Pelvic organ prolapse (POP) is a condition where the organs within the pelvis shift from their normal positions, often occurring after childbirth. This common health issue affects the pelvic floor, the support structure that helps hold the bladder, uterus, and rectum in place. Though it can be a source of significant discomfort and concern for many postpartum individuals, POP is highly treatable.
Defining Pelvic Organ Prolapse
Pelvic organ prolapse is defined as the descent of one or more of the pelvic organs into or past the vaginal canal, resulting from weakened support structures. The pelvic floor is a complex layer of muscles, fascia, and ligaments that acts like a supportive hammock for these organs. When this support system is damaged or overstretched, the organs may drop down, creating a noticeable bulge in the vagina.
The specific organ involved determines the type of prolapse. A Cystocele, the most frequent type, occurs when the bladder bulges into the front (anterior) wall of the vagina. If the rectum pushes into the back (posterior) wall of the vagina, it is called a Rectocele. When the uterus descends into the vaginal canal, it is known as Uterine Prolapse. The small bowel can also drop into the upper part of the vagina, which is classified as an Enterocele.
Recognizing the Symptoms and Causes
Symptoms
The physical signs of prolapse can vary greatly; some women experience no symptoms at all, while others have significant discomfort. A common subjective symptom is a feeling of heaviness, pressure, or a dragging sensation in the pelvis, often worsening by the end of the day or after physical activity. Individuals may feel or see a soft lump or bulge of tissue at or protruding from the vaginal opening.
Functional symptoms often include difficulties with urination, such as frequency, a constant urge to go, or the feeling of incomplete bladder emptying. Bowel function can also be affected, leading to constipation or the need to manually support the vaginal wall to complete a bowel movement, a technique known as splinting. Discomfort or pain during sexual intercourse is also a reported symptom.
Causes
The primary risk factor is vaginal delivery, which can injure the pelvic floor muscles and connective tissues. Specific delivery factors that increase this risk include the use of instruments like forceps or vacuum extractors, which place considerable strain on the pelvic floor. Delivering a large baby or experiencing a prolonged second stage of labor, the pushing phase, also contributes to trauma to the support structures.
Conservative Management Options
For mild to moderate prolapse, conservative management is the first line of defense and can be highly effective in managing symptoms. Lifestyle modifications focus on reducing chronic intra-abdominal pressure, which constantly strains the pelvic floor. This includes maintaining a healthy weight and preventing constipation through a high-fiber diet and adequate hydration.
Pelvic Floor Physical Therapy (PFPT) is a cornerstone of conservative treatment, focusing on strengthening and coordinating the pelvic floor muscles. PFPT is more comprehensive than simple Kegel exercises, often involving biofeedback, manual therapy, and training to ensure proper muscle relaxation and coordination with the core and breathing.
A pessary is a non-surgical device, typically made of medical-grade silicone, that is inserted into the vagina to provide mechanical support to the prolapsed organs. Pessaries come in many shapes and sizes, generally categorized as support or space-filling devices. Support pessaries, such as the Ring pessary, are often used for milder prolapse, while space-filling types, like the Gellhorn or Cube pessary, are reserved for more advanced cases.
Surgical Intervention
Surgery becomes an option when conservative treatments fail to provide adequate symptom relief or in cases of severe, high-grade prolapse. The goal of surgical intervention is to restore the pelvic organs to their natural anatomical position and alleviate discomfort. The surgical approach is divided into two primary repair methods: native tissue repair and mesh-augmented repair.
Native Tissue Repair (NTR)
Native Tissue Repair (NTR) uses the patient’s own ligaments and fascia to reconstruct and reinforce the vaginal walls. Procedures like anterior or posterior colporrhaphy are common examples and avoid the risks associated with foreign materials. While NTR is a safe option, it is associated with a higher rate of prolapse recurrence compared to augmented repairs.
Mesh-Augmented Repair
Mesh-Augmented Repair involves using a synthetic material, like surgical mesh, to reinforce the weakened support structures. Procedures like sacrocolpopexy, often performed abdominally or robotically, offer superior anatomical success and a lower recurrence rate for apical prolapse. However, this method carries risks of mesh-related complications, including erosion, infection, chronic pain, or new urinary symptoms.