Prolapse of the pelvic organs is often distressing for affected women. However, many women do not experience any symptoms, and may not be aware of the condition until it is found during a routine pelvic examination.
Prolapse affects one in two women over the age of 50 years and has an overall prevalence of 30-50%. Women may expect to have an 11-12% chance of having to have surgical repair for prolapse, and one-third will need a repeat surgery.
Symptomatic pelvic organ prolapse may present with a range of symptoms, such as:
- Pelvic pressure: The pelvic organs descend through the widened opening in the weakened pelvic floor, leading to a feeling of increased pressure in the pelvis.
- Pain: When pelvic pressure is more marked, the mass may compress adjacent nerves, causing leg pain or low backache. Sometimes the patient may complain of easy leg fatigue.
- Urinary symptoms: Incontinence, difficulty in initiating urination, and frequency may accompany descent of the urethra or bladder.
- Bowel symptoms: A woman who has a rectocele may experience difficulty with defecation because of the entrapment of stools in the outpouching formed by the rectum above the anal sphincter. This may cause abdominal, flank, or rectal pain, feeling of pressure, and constipation.
- Dyspareunia: Vaginal prolapse can cause mechanical interference with penetration, as well as irritation of the vaginal wall. This may lead to pain on intercourse as well. Finally, this may result in psychological stress and aversion to the act itself.
Prognosis of Asymptomatic Prolapse
If women have no symptoms, they need take no special treatment for the prolapse. The only indication for treatment is if the condition is causing significant symptoms.
Prognosis of Mild Grades of Prolapse
Women with mild to moderate prolapse, even without symptoms, may wish to avoid all factors that can increase the pressure on the pelvic muscles.
Lifestyle changes may include loss of weight for overweight women or quitting smoking for women who smoke. Constipation should be avoided as far as possible by including plenty of fresh fruits and vegetables in the diet, drinking enough water, and choosing whole grains. Meals should be regular and adequate for one’s energy consumption.
Women who routinely do heavy lifting, even at the gym, should abstain from it. Chronic cough or constipation should be treated appropriately.
Pelvic floor muscle training or Kegel’s exercises may be of benefit in relieving stress incontinence and hesitancy, symptoms which are typically associated with pelvic organ prolapse. This is most effective when taught individually, and in combination with the use of pessaries or with surgery, when indicated.
More major degrees of prolapse will not improve with pelvic floor muscle exercises alone. However, prolapse may keep from worsening with this training if consistently carried out.
Prognosis of Major Prolapse
For those with significantly severe symptoms or whose symptoms cause major inconvenience, surgical intervention can produce a real improvement in their quality of life. If surgery is contraindicated for any reason, or if the woman is unwilling to undergo surgical repair, ring pessaries help to keep the pelvic organs in place in many cases.
Surgery for prolapse should be preceded by a thorough evaluation using a scoring system such as the POP-Q, which will reveal which areas require strengthening. Moreover, surgeons who are skilled in using more modern and less invasive techniques of pelvic reconstruction will usually produce better results.
Surgery may be performed vaginally or abdominally with equal effectiveness. Both these routes may be adapted to laparoscopic surgery, which reduces the total recovery time. Complications following surgery may include urinary infection, urinary incontinence, pelvic infection, bleeding from the site of surgery, and sometimes vaginal, rectal, or urinary fistulae. The use of mesh may produce vaginal erosions, which can lead to chronic irritation, dyspareunia, bleeding, and fibrosis.
Recurrence of pelvic organ prolapse is a significant post-operative risk because it is difficult to strengthen the weakened pelvic tissues without using a permanent graft or mesh. The risk may be higher when cystocele surgery is done. The best correction rates are for a rectocele. Recurrence rates are least when the precipitating factors are avoided, and when pelvic floor muscle exercises are begun before the operation and continued regularly after the surgery.