Causes Associated with Pelvic Organ Prolapse

Causes (May include, but are not limited to):

• Pregnancy and childbirth
• Aging
• Menopause
• Weight gain or obesity
• Uterine masses or pelvic masses
• Chronic coughing, constipation, or heavy lifting
• Genetics
• Neurological or spinal cord injury
• History of prior pelvic surgery including hysterectomy

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Symptoms Associated with Pelvic Organ Prolapse

Prolapse symptoms include: a departure from normal sensation, structure or function, experienced by the woman in reference to the position of her pelvic organs. Symptoms are generally worse at the times when gravity might make the prolapse worse (i.e. after long periods of standing or exercise) and better when gravity is not a factor (i.e. lying supine.) Prolapse may be more prominent at times of abdominal straining (i.e. defecation.)

Symptoms (May include, but are not limited to):

• Feeling a lump ("something coming down")
• Low backache
• Pelvic heaviness
• Pelvic dragging sensation
• Feeling the need to digitally replace the prolapse in order to have a bowel movement or pass urine
• Difficulty or inability to empty the bladder or bowels
• Urinary leakage when pressure is put on the abdomen (Stress urinary incontinence or SUI)
• Constipation
• Pain during intercourse
• Vaginal bleeding

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Pelvic Organ Prolapse Illustration 1	Pelvic Organ Prolapse Illustration 2

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Types of Pelvic Organ Prolapse

There are several types of organ prolapse. They include the following:

• Bladder
• Urethra
• Uterus
• Vagina
• Small Bowel
• Rectum
• ...and others.

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Pelvic Organ Prolapse Illustration 1	Pelvic Organ Prolapse Illustration 2	Pelvic Organ Prolapse Illustration 3

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Non-surgical Treatments

Non-Surgical Treatment Options for Pelvic Organ Prolapse can include:

• Pelvic Floor Physical Therapy - A formal physical therapy consult with a physical therapist who specializes in muscular dysfunction of the pelvic floor muscles.
  

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Diagram of Pelvic Floor Physical Therapy Exercise set. May be representative of some exercises that can be performed.

PeriCoach brochure (source) An "Exercising with PeriCoach" video can be found here

• Pessary - A silicone pessary is a flexible device worn in the vagina for a period of time determined by your health care professional. It supports certain pelvic organs that have descended (prolapsed) and can help with urinary incontinence. Benefits include a non-invasive solution to the problem; it may also help determine the proper surgical procedure and improves quality of life. Incontinence pessaries are specifically designed to stabilize the urethra and prevent incontinence. Most pessaries must be inserted and removed by a health care professional.
  

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Various kinds of pessaries	Pessary and Pelvic Organ Prolapse

• Hormone Therapy - Hormone therapy can be beneficial for some patients with pelvic organ prolapse. See this handout from the International Urogynecological Association (IUGA) regarding Low Dose Vaginal Estrogen Therapy.
  

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Surgery to repair the pelvic floor means to reinforce the pelvic structures to restore the proper anatomical position of the affected organs. This can be accomplished by using one of the following materials:

• Autologous - using tissue from your own body

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Fascia Lata Tissue

• Biologic - using tissue from a cadaver or other mammal

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Cadaveric (biologic) Tissue	Veritas Tissue	Veritas Tissue

• Synthetic - using material that is manufactured

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Risks for these surgery procedures include, but are not limited to:

• Pain / Discomfort / Irritation
• Inflammation (redness, heat, pain, or swelling resulting from surgery)
• Infection
• Fistula formation (a hole/passage that develops between organs or anatomic structures that is repaired by surgery)
• Adhesion formation (scar tissue)
• Urinary incontinence (involuntary leaking of urine)
• Urinary retention/obstruction (involuntary storage of urine/blockage of urine flow)
• Voiding and Defecation dysfunction
• Wound dehiscence (opening of the incision after surgery)
• Nerve damage
• Perforation (or tearing) of vessels, nerves, bladder, ureter, colon, and other pelvic floor structures
• Hematoma (pooling of blood beneath the skin)
• Dyspareunia (pain during intercourse)

If Synthetic material is used, these risks are included:

• Mesh erosion (presence of suture or mesh material within the organs surrounding the vagina)
• Mesh extrusion (presence of suture or mesh material within the vagina)

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Surgery options include:

• Sacrocolpopexy is performed either through an abdominal incision or ‘keyholes’ (using a laparoscope or with a surgical robot), under general anesthesia. The vagina is first freed from the bladder at the front and the rectum at the back. A graft made of permanent synthetic mesh is used to cover the front and the back surfaces of the vagina. The mesh is then attached to the sacrum (a triangular shaped bone at the base of the spine ) as shown in the illustration. The mesh is then covered by a layer of tissue called the peritoneum that lines the abdominal cavity; this prevents the bowel from getting stuck to the mesh. Sacrocolpopexy can be performed at the same time as surgery for incontinence or vaginal repair for bladder or bowel prolapse.

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From the IUGA	Mesh used in Sacrocolpopexy	Abdominal incision and 'Keyhole' incisions

• Uterosacral Ligament Suspension: The uterosacral ligaments are the ligaments that attach the cervix to the sacrum (the flat bone at the bottom of the spine.) To repair prolapse in this fashion, the uterosacral ligaments are sewn to the top of the vagina. (see photo) This can be performed through an abdominal incision, vaginal incision, or small abdominal incisions (using a laparoscope or with a surgical robot) under general anesthesia. It can also be done at the same time as a hysterectomy as a preventative measure to help prevent future prolapse.

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Abdominal incision and 'Keyhole' incisions	ULS Illustration

• Sacrospinous Ligament Fixation: These are ligaments that are usually very strong and found on both sides of the pelvis. A repair, using this technique, can be done through an abdominal incision, small abdominal incisions (using a laparoscope or surgical robot), or through a vaginal incision. Stitches are places into these strong ligaments and then into the top of the vagina or cervix. This can be performed at the same time as a hysterectomy, incontinence (urine leakage) surgery, or other pelvic organ prolapse surgery.

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Abdominal incision and 'Keyhole' incisions	From the IUGA

• Colpocleisis: This is a surgery performed through the vagina and treats pelvic organ prolapse by sewing the top and bottom (or front and back) walls of the vagina together. The vagina is completely closed off and does not permit vaginal intercourse. This type of operation is only optimal and suggested to women who are no longer sexually active (and are not intending to be.)

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Front before surgery	Side before surgery	Front after surgery	Side after surgery

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