Pelvic organ prolapse
What you should know: Pelvic organ prolapse
With the joys of imminent motherhood to look forward to,
you no doubt have little time to worry about something that may (or
may not) be a problem for you in the future - prolapse. Dr
Anil Sharma explains.
Pelvic organ prolapse, or POP, occurs when the bladder or other
pelvic organs drop from their normal position and push down the
walls of the vagina. This happens when the muscles and ligament
supports of the pelvic organs get weak or stretched. The word
prolapse literally means "to slip forth". Organs that can be
involved in POP include the bladder, the urethra (tube that carries
the urine out of the bladder), the uterus, vagina, small bowel, and
rectum.
It is estimated that around one in three
women who have had at least one baby will end up needing treatment
for POP. Since many women simply put up with these problems and
think they are "just a woman's lot", the true extent of the problem
may be higher.
What causes POP?
POP is most often linked to childbirth, which causes stretching and
weakness in the muscles and ligaments. It can also lead
to damage to the nerves of these structures.
You may also get POP if you have a
total hysterectomy (where the cervix is removed as well as the
uterus) at a time in your life when the vaginal and
uterine supports are still strong. This is because this
operation involves cutting the ligaments either side of the cervix,
thereby causing more weakness in the supports.
POP can also be made worse by anything
that puts excessive pressure on the supports of the pelvic floor
(the lowest part of your pelvis just above the vagina at the lower
limit of the tummy). These include obesity, long-lasting coughs,
chronic constipation, and things like large ovarian cysts and
fibroids in the uterus (fibroids are usually benign lesions in the
muscle layer of the uterus).
Older women are more likely to have POP, not least because it has
had more time to develop but also because of the reduction in
oestrogen levels that occurs after the menopause. This leads to
thinning of the collagen that is a great supporting tissue in our
bodies. POP can also run in families.
What are the symptoms of POP?
- Pressure from pelvic organs pressing against the vaginal
wall.
- A feeling of something falling out of your vagina ("something
coming down") or sitting on a "bubble".
- A feeling of stretching in your groin area or pain in your
lower back.
- The accidental leakage of urine (incontinence), needing to
urinate a lot, or having to go more than once to empty the bladder.
Also, having a sudden strong desire to urinate may occur. While
urine incontinence and prolapse are related, one can occur without
the other.
- Reduced enjoyment of intercourse because the vaginal capacity
has increased, or due to embarrassment regarding the bulging.
- Problems with your bowels, such as constipation.
How is POP diagnosed?
After asking questions about your symptoms and about any
pregnancies or health problems, your doctor will likely
do a physical examination (including a pelvic exam). He or she will
then usually refer you to a gynaecological surgeon who has a
special interest in the treatment of POP. Patients may need other
tests to evaluate the prolapse further and these may include:
- Cystoscopy, which is a test to look at the interior lining of
the bladder and the urethra.
- Pelvic ultrasound scan, to image the pelvic structures. This
test is sometimes
undertaken to ensure that the ovaries and uterus look normal.
- Urodynamic tests, to accurately see how the bladder and nerves
store and release urine.
What to do in pregnancy and labour
If you are concerned about the effects of pregnancy and
childbirth on your pelvic floor, plan to do pelvic floor exercises
during and after pregnancy, and your antenatal class may be a good
starting point to enable interaction with a physiotherapist. In
terms of labour and childbirth, vaginal birth remains safest
overall (unless there are medical reasons to have a Caesarean
section).
While I appreciate the controversy about
lengths of time for the second stage of labour (the time from full
dilation to when the baby is born), it would seem logical that this
is not excessive. In theory, the longer the baby remains in the
birth canal, the higher the chance of damage to the muscles,
ligaments and nerves of the pelvic floor. In general terms, the
second stage should be around one hour for the first baby and less
for subsequent births before the obstetrician is called. You should
be proactive and discuss pelvic floor issues and plans for the
birth with your lead maternity carer.
Treatment of POP
Decisions about treatment usually depend on how bad things are and
what your symptoms are. If your prolapse is not severe and you are
happy to adopt a conservative approach, you may just decide to let
things be, and have another checkup if things "down below" get
worse.
Pelvic foor exercises: If your symptoms are mild,
you may be able to do pelvic floor exercises at home (see "Healing
your pelvic floor", OHbaby! Magazine Issue 11 (Spring 2010),
page 110). While these exercises will not reverse your prolapse,
they can both help prevent it getting worse quickly and
improve the results of surgery.
Lifestyle changes: Cutting back on caffeine (which
acts as a diuretic) can reduce some of the urinary symptoms you may
have associated with your prolapse. Losing weight or remaining in
the normal weight range and regularly exercising can be a great way
to prevent new prolapse, but beware of exercises that increase
downwards pressure on your pelvis, such as squats. In fact, given
the natural opening (the vagina) which allows women to birth a
baby, squats are probably a particularly damaging exercise. While
women with prolapse can carry on visiting gyms and exercising, some
advice is useful. In general terms they should avoid any heavy
lifting, but light weights for the upper body and legs are fine.
Walking and cycling with care to limit any pressure on the pelvic
floor are also likely fine, but more rigorous group cycling
exercises and running are not a good idea. After surgery, a
careful return to the gym is entirely possible.
It is also very useful to keep the bowels
moving regularly. Eating a diet high in fibre is a useful start,
but you may also need to see your family doctor for further advice.
With regard to your waterworks, around 2-2.5 litres of fluid a day
(with the odd tea or coffee) is reasonable, as dehydration is also
not good for a regular bowel habit. This will have to be
tailored appropriately if the waterworks are a problem as
well. Smokers should do their very best to quit, as chronic
coughs significantly increase the risk of prolapse.
Family doctors and gynaecologists will
also frequently prescribe a course of oestrogen cream to insert
into the vagina for post-menopausal women with prolapse. This is to
try and increase the thickness of the skin in those areas to try
and alleviate some of the symptoms and also to improve the healing
potential of the area if surgery is being planned.
Pessaries: After appropriate discussion, a pessary
(usually a plastic device) may control your symptoms. These are
usually in the shape of a large ring and are placed inside the
vagina to prevent the walls bulging down. These are suitable for
women who do not wish to consider an operation or when other
medical problems mean this is not possible. The ring does
need regular removal and replacement by your doctor (initially
after six to eight weeks, and then every five to six months).
Surgery: Surgery is the main treatment option for
pelvic organ prolapse, but is best delayed until after your family
is complete; otherwise, the physical strain of childbirth will
likely cause the surgery to fail. Surgery for POP has traditionally
involved using the existing tissues of the vagina with incisional
techniques and stitches that dissolve over time ("native" tissue
repair). Since this involves around a 30% chance of recurrent
prolapse (as the supporting tissues were damaged in the
first place), newer techniques involve using thin woven sheets of
polypropylene mesh to reconstruct the vagina. These techniques have
reduced the recurrence rate of POP to less than 10%. However, the
risks and limitations of using these meshes also need to be
discussed with patients. Furthermore, the individual circumstances,
including the severity of the prolapse, other health factors and
risks of recurrence, all need to be considered.
You may want to consider surgery if:
- You have a lot of pain because of the prolapsed organ.
- You have a problem with your bladder and bowels.
- The prolapse makes it hard for you to enjoy sex.
Types of surgery for pelvic organ prolapse
include:
- Repair of the tissue that supports a prolapsed organ.
- Surgery to repair the tissue around the vaginal walls.
- A sling to cure stress urinary incontinence (leakage of urine
when coughing, laughing, or exercising).
- Surgery to hitch up the vagina and attach it to a ligament in
the pelvis (sacrospinous fxation).
- Surgery to remove the uterus if it is very low (vaginal
hysterectomy).
Prolapse is being increasingly recognised as a real problem by
society, and the old taboos of not talking about these "personal"
problems are thankfully being broken. Modern management includes a
range of safe treatments that have revolutionised this area
and the newer surgical treatments are evolving rapidly.
Dr Anil Sharma is a specialist doctor in gynaecology and
maternity. He is very involved in lectures and updates for family
doctors and frequently takes part in debate regarding women's
health and maternity for TV, print media, and radio. He believes
that anxiety and fear can be conquered by knowledge. Anil
immigrated to New Zealand from the UK in 2001 with his wife,
Rachel, and he tries hard to be a hands-on and fun father (putting
golf and cars on hold for the time being) to their three
daughters, who were all born here. For further information
about Anil's practice, visit www.dranilsharma.co.nz
As seen in OHbaby!
magazine Issue 12: 2011
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