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Pelvic Organ Prolapse

Pelvic organ prolapse is a downward descent of female pelvic organs, including the bladder, uterus and the small or large bowel, resulting in protrusion of the vagina, uterus, or both. Prolapse development can be attributed to several factors, including vaginal child birth, advancing age and obesity. Vaginal delivery, hysterectomy, chronic straining, normal aging and abnormalities of connective tissue or connective-tissue repair predispose some women to disruption, stretching or dysfunction of the connective-tissue attachments of the vagina, resulting in prolapse.

Four main types of pelvic organ prolapse can occur:

Cleveland Clinic's gynecologic surgeons offer a variety of treatments designed to optimize each individual patient's results and restore normal function of the pelvic floor.

Normal Pelvic Anatomy

Normal Pelvic Anatomy

Cystocele

Cystocele

Rectocele

Rectocele

Uterine Prolapse

Uterine Prolapse

Established risk factors include:

  • Vaginal delivery
  • Advancing age
  • Obesity

Potential risk factors include:

  • Pregnancy (irrespective of mode of delivery)
  • Forceps delivery
  • Young age at first delivery
  • Prolonged second stage of labor (pushing)
  • Infant birthweight > 4,500 g
  • Shape or orientation of bony pelvis
  • Family history of pelvic organ prolapse
  • Race or ethnic origin
  • Occupations entailing heavy lifting
  • Constipation
  • Connective-tissue disorders
  • Previous hysterectomy
  • Selective estrogen-receptor modulators

Typical symptoms in women with pelvic organ prolapse:

Vaginal:

  • Sensation of a bulge or protrusion
  • Seeing or feeling a bulge or protrusion
  • Pressure
  • Heaviness

Urinary:

  • Incontinence
  • Frequency
  • Urgency
  • Weak or prolonged urinary stream
  • Hesitancy
  • Feeling of incomplete emptying
  • Manual reduction of prolapse to start or complete voiding
  • Position change to start or complete voiding

Bowel

  • Incontinence of flatus, or liquid or solid stool
  • Feeling of incomplete emptying
  • Straining during defecation
  • Urgency to defecate
  • Digital evacuation to complete defecation
  • Splinting, or pushing on or around the vagina or perineum, to start of complete defecation

Sexual

  • Dyspareunia (painful sexual intercourse)
  • Decreased sexual desire due to decreased body image associated with prolapse

Women have several options to treating pelvic organ prolapse. Listed below are explanations of those offered by Cleveland Clinic staff.

Non-surgical

Pelvic floor physical therapy is offered by specially trained physical therapists to strengthen the pelvic floor muscles, which are the foundation of lifelong pelvic organ support.

Pessary use is the only currently available, non-surgical intervention for women with pelvic organ prolapse. These devices are inserted into the vagina to reduce prolapse inside the vagina, to provide support to related pelvic structures, and to relieve pressure on the bladder and bowel. Approximately 20 different types of pessaries are available, made either of silicone or plastic. Use of these devices has been reserved for patients with symptomatic pelvic organ prolapse who decline surgery, are poor surgical candidates because of medical conditions or who need temporary relief of pregnancy-related prolapse or incontinence.

Gynecologists fit a patient's pessary based on the nature and extent of the prolapse and the patient's cognitive status, manual dexterity and level of sexual activity. The size of the vagina is estimated and the appropriate size and shape of pessary is inserted such that the prolapse is effectively reduced and the woman is comfortable with the device in place. Follow-up visits are necessary to ensure the pessary is functioning effectively. The most common side effects are vaginal discharge and odor.

Pessary

Pessary

Surgical

Traditional

Reconstructive surgery for prolapse aims to correct the prolapsed vagina while maintaining (or improving) vaginal sexual function and relieving any associated pelvic symptoms. Surgery can be undertaken by either an abdominal, laparoscopic (with or without robotic assistance) or vaginal route.

Sacrocolpopexy

The abdominal sacrocolpopexy can be done through an abdominal incision, laparoscopically, and robotically and suspends the upper vagina with synthetic mesh.

Abdominal Sacralcolpopexy

Abdominal Sacralcolpopexy


Vaginal Approach

For prolapse repairs that are performed vaginally, the surgeon attaches either the upper vagina or cervix to the ligament between the ischial spine and the sacrum (sacrospinous ligament) or to the ligaments between the sacrum and uterus (uterosacral ligaments).

An alternative to reconstructive surgery is obliterative surgery, which closes off the vaginal canal either partially or totally. This procedure is typically reserved for women who are no longer sexually active.

Ligament Surgery