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Nonoperative Management of Pelvic Organ Prolapse - Coggle Diagram
Nonoperative Management of Pelvic Organ Prolapse
The disease itself and how to identify it
What is POP?
Descent of anterior vaginal wall, posterior vaginal wall, or vaginal apex
May involve uterus/cervix or vaginal cuff after hysterectomy
Most specific symptom: vaginal bulge felt or seen
Other symptoms:
Pelvic pressure
Urinary symptoms
Bowel symptoms
Low backache
Spotting/bleeding/discharge if ulceration
Epidemiology
Common condition
40–50% of women may have prolapse on exam during life
Only 3–20% seek treatment
Prevalence increases with age
Demand for treatment expected to rise with aging population and obesity
Natural history can be:
Progression
Regression
Stability
Pathophysiology
Failure/weakening of pelvic support system
Support levels:
Level I: apical support
Cardinal ligaments
Uterosacral ligaments
Level II: mid-vaginal lateral support
Arcus tendineus fascia pelvis
Level III: distal vaginal support
Perineal body
Levator ani
Connective tissue + muscles interact together
No single support level acts alone
Risk Factors
Pregnancy and childbirth
Vaginal delivery strongly associated
Operative vaginal delivery increases risk further
Forceps + levator injury important
Aging and menopause
Risk increases after 50
Hypoestrogenism may affect support tissues
Genetic/hereditary factors
First-degree relative increases risk
Maternal inheritance may be stronger
Constipation/straining
Especially associated with posterior prolapse
Smoking/chronic cough
Theoretical risk, but data are weak
Heavy lifting/high-impact exercise
Evidence unclear
Diagnosis and Evaluation
ACOG recommends:
History
Symptom severity assessment
Physical exam
Discussion of treatment goals
History
Ask about:
Medical conditions
Obstetric history
Prior surgeries
Prior mesh
Prolapse symptoms
Sexual activity and future sexual goals
Dyspareunia
Urinary symptoms
Bowel symptoms
Key screening question:“Do you feel or see a vaginal bulge?”
Urinary and bowel symptoms
Urinary symptoms:
Hesitancy
Incomplete emptying
Double voiding
Need to reduce prolapse to void
Incontinence
UTIs
Important point:
Urinary symptoms may be associated with POP
But are not always caused by POP
If prolapse beyond hymen:
Check postvoid residual
Bowel symptoms:
Constipation
Straining
Incomplete emptying
Splinting
Fecal urgency/leakage
Physical Examination
Inspect vulva/vagina:
Atrophy
Irritation
Ulceration
Lesions
Use POP-Q system
Recommended because it is validated and reproducible
Uses hymen as reference point
Measures anterior, apical, posterior vaginal points
Stages 0–4
POP-Q stages
Stage 0: no prolapse
Stage 1: prolapse remains well above hymen
Stage 2: leading edge within 1 cm of hymen
Stage 3: more than 1 cm beyond hymen, not complete eversion
Stage 4: complete or near-complete vaginal prolapse
Patient Counseling
Explain anatomy clearly
Clarify what is actually prolapsing
Avoid assuming “bladder is dropping”
Explain that urinary/bowel symptoms may not improve with prolapse treatment
Align treatment with what bothers the patient most
Use educational handouts or visual tools
Additional Testing
Usually not needed before nonsurgical treatment
Consider testing only when clinically indicated:
Postvoid residual if prolapse beyond hymen
Renal ultrasound if high residual/hydronephrosis concern
Urodynamics if bothersome urinary symptoms or voiding dysfunction
Anal/transperineal ultrasound if sphincter injury affects management
Defecography only in selected bowel-symptom cases
Who Needs Treatment?
Treat if:
Bothersome symptoms
Medical complication, e.g. incomplete bladder emptying
Observation is reasonable if:
Mild prolapse
No significant symptoms
Advanced prolapse but minimal bother and no complication
Non Operative Treatment
Nonoperative Treatment Options
Main message:Symptomatic patients should be offered nonsurgical treatment first.
Options:
Pelvic floor muscle training
Pessary trial
Lifestyle/associated symptom management
Multidisciplinary care if urinary/bowel symptoms are prominent
Pelvic Floor Muscle Training
Systematic contraction of levator ani muscles
Goal:
Improve pelvic floor function
Improve symptoms and quality of life
Does not reverse prolapse
May help especially in mild prolapse
Low risk
Evidence:
Symptom improvement possible
Benefit may be limited or not sustained in some trials
Pessary may be more cost-effective in some comparisons
Pessary
Mechanical vaginal device that reduces prolapsed tissue
Can be:
Short-term treatment
Long-term treatment
Bridge before surgery
Diagnostic trial to see if symptom relief occurs
Should be offered to almost all symptomatic patients
Good option for:
Patients avoiding surgery
Frail patients
Comorbid patients
Patients awaiting specialist evaluation
Patients who have not completed childbearing
Support pessaries
Ring
Shaatz
Hodge
Gehrung
Ring pessary
Usually first option
Easy to insert/remove
Easier for self-management
Intercourse may be possible
Less effective in advanced stage 3–4 prolapse due to expulsion
Space-occupying pessaries
Gellhorn
Cube
Donut
Gellhorn
Useful if ring fails
More effective in advanced prolapse
Harder to self-manage
Requires more office care
Pessary Fitting and Follow-up
Correct fit:
Behind pubic arch
One fingerbreadth space around pessary
No pain
Patient can walk
Patient can void
No expulsion
Does not interfere with urination
First follow-up:
2–6 weeks
At follow-up:
Remove pessary
Speculum exam
Look for irritation, granulation, erosion
If self-managing:
Remove and wash with soap/water
Remove at least every 3–6 months
If not self-managing:
Follow-up usually no longer than every 6–9 months
More frequent if erosions or compliance concerns
Pessary Side Effects and Complications
Common:
Vaginal discharge
Odor
Bleeding
Discomfort
New stress urinary incontinence
Bowel symptoms
Vaginal erosion or ulceration
Rare but serious:
Incarceration
Vesicovaginal fistula
Rectovaginal fistula
Management of erosion:
Remove pessary for 4–6 weeks
Use vaginal estrogen
Reinsert once healed
Pessary Efficacy
More than 50% continue pessary use with improved quality of life
Discontinuation rates:
Around 24–41% by 12–24 months
About 1 in 5 may switch to surgery
Common reasons for discontinuation:
Discomfort
Bowel symptoms
Maintenance burden
Vaginal discharge
Stress incontinence
Sexual dysfunction
Erosions