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Pelvic Organ Prolapse
Pelvic organ prolapse refers to descent (or prolapse) of the vaginal walls and/ or uterus below their normal positions. In severe cases, the vaginal walls or cervix protrude beyond the vaginal opening and are visible or palpable outside the body.
Many women with pelvic organ prolapse report problems with bladder and bowel functions. However, these symptoms are not always due to pelvic organ prolapse and therefore accurate diagnosis is very important. Symptoms that are often associated with pelvic organ prolapse include urinary incontinence, difficult urination, discomfort with sexual intercourse, stool incontinence, difficult defecation, low back pain and low abdominal pain.
Traditionally, sub-types of pelvic organ prolapse were named for the adjacent organ: for example, prolapse of the vaginal wall adjacent to the rectum has been called a "rectocele". This implies that something is wrong with the rectum itself, but the problem stems from weaknesses of the vaginal wall and its muscular and ligamentous supports. Other examples of traditional names for types of prolapse include cystocele, urethrocele, uterine prolapse, enterocele, and rectocele. The phrase "pelvic relaxation" has also been used.
In most cases, pelvic organ prolapse is diagnosed during a gynecologic (pelvic) examination. By observing the position of the vaginal walls and cervix, the physician can identify areas of prolapse. Usually, the woman is examined while straining or bearing down to demonstrate all areas of prolapse. The position of various sites of prolapse can be measured to identify areas of mild, moderate, or severe weaknesses in support.
In some cases, "defecography" will be recommended. This x-ray test is especially useful in women with difficult defecation or rectal prolapse. Among women with urinary symptoms, urodynamic studies may be useful to clarify the relationship between prolapse and bladder function. Cystoscopy may also be recommended to identify weaknesses in the support of the vaginal wall adjacent to the bladder.
Some women with pelvic organ prolapse have minimal symptoms and do not require treatment. For a woman who is bothered by the symptoms from her prolapse, there are two treatment options. For women who choose to avoid surgery, the best option is a support device called a "pessary". This is an internal vaginal device, usually made of silicone, that supports the vaginal walls. A woman who chooses this option is fitted with an appropriate pessary during a gynecologic examination. Once inserted into the vagina, the pessary should be comfortable and should stay in place with a variety of activities. Most pessaries should be removed and reinserted periodically, at least once a week. Most women are able to remove and reinsert the pessary themselves. Some pessaries can be worn comfortably during intercourse, while others must be removed for intercourse.
The second option for the treatment of pelvic organ prolapse is surgery. The physician will recommend a specific type of surgery, based on the specific weakness(es) of the ligaments and the specific areas of prolapse. A combination of several surgical procedures may be performed at one time to correct multiple areas of prolapse within the pelvis. At Hopkins, we perform over a dozen different types of surgery for prolapse and select the procedure(s) based on the individual woman's needs.
Faculty at Johns Hopkins have been actively involved in research on the anatomy of vaginal support and the causes of pelvic organ prolapse. In addition, women with prolapse who receive their care at Hopkins may be eligible to participate in one of several ongoing research studies, some sponsored by the National Institutes of Health. One project is designed to determine which types of pessaries provide the best results for women with pelvic organ prolapse. Several other projects will determine which surgeries are most successful for treating women with certain types of pelvic organ prolapse.