pelvic organ prolapse
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Classification
- first degree: extension to the mid vagina
- second degree: approaching the hymenal ring
- third degree: at the hymenal ring
- fourth degree: beyond the hymenal ring
Epidemiology
- common in postmenopausal women
Physical examination
- pelvic examination
- pelvic organ prolapse can only be demonstrated in the supine position if the patient can generate adequate intra-abdominal pressure
- examination in the standing position if patient cannot generate adequate intra-abdominal pressure[3]
Clinical manifestations
- commonly occurs in association with stress urinary incontinence
- prolapse may wax & wane
- over a period of 4 years, maximal vaginal descent
- increasing body-mass index & history of >= 5 vaginal deliveries increases risk for progression of prolapse
- lower abdominal or pelvic tenderness, heaviness, pressure may be noted
- dyspareunia
- retroflexed uterus
Complications
- complications of mesh surgical repair[2]
- most frequent complications
- erosion through vaginal epithelium
- infection
- pain
- urinary problems
- recurrence of prolapse and/or incontinence
- other complications
- bowel, bladder, and blood vessel perforation during insertion
- vaginal scarring & mesh erosion
- most frequent complications
Management
- pelvic floor muscle training (Kegel exercises) may be useful for mild cases[9]
- unclear role in managing uterine prolapse (NEJM)[17]
- vaginal pessary[15]
- addition of vaginal pessary more effective than Kegel exercises alone[11]
- other indications
- patient does not want surgery
- need to delay surgery
- patient is poor surgical candidate[3]
- twice weekly vaginal estrogen also recommended[15]
- initial strategy of pessary therapy inferior to surgery for improvement at 24 months[16]
- surgical repair
- avoid pelvic mesh procedures[2][7][8][10]
- failure rate of surgical repair increases over time[4]
- not much benefit at 7 years
More general terms
More specific terms
- cystocele; vesicocele; bladder prolapse; anterior prolapse
- prolapse of the uterus; cervical incompetence; pudendal hernia
- rectocele; proctocele; rectal procidentia
References
- ↑ Bradley CS, Zimmerman MB, Qi Y, Nygaard IE. Natural history of pelvic organ prolapse in postmenopausal women. Obstet Gynecol. 2007 Apr;109(4):848-54. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17400845
- ↑ 2.0 2.1 2.2 FDA MedWatch Transvaginal Placement of Surgical Mesh http://www.fda.gov/medwatch/safety/2008/safety08.htm#Mesh
FDA NEWS RELEASE: July 13, 2011 FDA: Surgical placement of mesh to repair pelvic organ prolapse poses risks http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm262752.htm - ↑ 3.0 3.1 3.2 Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - ↑ 4.0 4.1 Nygaard I et al Long-term Outcomes Following Abdominal Sacrocolpopexy for Pelvic Organ Prolapse. JAMA. 2013;309(19):2016-2024. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23677313 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=1687577
Iglesia CB Pelvic Organ Prolapse Surgery. Long-term Outcomes and Implications for Shared Decision Making. JAMA. 2013;309(19):2045-2046 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23677317 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=1687565 - ↑ Kuncharapu I, Majeroni BA, Johnson DW. Pelvic organ prolapse. Am Fam Physician. 2010 May 1;81(9):1111-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20433127
- ↑ Miedel A, Tegerstedt G, Morlin B, Hammarstrom M A 5-year prospective follow-up study of vaginal surgery for pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2008 Dec;19(12):1593-601 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18696002
- ↑ 7.0 7.1 FDA News Release: April 29, 2014 FDA issues proposals to address risks associated with surgical mesh for transvaginal repair of pelvic organ prolapse. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm395192.htm
- ↑ 8.0 8.1 Maher CM, Feiner B, Baessler K, Glazener CM. Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review. Int Urogynecol J. 2011 Nov;22(11):1445-57 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21927941
- ↑ 9.0 9.1 Wiegersma M et al. Effect of pelvic floor muscle training compared with watchful waiting in older women with symptomatic mild pelvic organ prolapse: Randomised controlled trials in primary care. BMJ 2014 Dec 22; 349:g7378 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25533442 <Internet> http://www.bmj.com/content/349/bmj.g7378
- ↑ 10.0 10.1 FDA News Release. January 4, 2016 FDA strengthens requirements for surgical mesh for the transvaginal repair of pelvic organ prolapse to address safety risks. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm479732.htm
- ↑ 11.0 11.1 Cheung RY, Lee JH, Lee LL, Chung TK, Chan SS. Vaginal pessary in women with symptomatic pelvic organ prolapse: A randomized controlled trial. Obstet Gynecol 2016 Jun 6 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27275798
- ↑ Hagen S et al. Pelvic floor muscle training for secondary prevention of pelvic organ prolapse (PREVPROL): A multicentre randomised controlled trial. Lancet 2016 Dec 20 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28010994 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32109-2/abstract
Dekker JH. Pelvic organ prolapse: Prevention by training? Lancet 2016 Dec 20 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28010990 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32108-0/abstract - ↑ Glazener CM, Breeman S, Elders A et al. Mesh, graft, or standard repair for women having primary transvaginal anterior or posterior compartment prolapse surgery: Two parallel-group, multicentre, randomised, controlled trials (PROSPECT). Lancet 2016 Dec 20 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28010989 Free Article <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31596-3/abstract
Brincat C, Brubaker L. Mesh, graft, or standard repair for prolapse surgery? Lancet 2016 Dec 20 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28010987 Free Article <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32595-8/abstract - ↑ Morling JR, McAllister DA, Agur W et al. Adverse events after first, single, mesh and non-mesh surgical procedures for stress urinary incontinence and pelvic organ prolapse in Scotland, 1997-2016: A population- based cohort study. Lancet 2016 Dec 20; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28010993 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32572-7/abstract
McAchran SE, Goldman HB. Synthetic midurethral slings redeemed. Lancet 2016 Dec 20 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28010988 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32597-1/abstract - ↑ 15.0 15.1 15.2 Gold RS, Baruch Y, Amir H et al. A tailored flexible vaginal pessary treatment for pelvic organ prolapse in older women. J Am Geriatr Soc 2021 Sep; 69:2518. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33979457 https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17223
- ↑ 16.0 16.1 Thomas A Findings Question Value of Pessary for Pelvic Organ Prolapse. Medscape. January 03, 2023 https://www.medscape.com/viewarticle/986430
van der Vaart LR, Vollebregt A, Milani AL et al Effect of Pessary vs Surgery on Patient-Reported Improvement in Patients With Symptomatic Pelvic Organ Prolapse. A Randomized Clinical Trial. JAMA. 2022;328(23):2312-2323. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36538310 https://jamanetwork.com/journals/jama/article-abstract/2799654 - ↑ 17.0 17.1 NEJM Knowledge+ No authors listed Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214. Obstet Gynecol. 2019 Nov;134(5):e126-e142 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31651832
Doshani A, Teo RE, Mayne CJ, Tincello DG. Uterine prolapse. BMJ. 2007 Oct 20;335(7624):819-23. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17947787 PMCID: PMC2034734 Free PMC article. Review.