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Pelvic organ prolapse is a common condition in many women following vaginal delivery. It results from the descent of the uterus, urinary bladder, urethra, small intestine or rectum, along with and through the vaginal wall, as a result of weakened pelvic support.
Though it is not a life-threatening condition, pelvic organ prolapse can be a source of much embarrassment, inconvenience, restrictions, and general psychological stress. Self-worth may be severely reduced by having to wear a sanitary pad constantly, for instance, or the fear of smelling of urine may limit one’s social activity. Thus treatment of this condition is of great importance to improve the overall quality of life.
Asymptomatic prolapse may not need treatment. Lifestyle changes such as weight loss, and avoidance of heavy lifting, are advised to prevent the emergence of symptoms and to prevent the progression of the conditions.
Pelvic floor muscle training (PFMT) is thought to be an effective treatment for mild grades of prolapse, or even up to stage 3. PFMT taught one-on-one for 16 weeks to 6 months has been shown to bring about symptomatic improvement. Stress incontinence symptoms are especially responsive. Mild prolapse may be improved by regular pelvic exercises.
They are also called Kegel’s exercises and are best taught individually to make sure each patient understands which muscles to contract and how to exercise them. PFMT in combination with pessaries or surgery may be highly effective in preventing the recurrence of symptoms. This finding needs to be confirmed, however, as other studies have not been able to confirm this suggestion.
Pessaries are devices which can be inserted into the vagina, to prevent the vaginal wall from descending by providing mechanical support. They are most suitable for women who have minor stages of prolapse, and for those who cannot or will not agree to surgical repair of their prolapse.
Vaginal pessaries have been known from old times. Modern pessaries come in a variety of shapes and different sizes, to fit specific types and stages of prolapse. Latex and silicone pessaries are available. There is not much evidence on which type and material are best but more than three of four urogynecologists prescribe them as first-line treatment for mild prolapse. With repeated trials, each woman may be able to identify which pessary type and size best relieves her symptoms. These may range from urinary and bowel dysfunction to sexual dissatisfaction. Ring pessaries are the most common type in use.
Pelvic floor exercises in combination with pessary use may be more effective than either treatment used alone. Pessaries should be removed, cleaned thoroughly, and replaced properly every 4-6 months. Sometimes their use may be associated with mild vaginal bleeding, infection, vaginal ulceration, or urinary leakage to a small extent.
Estrogen therapy is useful in strengthening the pelvic muscles, ligaments, and vaginal mucosa, which brings about a marked improvement in pelvic floor strength. Topical estrogen therapy is preferred as it reduces the patient’s exposure to estrogen, and lowers the dosage.
Women have a 10-30% risk of pelvic organ prolapse repair in their lifetime. The repair involves support to the organ which is descending by attaching the vaginal vault or the uterus to a ligament in the pelvis or the sacrum.
Pelvic support reconstruction can be carried out through the vagina or the abdomen with equal rates of success. Laparoscopic surgical repair is another mode of treatment, which has smaller incisions and does not disrupt the normal strength of the abdominal wall too much. The principle of every repair is to pull back the prolapsed organ to its anatomic location and suture it to its supports, which are also strengthened in various ways.
The vaginal wall is also cut back to the required size so that it no longer bulges. The supports may be fashioned out of the woman’s fascia or may use synthetic mesh to repair the anterior and posterior vaginal walls. Autologous fascia has no risk of rejection but may provide lower objective measures of improvement. These measures are not always correlated with subjective or symptomatic relief, however.
Synthetic mesh, on the other hand, provides stronger and more durable support, but can and often does cause vaginal erosions, which may be painful. Its use has been cut back markedly as a result.
Biological grafts such as porcine grafts and absorbable meshes are therefore being studied as effective substitutes in the early healing stage, while avoiding the post-operative complications of synthetic mesh.
Mesh use still confers a superior anatomical outcome following the abdominal repair of pelvic organ prolapse. It leads to a lower incidence of dyspareunia following the procedure, but with increased operative and recovery duration.
If the prolapse is advanced in stage, hysterectomy is sometimes the best option, as in complete uterovaginal prolapse. However, women often want the uterus to be spared, and therefore more procedures to repair the vaginal vault without removing the uterus are becoming more popular. These may become more common still, because evidence shows that there is not much difference in functional outcomes whether the uterus is spared or not, as long as the vaginal fascia and pelvic ligaments are firmly attached.
Colpocleisis is a last-resort surgery that closes off the vagina permanently. It is useful in women who are very frail or very old, and cannot withstand the rigors of any longer procedure. It may also be advised if several previous operations have proved unsuccessful. It prevents future intercourse.
Surgical repair usually increases the quality of life. However, there is a risk of persistent symptomatology, or the symptoms may even worsen. For this reason, some surgeons prefer to repair the bladder supports at the time of prolapse repair, even if the woman has no stress incontinence. This may reduce the incidence of post-operative stress symptoms, but increases the operating time and the rate of complications.
Complications of surgical repair include bleeding, infection, anesthetic complications, urinary infections, and sometimes urinary tract damage. Dyspareunia and recurrence may also occur.