Dr Eugene Huang
Senior Consultant, SingHealth Duke-NUS Pelvic Floor Disorders Centre; Department of Urogynaecology, KK Women’s and Children’s Hospital

Treatment options for pelvic organ prolapse can vary depending on the patient’s health status, circumstances and preferences. Although a benign urogynaecological condition, resulting complications can be detrimental to a woman’s health. As early diagnosis and management are key to achieving optimal clinical outcomes and patient satisfaction, find out how it can be effectively managed in primary care.

INTRODUCTION

Pelvic organ prolapse occurs due to weakening of the supporting structures of the pelvic floor musculature, ligaments and connective tissues, resulting in the descent of the pelvic organs from their normal positions. These include the uterus, vagina, bladder and rectum.

Women usually present with a protrusion in the genital area or a vaginal bulge, and may also manifest with symptoms relating to urinary, bowel, and/or sexual function. This is a common urogynaecological condition that disproportionately affects older women due to factors such as menopause, pregnancy, childbirth and obesity. Pelvic organ prolapse not only causes physical discomfort, but may also lead to psychological distress, social isolation and loss of independence.

Epidemiology

Based on epidemiological studies, pelvic floor dysfunction resulting in pelvic organ prolapse occurs in about 50% of parous women, and approximately 11% of these women will have undergone a surgical correction by age 80. In women who have undergone hysterectomy, their risk of developing vaginal vault prolapse later in life is about 6 to 8%.

The effects of ageing and the associated physiological changes in the genitourinary tract make elderly women more susceptible to the development of pelvic floor disorders such as prolapse and incontinence.

As global populations age and life expectancy increase, societies around the world including Singapore, are witnessing an unprecedented increase in the proportion of elderly individuals. The ageing population presents unique challenges for health care systems, particularly in addressing age-related conditions that significantly affect a woman’s quality of life such as pelvic organ prolapse.

Therefore, it is imperative for primary care physicians to be aware of this condition, so as to promote prevention, early diagnosis, and holistic management approaches tailored to the needs of women.

DETERMINING THE EXTENT ANDSEVERITY OF PELVIC ORGAN PROLAPSE

Extent

Pelvic organ prolapse is classified based on the extent of pelvic organ descent in relation to the vaginal hymen. The Pelvic Organ Prolapse Quantification (POP-Q) system is the most widely used system to quantify and determine prolapse severity.

Six points along the anterior vaginal wall (Aa, Ba), posterior vaginal wall (Ap, Bp) and at the apex (C, D) relative to the hymen, along with measurements of the genital hiatus (gh), perineal body (pb) and total vaginal length (tvl) are used to quantify prolapse. Points proximal to the hymen are given negative values, whereas points distal to the hymen are given positive values.

Negative values mean that the prolapse is within the vaginal canal.

Positive values mean that the prolapse is beyond the hymen and external protrusion of the prolapse can be seen on physical examination.

The severity of the prolapse is determined by the stage assigned based on the extent of the prolapse and is shown in the table below.

Women with Stage I prolapse are generally asymptomatic and the condition may only be diagnosed at speculum examination, such as during a cervical smear test.

Women with Stage II or higher prolapse will usually present with symptoms such as a heaviness or pressure sensation in the pelvis, lower back discomfort, vaginal bulge, or associated symptoms such as urinary urgency and frequency, sensation of incomplete bladder emptying, difficulty with opening their bowels and dyspareunia.

Complications of pelvic organ prolapse

Even though pelvic organ prolapse is a non-life threatening benign condition, it can be associated with complications, particularly of the urinary tract. Pelvic organ prolapse is a significant cause of bladder outlet obstruction in women.

With increasing stages of prolapse, the risks of voiding dysfunction resulting in chronic urinary retention increases. The associated slow urinary stream andhesitancy makes voiding a hassle for women, and at the same time increasing their risk of recurrent urinary tract infections, urinary tract stones and in the most severe cases, hydronephrosis and renal impairment which can be life-threatening.

Besides urinary complications, women with severe prolapse may present with obstructed defaecation, leading to various physical complications such as rectal prolapse and faecal incontinence. Many women with bowel symptoms need to reduce their prolapse or press on their vagina to empty their bowels and this has a substantial negative impact on their quality of life.

The constant exposure of prolapsed tissues not only results in sexual dysfunction, but also cause dragging sensation affecting mobility and quality oflife, predisposing women to chronic vaginal bleeding, erosions and ulcerations which may lead to infection, anaemia, pain, prolapse irreducibility, and rarely, malignant transformation of chronic ulcers.

Treatment of pelvic organ prolapse

Treatment options for pelvic organ prolapse can be broadly divided into conservative, pelvic floor muscle training, vaginal pessaries and surgical treatment.

• Conservative management and pelvic floor muscle training are useful for mild prolapse (Stage I to II) or for women with minimal symptoms.
• Definitive treatment with vaginal pessaries or surgery is generally recommended for symptomatic women with moderate to severe prolapse (Stage II to IV).

Conservative management

Conservative management includes losing weight and avoiding activities or conditions that increases intra abdominal pressure such as heavy lifting, high-impact physical exercises and constipation.

Pelvic floor muscle training or Kegel exercises involves repeatedly contracting and relaxing the pelvic floor muscles to strengthen the pelvic floor musculature supporting the pelvic organs and their functions.

Women should aim to do at least 3 sets a day. Each set should consist of at least 8 contractions, holding each contraction for at least 10 seconds.

Vaginal pessaries

Vaginal pessaries are mechanical devices to support a prolapsed organ. They need to be correctly sized and can be used in the interim while awaiting surgical treatment.

In Singapore, the ring pessary is the most commonly used device and needs to be replaced every four to six months to prevent infection, vaginal erosions, bleeding and incarceration. Topical vaginal oestrogen therapy can be used for mild vaginal erosions, but severe erosions or infection will require removal of the pessary to allow time for tissue healing.

In women with severe prolapse or in those with avery wide genital hiatus and/or poor pelvic tone who do not desire sexual function, an obliterative pessary such as Gellhorn pessary may be used.

Surgical treatments

The main aims of surgical treatment are to restore the normal anatomy of the prolapsed organs and to reduce prolapse complications. This is achieved via a reconstructive surgical procedure which may be approached vaginally or abdominally (usually vialaparoscopy).

The most common vaginal surgical procedure is vaginal hysterectomy and pelvic floor repair (colporrhaphy), in combination with an apical suspension procedure such as sacrospinous ligament fixation and uterosacral ligament suspension.

In younger women who desire surgical repair durability and minimal effect on sexual function, mesh sacrocolpopexy or sacrohysteropexy can be used to correct apical prolapse. Obliterative surgery such ascolpocleisis (vaginal closure) may be performed in frail and elderly women who cannot tolerate prolonged surgery.

Treatment options and choices must take into account the lifestyle concerns and comorbidities of the woman. It is important to note that treatment should not be based solely on chronological age. Whether and how to treat pelvic organ prolapse depends on the woman’s functional status, degree of bother and her treatment preferences. In general, anatomical prolapse without bothersome or red-flag symptoms rarely requires treatment.

In general, anatomical prolapse without bothersome or red-flag symptoms rarely requires treatment. However, treatment must be considered if the prolapse is associated with the following:

• Bothersome symptoms affecting quality of life
• Depression, poor self-image, impaired participation in social activities
• Associated urinary, bowel and/or sexual symptoms
• Vaginal discomfort and bleeding

Preventing pelvic organ prolapse

Pelvic floor muscle training has been shown to reduce the risk of developing pelvic organ prolapse. Pelvic floor exercises should ideally be supervised and reinforced by a pelvic floor physiotherapist, and it is important to maintain training consistency throughout one’s lifetime.

Maintaining a healthy weight and avoiding obesity will not only reduce prolapse risks, but also improve overall health.

Avoiding activities or conditions that increase intra abdominal pressure such as mechanical factors and straining is important advice that can be given to women.

Other risk factors such as prolonged second stage during labour and instrumental deliveries may be mitigated by avoidance of prolonged labour and judicious use of forceps/vacuum devices for assisted vaginal deliveries.

Managing pelvic organ prolapse in primary care

It is important to assess the woman’s symptoms, degree of bother and severity of the prolapse. Women should be referred to a urogynaecologist if her symptoms are bothersome and affecting quality of life, or if the prolapse is Stage II or higher.

If the prolapse is mild with minimal or no symptoms and amenable to conservative management and pelvic floor muscle training, it is good practice to do a baseline urinary screen to exclude infection and ensure that cervical cancer screening is up to date.

If the prolapse is moderate to severe, assessment for urinary retention using abdominal palpation, bladder scan/ultrasound or in/out catheterisation is recommended. If the post-void residual urine volume is more than 150 ml, intermittent self-catheterisation or insertion of an in dwelling urinary catheter is recommended.

Renal function tests and imaging of the upper urinary tract should be considered to exclude complications such as hydronephrosis and renal impairment due to chronic prolapse, urinary retention and reflux.

WHEN TO REFER

• Prolapse associated with sexual dysfunction
• Prolapse associated with impairment of daily activities or quality of life
• Recurrent pelvic organ prolapse
• Women with a history of urogynaecological surgery presenting with symptoms
• Features of urological compromise associated with pelvic organ prolapse e.g., severe incontinence, hydronephrosis, decline in renal function

CONCLUSIONS

Pelvic organ prolapse is a common urogynaecological condition that has a significant impact on a woman’s quality of life. Although this is a benign condition, it can be associated with complications that can be detrimental to a woman’s health.  Treatment should be tailored to each individual’s health status, circumstances and preferences. Prevention, early diagnosis and management are key to achieving optimal clinical outcomes and patient satisfaction.

REFERENCES

1. Olsen, A.L.; Smith, V.J.; Bergstrom, J.O.; Colling, J.C.; Clark, A.L. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet. Gynecol.1997, 89, 501–506.
2. Aigmueller, T.; Dungl, A.; Hinterholzer, S.; Geiss, I.; Riss, P. An estimation of the frequency of surgery for posthysterectomy vault prolapse. Int. Urogynecol. J. 2009,21, 299–302.
3. Schweitzer, K.J., Vierhout, M.E. and Milani, A.L. (2005), Surgery for pelvic organ prolapse in women of 80 years of age and older. Acta Obstetricia et GynecologicaScandinavica, 84: 286-289.
4. Haylen, B.T., Maher, C.F., Barber, M.D. et al. An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint report on the terminologyfor female pelvic organ prolapse (POP). Int Urogynecol J 27, 165–194 (2016).
5. National Institute for Health and Care Excellence (NICE) guideline. Urinary incontinence and pelvic organ prolapse in women: management. Published 2 April 2019, last updated 24 June 2019. 

Dr Eugene Huang is a senior consultant obstetrician, gynaecologist and subspecialisturogynaecologist at KK Women’s and Children’s Hospital. He has a special interest inminimally invasive surgical techniques for pelvic organ prolapse treatment. He is currently the Section Chair for Urogynaecology of the College of Obstetricians & Gynaecologists, Singapore, and is affiliated with several professional organisations, including the International Urogynecological Association and the International Continence Society.

GPs can call the SingHealth Duke-NUS Pelvic Floor Disorders Centre for appointments at the following hotlines:

Singapore General Hospital                   6326 6060
Changi General Hospital                        6788 3003
Sengkang General Hospital                   6930 6000
KK Women’s and Children’s Hospital   6692 2984