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With advances in medical care, chronic diseases are identified and treatable in our rapidly ageing population. The problem of pelvic organ prolapse (POP) is getting more common as time passes, and it is the adverse effects on the quality of life in the older population that should be addressed. Unfortunately, due to social norms in our Asian culture, this is not something we discuss with frank and open honesty.
A prolapse occurs when an organ displaces beyond its normal position, similar to a hernia. The displacement of the uterus (womb) is called utero-vaginal prolapse, with the urethra and bladder it is termed a cysto-urethrocoele, with the rectum it is termed a rectocoele, and the eversion of the vagina in patients with a previous hysterectomy is called a vault prolapse. When there is pelvic organ prolapse, frequently urinary incontinence (UI) is associated, as the same mechanism of damage causes both disease entities.
The damage to the supporting fascial-ligamentous structures of the pelvis predisposes to pelvic organ prolapse.
Pregnancy, childbirth, birth weight, parity, previous pelvic surgery, and menopause.
Chronic cough, asthma, constipation, carrying heavy loads, or obesity predispose and worsen prolapse.
When patients present with POP, assessment for urinary incontinence is required as both conditions are interconnected. There is the entity of occult urodynamic stress incontinence (USI), which has an incidence rate of 23-50%.
Treatable medical conditions should be assessed and therapy optimisation instituted, including improving asthma control, correcting constipation, or controlling weight loss. Previous conservative, medical and surgical treatment for pelvic organ prolapse should be noted as they affect treatment outcomes.
Routine urine microscopy and culture are performed to exclude infection, and an ultrasound of the pelvis is useful in excluding gynaecological conditions that require urgent treatment (e.g. ovarian cancer) or impact on prolapse (e.g. large fibroid causing pressure effects). An ultrasound of the upper renal tract can be done for severe POP, as up to one-third of patients may have obstructive uropathic changes.13 Ultrasound can also be used to delineate the pelvic floor to aid in localising defects.
An essential part of the assessment would be urodynamic studies, which comprise uroflowmetry, simple filling and voiding cystometry, and urethral pressure profilometry. These tests are performed when urinary symptoms are complex and/or there is a need for surgery. Uroflowmetry is a useful screen for possible voiding dysfunction.
Cystometry involves inserting catheters into the bladder and rectum to monitor pressure changes concerning the volume of instilled sterile fluids. It allows for the diagnosis of urodynamic stress incontinence (USI) and occult USI, detrusor overactivity (DO), or mixed urinary incontinence and causes of voiding dysfunction. There is a 3% risk of UTI with urodynamics, hence preventive antibiotics are given immediately after the procedure.
An experienced obstetrician is required to manage the pregnancy optimally, as it reduces the future risk of pelvic organ prolapse. This includes controlling constipation, monitoring weight increase and estimated fetal weight gain, timing the delivery to reduce the risk of pelvic floor injury, and most importantly, teaching and monitoring antenatal and post-natal pelvic floor exercise (PFE) activity.
This popular non-surgical treatment is also called Kegel’s exercise, and regular exercise may prevent or reduce prolapse occurrence. Once prolapse has occurred, PFE improves prolapse symptoms in up to 50% of patients who regularly do it; but it is a temporising measure and does not cure POP.
In cases where there is significant prolapse but the patients themselves are not suitable or keen for surgery, a vaginal pessary fitting may suit the patient’s needs. The most common is a ring pessary, used to support and relieve prolapse symptoms. Patients fitted with a pessary will require regular ring changes every three to four months.
For long-term relief, surgical intervention is the best option for patients with POP.In cases of utero-vaginal prolapse, a vaginal hysterectomy can be performed.If the patient prefers to keep her uterus, a Manchester operation can remove the prolapsing cervix whilst retaining the uterus.
In cases of cystocoele and/or rectocoele, repair of the herniating organ is achieved by an anterior and posterior colporrhaphy or a pelvic floor repair.
In severe vault prolapse (after the vaginal hysterectomy) or severe utero-vaginal prolapse, a sacrospinous ligament fixation attaches the top of the vagina to a ligament in the pelvis with non-absorbable sutures.
These operations are frequently done in combinations, as isolated repairs are not as durable, and combined repairs have a synergistic effect in reducing prolapse recurrence, especially when it comes to cystourethrocoele.
In almost all cases, a reconstruction of the disrupted perineal body (perineorrhaphy) is paramount in supporting the entire pelvic floor. The reduction in vaginal aperture diameter also reduces pressure transmission forces that predispose to prolapse.
In any surgery, anaesthesia is used to ensure patient comfort and can be regional or general anaesthesia. All forms of anaesthesia have complications; this can be explained by the anaesthetist before the operation.
Urinary tract infection is reduced by early ambulation, removing the urinary catheter as soon as it is deemed safe and appropriate antibiotic cover.
Pneumonia, or chest infections, can be prevented by deep breathing exercises and early ambulation.
Deep vein thrombosis, where blood clots develop in the legs, can be prevented by using preventive stockings and calf compression devices, early ambulation, and injections that thin the blood (low-molecular-weight heparin).
In July 2011, however, the U.S. Food and Drug Administration (FDA) announced that there were multiple complaints of mesh-related complications, mesh exposure through vaginal tissue (erosion), pain, infection, bleeding, pain during sexual intercourse, and so on.
The number of complaints between 2008 and 2010 was reported to be “1,503 adverse events”. This prompted a “review of scientific literature published between 1996 and 2010 comparing mesh surgeries to non-mesh surgeries.”
The agency review suggests that many patients who undergo transvaginal POP repair with mesh are exposed to additional risks, compared to patients who undergo POP repair with stitches alone. While mesh often corrected anatomy, there was no evidence that mesh provided any greater clinical benefit than non-mesh surgeries.
This triggered certain companies to withdraw prolapse mesh kit products and cease production amidst a flurry of mounting legal complaints. Currently, natural tissue repairs appear to be the safest and have a low complication rate if done by experienced specialists.
If you are experiencing symptoms of pelvic organ prolapse, it is important to seek proper medical attention. Your primary care doctor may refer you to a specialist who focuses on pelvic floor disorders, such as a urogynecologist or a gynaecologist. These doctors have specialised training and experience in diagnosing and treating pelvic prolapse.
As pelvic prolapse can be complex and have long-term effects, it is important to find a doctor you feel comfortable with and trust. Remember to ask questions during your consultation and discuss any concerns you may have. Your doctor will work with you to determine the best treatment plan for your individual case.
Early detection and proper management by a doctor can greatly improve your quality of life and prevent complications related to pelvic organ prolapse. So don’t hesitate to seek help and take control of your health.
Dr Tseng's expertise covers urinary incontinence and pelvic organ prolapse, apart from that, his particular interest lies in the holistic management of Overactive Bladder Syndrome and other functional bladder conditions. With many years of experience in this field, he is committed to providing patients
