II. Definition

  1. Pelvic organs (Bladder, Uterus, vagina) protrudes out of vaginal canal
    1. Herniation of anterior vaginal wall (2-3 fold more common than posterior and apical prolapse)
    2. Herniation of posterior vaginal wall
    3. Herniation of vaginal apex (Uterus, Cervix, vaginal cuff)
  2. Pelvic Organ Prolapse replaces older terms (Cystocele, Uterocele, Rectocele)
    1. Reflects uncertainty on examination of which organs are actually prolapsing

III. Epidemiology

  1. Prevalence increases with age and peaks at 5% for those over age 60 years old

IV. Pathophysiology

  1. Levator ani Muscle
    1. Normally supports the vagina from prolapse in the face of increased intraabdominal pressure
    2. When levator ani loses tone, vaginal opening widens, allows pelvic organs to prolapse
    3. Levator ani is injured in 21-36% of vaginal deliveries in Nulliparous women
      1. Dietz (2005) Obstet Gynecol 106(4): 707-12 [PubMed]
  2. Other factors
    1. Connective tissue weakening
    2. Pudendal nerve injury from child birth

V. Grading: Braden-Walker System (with quatification system)

  1. Evaluate when patient performing valsalva or straining
  2. Grade 0: No prolapse
  3. Grade 1: Descent halfway to hymen (or greater than 1 cm above hymen)
  4. Grade 2: Descent to the hymen (within 1 cm of hymen)
  5. Grade 3: Descent halfway passed the hymen (>1 cm below the hymen, but not completely protruding)
  6. Grade 4: Maximal possible descent

VI. Grading: Older system

  1. First-degree: On pressing on perineum, Cervix visible
  2. Second-degree: Cervix protrudes via vaginal introitus
  3. Third-degree: Entire Uterus is external to introitus

VII. Symptoms

  1. Asymptomatic in most patients
  2. Peristent pelvic pressure provoked by straining, standing, lifting, coughing or physical exertion
  3. Patient notes protruding tissue or bulging from introitus (most specific for prolapse)
  4. Spotting or bleeding per vagina
  5. Vaginal Discharge (typically with complete Uterine Prolapse)
  6. Patients may apply pressure to perineum or posterior vagina to aid stool evacuation

VIII. Signs

  1. Exam is variable
    1. Prolapse findings vary by day, Bladder fullness, rectal fullness
    2. Observe for prolapse with speculum
      1. Observe Cervix or vaginal cuff on valsalva
      2. Observe anterior and posterior vaginal walls on valsalva
  2. Uterine Prolapse on provocative maneuvers
    1. Valsalva
    2. Standing

IX. Imaging

  1. Bedside Ultrasound
    1. Measure post-void residual
    2. Evaluate for Hydronephrosis

XI. Risk Factors

  1. Decreased support of pelvic organs
    1. Multiparous women (most commonly associated risk factor)
      1. Vaginal deliveries
      2. Prolonged labor, instrumented delivery, episiotomy
    2. Advanced age (esp. Menopause)
    3. Prior Hysterectomy
    4. Connective Tissue Disorders (Ehlers-Danlos Syndrome)
  2. Increased intraabdominal pressures
    1. Overweight or obese
    2. Constipation
    3. Heavy lifting
    4. Ascites
  3. Nerve disorders (especially affecting pudendal nerve)
    1. Spina Bifida Occulta

XII. Complications

  1. Urinary Incontinence
    1. Stress Incontinence (40%)
  2. Voiding dysfunction
    1. Overactive Bladder (37%)
    2. Bladder outlet obstruction
  3. Rectal dysfunction
    1. Fecal Incontinence (50%)
    2. Incomplete Defecation
  4. Sexual Dysfunction

XIII. Management

  1. General Measures
    1. Treat Constipation
    2. Weight loss in Obesity
    3. Tobacco Cessation
    4. Avoid heavy lifting
  2. Indications for more aggressive management
    1. Hydronephrosis from ureteral kinking
    2. Recurrent Urinary Tract Infections
    3. Bladder outlet obstruction with ureteral reflux
    4. Severe cervical or vaginal erosions
  3. Mechanical Support
    1. Kegal Exercises (Pelvic Floor Exercises)
      1. Improves Stress Incontinence and Urge Incontinence
      2. Does not treat or reverse Pelvic Organ Prolapse
    2. Pessary
      1. First choice intervention for two thirds of Pelvic Organ Prolapse patients
      2. High level of compliance (77% continue Pessary beyond 1 year)
      3. Effective for all levels of prolapse stages
  4. Medications
    1. Consider Estrogen Replacement Therapy
  5. Surgery
    1. Hysterectomy or hysteropexy
    2. Trasvaginal sacrospinous fixation (sacrocolpopexy)
      1. Placed abdominally or transvaginally
      2. However, transvaginal mesh is associated with complications and no longer recommended for most patients
    3. Colpocleisis
      1. Obliterative surgery for high risk patients with multiple comorbidity
      2. Highest cure rate with lowest morbidity
      3. Only applicable to women who no longer wish to have vaginal intercourse

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Related Studies

Ontology: Rectocele (C0149771)

Definition (MSHCZE) Sakovité vyklenutí a pokles konečníku do oblasti introitu při descensu pochvy a dělohy. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (MSH) A hernial protrusion of part of the rectum into the vagina. (Dorland, 28th ed)
Concepts Disease or Syndrome (T047) , Acquired Abnormality (T020)
MSH D020047
ICD9 618.04
ICD10 N81.6
SnomedCT 447072005, 266658002, 155991000, 62730001
English Rectocele, Proctocele, Rectocoele, rectocele, vaginal rectocele, rectocele (diagnosis), rectocele (physical finding), Proctoceles, Rectoceles, Rectocele [Disease/Finding], rectoceles, proctocele, Herniation of rectum into vagina, Rectovaginal prolapse, Herniation of rectum into vagina (disorder), Rectovaginal hernia, hernia; rectovaginal, rectovaginal; hernia, Proctocele, NOS, Rectocele, NOS, rectocoele
Swedish Ändtarmsbråck
Japanese チョクチョウリュウ, 経腟直腸脱, 直腸瘤, 直腸脱-経腟, 直腸脱-腟内, 腟内直腸脱
Czech výhřez konečníku, rektokéla, Rektokéla
Finnish Rektoseele
Italian Proctocele, Rettocele
Korean 직장류
Polish Przepuklina odbytnicy
Spanish herniación de recto en vagina, prolapso rectovaginal, herniación de recto en vagina (trastorno), hernia rectovaginal, proctocele, rectocele (trastorno), rectocele, Rectocele
Hungarian Rectocele
Norwegian Rektocele, Proktocele
Dutch hernia; rectovaginaal, rectovaginaal; hernia, Rectoklel, rectokèle, Rectocele, Rectokèle
Portuguese Rectocelo, Retocele
French Rectocèle, Proctocèle
German Rektozele

Ontology: Prolapse of female genital organs (C0156349)

Concepts Disease or Syndrome (T047)
ICD9 618
SnomedCT 155995009, 198283007, 155989008, 73998008
English Genital prolapse NOS, genital prolapse, genital prolapse (diagnosis), prolapse genital, Genital prolapse (disorder), Genital prolapse NOS (disorder), Genital prolapse, Prolapse of female genital organs (disorder), genital; prolapse, prolapse; genital, Genital prolapse, NOS, Prolapse of female genital organs, NOS, Prolapse of female genital organs
Italian Prolasso genitale, Prolasso genitale NAS
Dutch geslachtsorgaanprolaps NAO, genitaal; prolaps, prolaps; genitaal, genitale prolaps
French Prolapsus génital SAI, Prolapsus génital
German Prolaps der Geschlechtsorgane NNB, Prolaps der Geschlechtsorgane
Portuguese Prolapso genital NE, Prolapso genital
Spanish Prolapso genital NEOM, Genital prolapse NOS, prolapso genital, SAI (trastorno), prolapso genital, SAI, prolapso de los órganos genitales femeninos (trastorno), prolapso de los órganos genitales femeninos, prolapso genital, Prolapso genital
Japanese 性器脱, 性器脱NOS, セイキダツ, セイキダツNOS
Czech Prolaps pohlavních orgánů NOS, Prolaps pohlavních orgánů
Hungarian Genitalis prolapsus k.m.n., Genitalis prolapsus

Ontology: Cystocele (female) (C1394494)

Definition (SNOMEDCT_US) A condition characterized by the herniation of the bladder into the vagina due to tearing of the tough fibrous wall between a woman's bladder and her vagina (the pubovesical fascia).
Concepts Disease or Syndrome (T047)
ICD10 N81.1 , N81.10
SnomedCT 252005008
English cystocele (physical finding), vaginal cystocele, fallen bladder, cystocele, cystocele (diagnosis), Cystocele, unspecified, Cystocele (female), Cystocele (disorder), Female cystocele, Vaginal cystocele, Female cystocele (disorder), Cystocele, Bladder cystocele, cystocele; female
German Zystozele
Korean 방광류
Dutch cystokèle; vrouw, Cystoklel
Spanish cistocele (trastorno), cistocele