Assessment of pelvic floor dysfunction and prolapse

What is pelvic organ prolapse (POP)?

Pelvic organ prolapse (POP) is the movement of the front wall of the vagina (adjacent to the bladder) and the bladder – cystocele. Posterior wall descent involves movement of the back wall of the vagina with the bowel behind it – rectocele. Descent of bowel loops and the top of the vaginal wall is called an enterocele. Descent of the cervix and/or the uterus is called an apical prolapse. Often some or all of these variables are present together.

The strength of the pelvic floor depends on muscles and supporting tissue (connective tissue) which form a diaphragm. Through this diaphragm passes the bladder, urethra, the vagina and the bowel. The diaphragm itself is supported by ligaments, bones and muscles that make up the pelvic floor.

The issues that relate to the incidence of a symptomatic prolapse include

• Childbirth – especially forceps delivery
• Your age
• The intrinsic strength of your tissues, perhaps genetic factors (including your race)
• Obesity (especially BMIs equal to or over 30kg/per M2.

The role of elective caesarean

The role of elective caesarean section versus vaginal delivery is complex and numerous studies, especially involve issues related to operative obstetric deliveries (forceps deliveries). There is some evidence that ventouse or vacuum deliveries do not significantly change the risk of POP.

What are the symptoms of POP ?

Symptoms of POP include pressure symptoms including the feeling of a lump inside the vagina.

Urinary symptoms are common with a cystocele, stress incontinence or loss of urine on coughing or sneezing, and ultimately a feeling of incomplete emptying of the bladder. Other symptoms involving the bladder include urgency and frequency.

Bowel symptoms are commonly constipation and a feeling of incomplete emptying of the bowel. Incontinence can occur as an uncommon symptom.

Prolapses usually worsen as we age due to gravity, the fact that our tissues weaken, and after the menopause (if untreated with MHT). Oestrogen deficiency weakens tissues further.

What treatment options are available?

Treatment is indicated if symptoms interfere with your quality of life especially incontinence or difficulties with intercourse.

Conservative treatment includes pelvic floor physiotherapy and the use of pessaries – especially suitable for treatment for one to two years, or if you are too unfit for surgery. Pessaries are silicon ring devices that sit under the symphysis pubis and hold up any cystocele, rectocele or apex of the prolapse.
Topical vaginal oestrogens also help strengthen connective tissue in postmenopausal women. The bladder itself has tissue which is also oestrogen dependent and this may help urinary symptoms.

Surgical treatment is especially indicated if symptoms are significant and conservative treatment has failed. A number of procedures are available depending on the nature of the POP.