), estrogen deficiency, previous hysterectomy, connective tissue disorders (e.g. Ehlers–Danlos syndrome), low socioeconomic status, ethnicity and family history. 4,5
The risk of prolapse increases with increasing parity, specifically the number of vaginal deliveries. The Oxford Family Planning study, which followed over 17,000 women for 17 years, found that hospital admission for prolapse increased four-fold in women having one child, eight-fold in those having two children, and nine- and 10-fold for those having three or four as compared with nulliparous women. 6
Obesity leads to a chronic rise in intra-abdominal pressure. Swift et al. found women with a body mass index >25 to have a two-fold increased risk of developing prolapse as compared with other women. 1 Weight loss may lead to regression of prolapse and should always be promoted prior to considering surgical intervention to minimize surgical and anaesthetic risks and reduce the risk of prolapse recurrence.
Advancing age contributes to prolapse development in a variety of ways. Estrogen deficiency is thought to be the major factor. Lang et al. found significantly lower levels of serum estrogen and estrogen receptors in the cardinal and uterosacral ligaments of premenopausal women with prolapse as compared with controls. They also found the number of estrogen receptors increased with years from menopause, possibly indicating that estrogen receptor values are in negative correlation with serum estrogen levels in postmenopausal women. 8
Decreasing estrogen levels also lead to a reduction in total collagen content, which again predisposes to prolapse. 4
Epidemiological studies have previously shown that prolapse deteriorates with age. Recent studies have challenged this idea finding that prolapse may wax and wane and that mild (grade 1) prolapse may regress. 9–11 Handa et al. 10 found annual rates of regression (per 100 women-years) for grade 1 prolapse to be 23.5 for cystocele, 22 for rectocele and 48 for uterine prolapse. Factors to make regression less likely include obesity and grand multiparity. These findings would support conservative management of prolapse at least as an initial step.
Presentation
Prolapse can be asymptomatic and only noticed when examined for an unrelated reason, e.g. routine cervical smear. Symptomatic women often present with the sensation of pressure in the vagina or the feeling of a bulge in or coming out of the vagina. Associated symptoms include urinary, defecatory and/or sexual dysfunction.
The correlation between the severity of symptoms and stage of the prolapse is poor. There are a variety of questionnaires that can be used to evaluate the impact of patients’ symptoms on their quality of life and to assess the benefit of any treatments tried.
Diagnosis
Following a detailed history, POP is diagnosed and classified by a pelvic examination. The Pelvic Organ Prolapse Quantification (POPQ) system is now the most widely used tool to stage prolapse. It provides a detailed description of vaginal anatomy that can be grouped into one of four stages.
12
Specific compartments can be used to further define the prolapse, e.g. stage 2 anterior wall prolapse.
Management
Women with symptomatic prolapse can be managed expectantly or can be offered conservative or surgical therapy.
Treatment should be individualized to each patient and her symptoms and the impact they have on her quality of life.
Kapoor et al. 13 found that nearly two-thirds of women with symptomatic prolapse initially opted for conservative management. Those requesting surgery are often younger, sexually active and have more severe prolapse and associated symptoms.
Expectant management
This is appropriate for those women with mild prolapse and/or associated symptoms or in those who decline treatment or who are unfit for a surgical approach when conservative treatment has failed. Any underlying exacerbating factors should be addressed, e.g. weight loss, smoking cessation, treating constipation and optimizing treatment of coexisting conditions, e.g. chronic obstructive airways disease and, when possible, avoidance of precipitating factors such as heavy lifting and prolonged standing.
Pelvic floor muscle training
Although there are limited data on their effectiveness, pelvic floor exercises are often recommended as first-line treatment for stage 1–2 prolapse. 3 The aim of pelvic floor muscle training (PFMT) is to improve coordination, endurance and functional strength of the pelvic floor muscles. Neuromuscular stimulation can be used to initiate muscle contraction if a woman is unable to contract her pelvic floor and this and biofeedback can aid teaching of the exercise techniques and ensure correct muscles are being used. The use of Kegel (weighted) cones can also help. 5 Hahn found that PFMT was more effective when taught and supervised by a trained professional, e.g. a physiotherapist. Ying et al. 14 suggested that ultrasound could be used to improve effectiveness of PFMT by showing women visually which muscles to contract and then observing their techniques with ultrasound before discharging them with an at-home training programme.
A Cochrane review in 2009 15 identified three randomized controlled trials examining the effectiveness of PFMT on the management of prolapse. All three trials involved small numbers and had various limitations. The review concluded that there was still no significant evidence to guide practice.
Braekken et al. in 2010 published results of an assessor-blinded randomized, controlled trial (The POP Study). One hundred and nine women with stage 1–3 prolapse were randomized to PFMT or control. Nineteen percent of women in the PFMT group improved to stage 1 on the POPQ assessment versus 8% in the control group. Seventy-four percent of women in the PFMT group reported a reduced frequency of vaginal bulging after six months. 16
It is hoped that results of the ongoing Pelvic Organ Prolapse PhysiotherapY (POPPY) Trial, an Australian-based randomized study, may provide further needed evidence.
Topical estrogens
Estrogens are used to prevent or improve vaginal atrophy and/or dryness that can lead to discomfort and dyspareunia. It is thought that use may prevent or treat vaginal prolapse when used alone or with other treatments, e.g. pelvic floor muscles training or pessaries.
In theory, the use of topical estrogen will restore thickness, elasticity and pH of the vagina and improve strength and function of pelvic fascia, ligaments and muscles.
A Cochrane review by Ismail et al. 17 in 2010 found that the use of estrogen prior to surgery for prolapse reduced the incidence of cystitis in the four weeks after surgery; however, numbers involved were small.
Another Cochrane review by Suckling et al. 18 examining effects of local estrogen for vaginal atrophy in postmenopausal women identified 19 trials involving 4162 women. The authors concluded that estrogen creams, pessaries, tablets and vaginal rings were all equally effective at managing symptoms of vaginal atrophy. Women preferred the vaginal ring due to its ease of use and comfort. A vaginal ring Estring® (Pfizer, New York City, New York, USA) is available in the UK. Topical estrogen may also improve urinary incontinence. 19
Selective estrogen receptor modulators
Selective estrogen receptor modulators, such as raloxifene, are used in the treatment of osteoporosis. Several studies have examined their possible effects on the urogenital tract. 17,20,21
Sharma et al. 20 concluded that their use did not adversely effect urinary incontinence or prolapse.
A meta-analysis by Goldstein found a significant reduction in the need for prolapse surgery in women over 60 taking raloxifene compared with a placebo after three years (odds ratio 0.47, 95% confidence interval 0.28–0.80). It is unclear as to whether this is due to an estrogenic effect or not and as numbers were small raloxifene cannot be recommended as a treatment for prolapse. 17
Pessaries
A pessary trial can be offered to all women with symptomatic prolapse. Any active infections should be treated prior to insertion.
Patient acceptance of pessaries varies from 42 to 100%. Appropriate counselling and support can improve compliance.
There are a large variety of pessaries available. They can be classified into two groups: support and space filling. Support pessaries (e.g. ring, Gehrung and Shaatz) can be used to treat all stages of prolapse and/or stress urinary incontinence. Space-filling pessaries (e.g. Gellhorn, cube or donut) are reserved for severe (grade 3–4) prolapse.
Pessaries are fitted by trial and error. Several sizes and/or styles are often tried prior to finding the most effective and comfortable. Prior to leaving the clinic the patient should mobilize, cough and void to ensure that the pessary does not become dislodged, is comfortable, does not impede voiding and does not unmask any stress incontinence. 22
The patient should be reviewed 2–4 weeks after initial insertion so ensure its effectiveness. The pessary should be removed and the vagina examined for any ulcerations. The use of topical estrogen can minimize irritation with pessary use in postmenopausal women. Follow-up can then be increased to every 3–6 months.
The most common side-effect of pessary used is increased vaginal discharge and odour. 22 Occasionally, a pessary can be forgotten or neglected and become embedded in the virginal mucosa. This can lead to difficult and painful removal. The use of topical estrogen can assist in removal. Sometimes a stuck ring pessary can be grasped with a sponge holder and then cut before being threaded out of the vagina. Occasionally, removal under anaesthetic is needed.
A 2004 Cochrane review by Adams et al. 23 identified no randomized trial comparing various types of pessaries.
Since then Cundiff et al. 24 compared the ring with support and Gellhorn pessaries. This was a randomized crossover trial. One hundred and thirty-four postmenopausal women were randomized to use each pessary for three months and quality-of-life questionnaires and visual analogue scores used to measure outcomes. Both pessaries were found to be of equal effectiveness in relieving prolapse symptoms and voiding dysfunction.
Surgical treatment
Surgery is offered to patients who are symptomatic and have declined or failed to respond to conservative treatment. The optimal procedure (or procedures) is not known. The principle of surgical intervention is improvement of subjective outcome and quality of life at the expense of minimal complications. Trends in surgical management of POP among UK practitioners have not changed significantly in the last five years. 25 For anterior and posterior vaginal wall prolapse, anterior colporrhaphy and posterior repair, respectively, are the procedures of choice. In women with uterovaginal prolapse, the procedure of choice still remains vaginal hysterectomy and repair. 25 However, just simple hysterectomy is not effective in correcting uterovaginal prolapse. Vault suspension is indicated with hysterectomy and a wide variety of techniques exist for vault suspension. It is important to note that when vault suspension is performed ‘prophylactically’, techniques that distort vaginal axis, i.e. sacrospinious ligament suspension, should be avoided. The aim of surgery is to restore vaginal axis using endogenous material and procedures commonly used include McCall culdeplasty and suturing of the uterosacral ligaments to the vault.
Trials with long-term outcome figures comparing uterine preservation with hysterectomy for treatment of uterovaginal prolapse are lacking. The Manchester procedure is largely of historical interest. Complications like cervical incompetence, stenosis and subfertility defeat the purpose of its indication as a fertility sparing procedure. A variety of abdominal approaches had been described. The original Gilliam's procedure is outdated due to high failure rate but synthetic material (mesh) may be used to attach the isthmic region to the anterior sacral ligament. In absence of robust outcome data following fertility sparing prolapse surgery, extreme caution should be exercised when counselling patients regarding uterine preservation for fertility indications.
Posthysterectomy apical prolapse requires surgical repair, which includes repair of vaginal walls and suspension of vaginal apex. Treatment of apical prolapse can be performed by a wide variety of techniques and include laparoscopic, abdominal and vaginal approaches. Surgeons generally have a preferred mode of access for treatment of apical prolapse. With vaginal route the procedure requires less operating time and is associated with early mobilization and reduced hospital stay. Abdominal approach has the advantage of restoring the normal vaginal axis and is associated with a lower rate of recurrent vault prolapse and dyspareunia than with vaginal sacrospinious fixation. 26 However, these benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach.
Laparoscopic sacrocolpopexy requires the skill of laparoscopic suturing and hence it has not been widely adopted. There is no randomized trial comparing laparoscopic vault suspension with established procedures but various retrospective case series confirm laparoscopic sacrocolpopexy as a safe and effective procedure for the treatment of vaginal vault prolapse with a success rate comparable to abdominal approach. 27,28 However, the perceived benefits (including cost-effectiveness) of laparoscopic surgery over-established procedures for prolapse surgery need to be established in a randomized study before it is recommended as a gold standard.
Nearly 30% of patients who underwent prolapse surgery will have repeat surgery at some point. 2 The concept of reinforcing the attenuated pelvic fascia with synthetic or biological material was introduced to pelvic re-constructive surgery with a view to reduce failure of surgical repairs for POP. Earlier reports described usage of absorbable mesh, non-absorbable mesh or biological grafts sutured as an overlay but subsequently various case series were reported using a variety of mesh kits.
It is clear from recent randomized trials that synthetic mesh kits provide greater support for the vaginal walls than standard native tissue repairs; however, overall patients’ satisfaction rate for prolapse surgery outcomes are no different whether done with mesh kit or standard native tissue. The reoperation rate following a standard native tissue repair is roughly 10%, which is same as the overall re-operation rate after synthetic, mesh kit surgery (failure and mesh complications). 29–31
In summary, basic trends in prolapse surgery remain unchanged. The case for using mesh kit for recurrent prolapse is gaining popularity; however, efforts should be made to identify a subgroup of patients who are at a higher risk of recurrence and better define risk factors for mesh complications. This will eventually refine indications of mesh in prolapse surgery and reduce recurrence and complications associated with mesh kits.
Conclusion
POP affects a large number of women. Incidence increases after the menopause. POP can present with a variety of symptoms to a range of health professionals.
Careful assessment, diagnosis and patient education can optimize management.
There are a variety of surgical methods to treat POP but surgery is associated with risks and complications and nearly 10% of women having prolapse surgery will require a repeat procedure.
It is important to also consider more conservative treatment methods and lifestyle modification in the prevention and management of POP.
Competing interests
None declared.