Pelvic Organ Prolapse: Help and Hope
By Sherrie Palm
Pelvic organ prolapse is an extremely common female health condition that has been on medical record for over 4000 years; unfortunately receives little acknowledgment. Women in every country around the world experience symptoms of POP yet have little idea what is occurring in their bodies because they are embarrassed to discuss them with anyone. It's long past time to shift recognition and establish a dialogue.
Pelvic organ prolapse (POP) can occur when the PC or pelvic floor muscles weaken and one or more organs shift out of their normal positions into the vaginal canal. In advanced cases of POP, tissues push through the vaginal canal and bulge outside of the body. The worst case scenario is a woman's uterus can be completely outside of the vagina. There are 5 types of POP; organs that can prolapse are the bladder (cystocele), intestines (enterocele), rectum (rectocele), uterus (uterine), and vagina (vaginal vault). There are 4 levels of severity; grade 1 is the mildest, grade 4 the most severe.
Statistical capture for prevalence of pelvic organ prolapse in most countries is sorely lacking and difficult to estimate because there is little screening in place and many women are too embarrassed to mention symptoms to their physicians. The current estimate of pelvic organ prolapse occurrence in the US is 3.3 million. POP is common in both developed and developing countries; there are 600,000 women in Nepal with uterine prolapse. A World Health Organization (WHO) study indicated that half of the women in Lebanon had at least 1 type of prolapse. ‘Guestimates’ indicate that there are 34 million women worldwide with POP and studies frequently estimate that up to 50% of the female population has POP. The reality is we truly don't know what the real figures are-there has been no accurate stat capture to date.
Vaginal childbirth and menopause are the 2 leading causes of pelvic organ prolapse;nearly every woman has at least 1 hash mark on her risk factor profile. Women with POP typically have multiple risk factors, but even 1 damaging child birthing experience can be sufficient to cause problems that evolve into pelvic organ prolapse. Women in every age demographic experience pelvic organ prolapse.
POP studies frequently have prominent numbers of women over the age of 50 and Caucasian, rather than including young women who have given birth and a more diverse balance of women from multiple races and nationalities. Accurate data related to occurrence and impact of pelvic organ prolapse will be more readily attainable after pelvic organ prolapse becomes common knowledge. Because studies related to pelvic organ prolapse are now beginning to become more widespread, statistics may shift significantly in the near future. Frequently women do not disclose indicators of pelvic organ prolapse to physicians because of embarrassment related to symptoms.
Some current statistics related to pelvic organ prolapse are:
- Research frequently estimates that up to 50% of women experience pelvic organ prolapse;
- 40-70% of women experience urinary incontinence (stats vary significantly by study, not all UI is related to POP but UI is a common symptom of POP);
- There are 300,000 surgeries annually in the US for POP;
- Nearly 1/3 of women of women with pelvic organ prolapse will have multiple POP surgeries;
- 1 out of 3 women suffer sphincter damage during childbirth resulting in fecal incontinence;
- 20% of the women in the UK waiting for major gynaecological surgery are women with pelvic organ prolapse;
- In 2016, nearly 10 million women in the U.S. finished road races; 30-70% of women experience urinary leakage while exercising (running, jogging, aerobics).
Research related to vaginal childbirth indicates that women are predisposed to the following types of damage that lead to pelvic organ prolapse:
- Pressure on organs/tissues;
- Pudendal (nerve) denervation (crush or stretch);
- Levator Ani Denervation;
- Connective tissue damage (fascia);
- Pelvic floor muscle weakening;
- Mechanical disruption of rectal sphincter.
Each of the 5 types of POP has its own symptoms, but in general the most common symptoms can include:
- Pressure, pain, or ‘fullness’ in vagina or rectum or both;
- Sensation of ‘your insides falling out’, vaginal tissue bulge;
- Urinary incontinence;
- Urine retention;
- Fecal incontinence;
- Chronic constipation;
- Back/pelvic pain;
- Tampons pushing out;
- Painful intercourse;
- Lack of sexual sensation;
- Coital incontinence (leakage of urine or stool during intimacy).
There are multiple causes of POP; factors vary with age and it is likely that most women have more than one cause of significance and additional contributing factors that add to individual dynamic. The most common causes of POP are:
- Vaginal childbirth - complications from large birth weight babies, long 2nd stage labor, nerve damage, forceps or suction deliveries, multiple childbirths, improperly repaired episiotomy; impact of childbirth may occur immediately after a difficult delivery or may not show up until 20 years later;
- Menopause - age related pelvic floor muscle tissue integrity impact due to drop in estrogen level; this impacts strength, elasticity, and density of muscle tissue;
- Chronic constipation - IBS (irritable bowel syndrome), poor diet, or lack of exercise may impact regularity, repetitive downward pushing to have a bowel movement pushes pelvic tissues down repetitively;
- Chronic coughing - smoking, allergies, bronchitis, and emphysema can create chronic coughing jerking tissues down;
- Heavy lifting - lifting children, repetitive heavy lifting at work, weight trainers;
- Aggressive exercise - joggers, marathon runners, aerobics-repetitive downward pounding of internal structures;
- Genetics - a family member with POP means you may be predisposed to POP;
- Neuromuscular diseases - MS, diabetic neuropathy, Marfan (collagen deficiency), or Ehlers-Danlos Syndrome (joint hypermobility and tissue fragility).
It is also possible for women who have never given birth to have POP; there are several non-childbirth related causes.
The diagnostic process for pelvic organ prolapse will vary, based on type your physician suspects you have and the tests your physician is familiar with and prefers to utilize. Traditionally the basic check for POP will start with a pelvic exam. Once it is determined you have pelvic organ prolapse, additional tests that may be required are:
- Digital rectal exam;
- Pelvic ultrasound;
- Pelvic MRI;
- Urodynamic study;
- Pelvic floor strength tests;
- Hormone level evaluation;
There are multiple treatment options for pelvic organ prolapse, both surgical and non-surgical. The first step is to get a definitive diagnosis of type(s) and degree of pelvic organ prolapse. Since there are multiple layers to the POP dynamic, you are most likely to have success with your treatment path of choice if you know exactly what kinds of POP need to be treated. Each treatment has unique benefits, and which choice you make will be influenced by your personal dynamic, type of POP, whether or not you are through having children, age, length of time you have been suffering with symptoms, intensity of symptoms, additional medical conditions, your desire to have an active sex life, and financial considerations.
The specialists who are Female Pelvic Medicine Reconstructive Surgery (FPMRS) trained in pelvic organ prolapse may be urogynecologists or urologists. Gynecologists and primary care physicians will diagnose pelvic organ prolapse, but a POP specialist will give you greater potential for successful treatment. A FPMRS urogynecologist or urologist will be able to advise patients about both surgical and non-surgical treatment options.
Surgical Treatment Options
There are multiple surgical treatment options for pelvic organ prolapse; once a definitive diagnosis is in place, you surgical choices will be outlined by your physician. Surgical treatment options include a variety of choices within each category; type utilized will vary with type/degree of POP and surgeon/patient choice:
- Abdominal repair;
- Transvaginal repairs (through the vagina);
- Robotic repairs;
- Laparoscopic repairs;
- Combinations of the above.
Most urogynecologists utilize polypropylene mesh for many pelvic organ prolapse procedures to provide a sustainable repair. There is considerable controversy regarding the use of polypropylene mesh for transvaginal procedures; some physicians refuse to utilize mesh in any POP repairs, others use it exclusively for abdominal procedures, some use it for both. A significant number of POP surgeons feel it is an intricate tool for long term results. Worth noting is the fact that POP repairs that do not incorporate mesh frequently fail in 1-5 years because stitching weakened or damaged human tissue for support typically fails in time.
Non-surgical Treatment Options
Often when women prefer non-surgical treatment, they are referred to physical therapists or physiotherapists. Women's Health physical therapists have a significant variety of treatment options they can offer a woman with pelvic organ prolapse; since women's needs vary considerably based on type/degree of prolapse; treatment regimens will be unique from woman to woman.
There are multiple non-surgical treatment options for POP, often women will utilize two or three treatment options at the same time for the best improvement of their symptoms. Non-surgical treatment options include:
- Kegel Exercises;
- Kegel assist devices;
- Core/floor strengthening exercises (hab-it, pilates, Pfilates);
- Electrical Stimulation;
- Hormone replacement therapy;
- Support garments;
- Tibial nerve stimulation.
Impact to Intimacy
One aspect of pelvic organ prolapse that is significant and receives little press time is the impact of POP to intimacy. Coital incontinence (urine or stool leakage during intercourse), painful intercourse, or loss of sensation can have significant ramifications to an intimate relationship. Open communication between partners is ideal, but seldom occurs with the embarrassing symptoms that pelvic organ prolapse displays. Spontaneity is difficult to achieve and any of these symptoms can create a significant gap in communication. The norm is women are too embarrassed to disclose these symptoms to their partners, and men assume women are not engaging in intimacy because they have no interest. The impact to relationships is considerable. When a medical condition is not disclosed to intimate partners, it creates boundaries that are difficult to overcome. When women are not aware of the cause of the symptoms they are experiencing and are too embarrassed by them to disclose details to their physicians, they usually have no idea how to address them.
Help and Hope for Women
Pelvic organ prolapse is a global women's health pandemic; since vaginal childbirth and menopause are the two leading causes, nearly every woman has at least one hash mark on her risk factor profile. Pelvic organ prolapse undoubtedly encompasses the widest demographic of all women's health issues. The dynamic behind pelvic organ prolapse is likely more diverse than any other health condition women will experience. Multiple types of pelvic organ prolapse display a variety of symptoms; women's unique childbirth, occupation, genetics, general health, and social activities history vary significantly. The demographic variable are diverse. Countless women suffer silently with symptoms they don't understand. When we don't recognize the cause of symptoms, our minds can be our worst enemies, imagining the most negative scenario.
There is help and hope for women with POP; treatment options evolve daily that can be utilized to control, improve, or repair this cryptic health condition. The most positive direction we can take is to increase awareness to enable women to recognize POP symptoms when they first occur. Women who have been diagnosed with POP need to come out of the closet with their diagnosis and treatment paths and share that information with other women, their mothers, their daughters, their sisters, their friends. Once we take pelvic organ prolapse out of the closet and make it common knowledge for women, routine screening protocol for pelvic organ prolapse during pelvic exams is established, POP will become more readily identifiable and women will be able to seek earlier, less aggressive treatment.