Pelvic organ prolapse means prolapse or drop of pelvic organs (bowel, bladder, rectum or uterus) from its normal position or in other words the muscles, ligaments and tissues that support pelvic organs becomes weak to hold organs in place. It occurs when a group of muscles and tissues that support the pelvic organs becomes weak and cannot hold the organs firmly in their place.

In an interview with HT Lifestyle, Richa Bathla, Lactation Consultant and Women’s Health Physiotherapist at Cloudnine Group of Hospitals in Faridabad, shared that there are various factors that weaken pelvic floor and increase the chances of developing pelvic organ prolapse are -

• Being overweight
• History of Hysterectomy
• Undergoing menopausal phase
• Multiple vaginal child birth having twins or triplets
• Long term pressure in abdominal cavity such as chronic coughing, chronic constipation and heavy weight lifting increase chance of developing POP.
• Family history of POP
• Collagen irregularities like Ehlers Danlos syndrome in which connective tissue of pelvic floor becomes weak leading to Pelvic organ prolapse.

Different types of Prolapse:

According to Richa Bathla, the types of prolapse depends upon the weakness in pelvic floor and what organs are affected.

• Anterior vaginal wall prolapse (dropped bladder) - It occurs due to weak Pelvic floor muscles above vagina causing bladder to slip out of its place and bulge into vagina. This anterior vaginal wall prolapse is the most common type of POP, also known as Cystocele.
• Uterine prolapse - It occurs due to weakening of pelvic floor muscles causing uterus to drop into vaginal canal.
• Posterior vaginal wall prolapse (dropped rectum) - It occurs due to weakening of pelvic floor muscles between vagina and rectum, causing rectum to bulge into back wall of vagina. This type of prolapse is known as rectocele.
• Vaginal vault prolapse - It basically happens after hysterectomy when uterus is removed and top part of vagina drop into vaginal canal.
• Enterocele - It occurs due to weakening of pelvic muscles causing small intestine to bulge into top of vagina.

Symptoms:

Uterine prolapse is most common after childbirth. Richa Bathla revealed that the symptoms of uterine prolapse are -

• Feeling heaviness in the pelvis
• Feeling tissue bulge out of vagina.
• Uncontrolled leakage of urine (incontinence)
• Discomfort in pelvis or lower back
• Sexual concerns-feeling as such vaginal tissue is loose.
• Always urge of passing urine even if the bladder is empty.

She said, “Other symptoms includes heaviness, bulging inside or outside of the vagina, lower back pain, pain during intercourse (dyspareunia), bladder and/or bowel problems such as feeling of incomplete emptying after voiding.”

Diagnosis and Assessment:

Richa Bathla explained, “Diagnosis of POP begins with medical history and examination of pelvic organs which helps healthcare professional to find out type of prolapse a person has. Certain tests are done to find out POP. It includes Pelvic floor strength test (healthcare professional test the strength of pelvic floor and sphincter muscles during pelvic examination) and second one; Bladder function test (it measures how well the bladder empties and also whether bladder leaks when it is held in place during pelvic examination).” She elaborated -

Pelvic examination: In case of urinary incontinence patient needs to be examined with full bladder and patient is asked to cough or strain and leakage of urine confirms positive stress provocation stress. Examination in lithotomy position can be done if there is any vaginal bulge visible. Examination is done in standing, dorsal position, per vaginal and recto vaginal examination can be done if there is vaginal wall and uterine prolapse.

Assessment: Depending on presence of symptoms and severity of prolapse, various tests are included such as-

• Urinary Ultrasound to assess the emptying of bladder.
• Urodynamic study to check the blockage related to prolapse, bladder function and severity of urinary incontinence.
• Trial of vaginal pessary to check whether prolapse can be corrected.

Grading of Prolapse:

• First degree: The lowest part of the prolapse lies above the introitus (opening of the vagina).
• Second degree: The lowest part of the prolapse extends to the level of the introitus on straining.
• Third degree: The lowest part of the prolapse extends through the introitus and lies outside the vagina.

Pelvic organ prolapse treatment:

As per Richa Bathla, it includes conservative treatment -

• Pelvic floor exercises.
• Drink plenty of fluids and high fibre such as fruits, vegetables and whole grains to prevent constipation.
• Avoid heavy weight lifting- posture should be taken care while lifting weights.
• Maintain weight by following healthy lifestyle and diet.
• Quit smoking
• Strengthen and retrain your pelvic floor muscles to support pelvic organs.
• Posture movement-advice correct posture and movement to prevent strain on pelvic floor muscles. Avoid prolonged standing and try to take break in between.
• Bowel movement retraining-Training how to pass motions without straining pelvic floor muscles.
• Try lower impact exercises like Pilates, yoga, swimming, walking and cycling. High impact exercises should be avoided like jumping and running.
• Vaginal pessary can be used.
• Abdominal or tummy massage helps to improve natural movement of bowel.
• Holding on technique for patients who have faecal urgency

On the other hand, surgical treatments depends upon type and degree of prolapse. It includes-

• Mesh repair-It is indicated in case of severe prolapse to enhance degree of support to pelvic floor preventing its recurrence.
• Pelvic floor repair- If the urethra, bladder, rectum or intestines protrude through the vaginal wall, then pelvic floor will be repaired and strengthened with sutures to correct the prolapse.
• Vaginal hysterectomy-This is done when uterus protrudes through vaginal opening.
• Sacrospinous ligament fixation- This is done in cases of severe uterine prolapse and to reduce the chance of prolapse recurrence.

Impact of POP on women's lives:

• Patients suffer from anxiety and depression, isolation in relationship, disturbing sleep pattern, increased stress and low self-esteem.
• Patients feel a sense of isolation when they suffer from prolapse. It creates an embarrassing situation among friends, family and partners. It is seen that patients experiencing incontinence face a lot of anxiety while travelling as they are always worried about accessibility of toilets causing them to limit themselves to specific location restricting social gathering and short trips even, resulting in loss of confidence.
• There is an increased emotional stress caused by fear of personal hygiene issues such as odour from urine or faeces and soiling clothes in public.
• POP can impact the most intimate parts of our body affecting sexual relationship. Fear of acceptance and understanding sexual partner can lead to anxiety.

According to some studies, the weakness of pelvic muscles could contribute to the inability of a woman to achieve orgasm and women who had anorgasmia showed a significantly lower pubococcygeus muscle strength as compared with those who had orgasm.