What is Pelvic Organ Prolapse?

Pelvic organ prolapse (POP) is a type of weak pelvic floor supporting tissue caused by various reasons, causing the pelvic organs to descend and shift, causing abnormal organ positions and functions. Prolapse of genital mass is the main symptom, with or without urination, defecation abnormality, genital bleeding, inflammation, etc., which affect the patient's quality of life to varying degrees.

Basic Information

Visiting department

Obstetrics and Gynecology

Common causes

Vaginal birth injuries and degenerative changes in pelvic floor tissue after menopause and diseases with increased abdominal pressure

Common symptoms

Prolapse of vaginal mass with varying degrees of lumbosacral soreness or sag

Causes of pelvic organ prolapse

The female pelvic floor is composed of multiple layers of muscles and fascias that close the pelvic outlet, with urethra, vagina and rectum penetration. The pelvic floor tissues play an important role in keeping the pelvic organs such as the uterus, bladder, and rectum in a normal position. Weak pelvic floor muscles and fascial tissues can cause pelvic organs to prolapse.

Factors affecting pelvic floor tissue include:

Susceptibility factor

Gender, race, anatomy, culture, environment, etc .;

Predisposing factor

Childbirth, nerve injury, muscle injury radiation, tissue laceration, radical surgery, etc .;

3. Trigger factors

Constipation, occupation, chronic cough, entertainment, smoking, obesity, surgery, menopause, lung disease, menstrual cycle, infection, drugs, etc .;

4. Decompensation factors

Age, dementia, frailty, etc.

Many of the above factors can cause weak pelvic floor support. Among them, the most common causes are: vaginal birth injury, degeneration of pelvic floor tissue after menopause, and diseases with increased abdominal pressure, such as obesity, chronic constipation, and chronic cough. During the delivery process, the soft birth canal and the surrounding pelvic floor tissues can expand, muscle fibers stretch and even tear, and pelvic floor nerve damage. If you participate in physical labor prematurely after delivery, it will affect the recovery of pelvic floor tissue tension. In the 1920s and 1940s, the incidence was mainly young postpartum patients and prolific elderly people. Now the obstetric technology is improved, and the pelvic floor dysfunction caused by birth injuries has been significantly reduced. However, with the aging of the social population, postmenopausal estrogen levels decline, and pelvic floor muscle ligament tissue support declines, making POP still a common disease in middle-aged and elderly women, which seriously affects women's health and quality of life.

Classification of pelvic organ prolapse

Female pelvic organ prolapse is usually divided into anterior vaginal wall bulge, uterine prolapse, vaginal top prolapse, intestinal hernia and posterior vaginal wall bulge according to different parts. Multi-site prolapse often coexists.

In modern times, women's pelvic cavity is divided into three areas: front, middle and back. Therefore, pelvic organ prolapse is divided into:

Anterior pelvic defects: including bulging of the bladder and anterior wall of the vagina and urinary incontinence;

Middle pelvic defects: including prolapse of the uterus and vagina (for those who have removed the uterus);

Posterior pelvic defects: including posterior vaginal wall and rectal bulge, which can be combined with intestinal hernia.

Clinical manifestations of pelvic organ prolapse

Mild patients generally have no discomfort. Severe patients can consciously have prolapse of vaginal masses, lumbosacral soreness or falling sensation to varying degrees, symptoms after prolonged standing or exertion are obvious, symptoms are relieved after bed rest, and defecation can be accompanied Difficulty urinating. The exposed cervix or vaginal wall is rubbed with clothes for a long time, which can cause ulcers and bleeding in the cervix or vaginal wall, and there will be purulent secretions after secondary infection. Uterine prolapse rarely affects menstruation and does not even affect conception, pregnancy and childbirth. Those with anterior vaginal wall bulge may have dysuria, such as insufficiency of urine, urinary retention, urinary incontinence, etc. Sometimes the anterior vaginal wall needs to be lifted up to urinate. Swelling of the posterior vaginal wall may be accompanied by difficulty in defecation, and sometimes it is necessary to push the swollen posterior wall of the vagina with fingers to discharge feces.

Pelvic organ prolapse often exists in multiple parts at the same time, such as uterine prolapse often accompanied by vaginal anterior and posterior wall swelling, vaginal mucosa thickening and keratosis, cervical hypertrophy and prolongation. The anterior vaginal wall was spherically bulged, the bladder was soft, and the vaginal mucosal folds disappeared. When the posterior wall of the vagina bulges, it is often accompanied by old perineal lacerations, and the rectum protruding into the vagina can be touched when the anus is digitally diagnosed.

Diagnosis of pelvic organ prolapse

According to medical history and physical examination, pelvic organ prolapse is easily diagnosed. During the examination, the patient should be instructed to hold the breath down or increase the abdominal pressure to determine the severity of the prolapse and to grade it, while paying attention to the presence of ulcers.

Differential diagnosis of pelvic organ prolapse

Urethral tumor

Female urethral tumors are often associated with urinary symptoms, such as frequent urination, urgency, hematuria, etc. There are often changes in the urinary line. On examination, the tumor is located in the urethra or around the urethral orifice. The posterior wall of the vagina and the cervix are normal, and urethroscopy and cystoscopy can confirm the source of the mass.

Vaginal wall tumor

It can occur in different positions of the vagina, showing local bulges. The tumors are mostly solid, difficult to push, and difficult to deform. Except for the tumors, the positions of the vaginal walls and cervix are normal.

3. Inverted uterus

It refers to a lesion that the bottom of the uterus sinks into the uterine cavity, or even comes out of the cervix. This is a rare and serious complication during delivery, most of which occur in the third stage of labor.

4. Uterine submucosal fibroids

Submucosal fibroids that protrude outside the cervix and even the vaginal opening are easily confused with uterine prolapse. Most patients with submucosal fibroids have a history of menstruation. The mass is solid, red, and tough. The pedicle is connected to the uterine cavity, and the cervix can touch the cervix.

Pelvic organ prolapse treatment

Non-surgical treatment

Patients with mild unconscious symptoms (stages and , especially the point of fall of prolapse above the hymen), and no special symptoms can choose to observe. General precautions for POP patients: Once pelvic organ prolapse is diagnosed, it is necessary to avoid lifting heavy objects as much as possible to avoid constipation, chronic cough, and obesity that increase abdominal pressure. It is recommended that obese patients lose weight appropriately; behavior training for constipation patients to improve bowel habits, such as regular bowel movements, diet adjustment (increasing dietary fiber), laxatives or enemas to avoid forced bowel movements. People with symptoms of urinary incontinence may have behavioral adjustments (timed urination, etc.), pelvic floor muscle training, and medication.

(1) Pelvic floor function exercise Pelvic floor muscle exercise is also called Kegel exercise: it is by far the simplest, easy, safe and effective method of pelvic floor rehabilitation. It is used to guide patients to repeatedly perform anal and vaginal contractions, relax after each contraction for 3 seconds, and continue for 15 to 30 minutes. Perform 2 to 3 groups of exercises daily, 4 to 6 weeks as a course of treatment, but be sure to pay attention Do not contract your abdominal and thigh muscles at the same time. The correct exercise method can strengthen weak pelvic floor muscle tissue strength, enhance pelvic floor support, improve and prevent the further development of early prolapse. Pelvic floor functional training can also be supplemented with pelvic floor functional training methods such as biofeedback therapy or electrical stimulation to enhance the effect of pelvic floor functional training.

(2) pessary treatment The pessary is an ancient conservative treatment for pelvic organ prolapse. A pessary can be used for patients with moderate to severe pelvic floor defects that require discomfort due to prolapse. At present, it is also the only specific non-surgical treatment of POP, especially for patients who are older, have severe medical complications and cannot tolerate surgery, or have concerns about surgical treatment and are unwilling to undergo surgical treatment. At present, it is used as a first-line treatment program for pelvic organ prolapse in foreign countries, and it can also be used as an auxiliary treatment method before surgery. The doctor will choose the shape and size of the pessary according to the specific situation of the patient, and guide the patient or family to learn how to place it.

2. Surgical treatment

Surgical treatment is the main treatment for severe prolapse. Statistics show that about 11% of women need to undergo prolapse surgery in their lifetime, and about 30% of them need to be re-surgery within 4 years after the first surgery. According to the patient's specific condition, including age, severity of prolapse, general body conditions, previous surgical history, and proposed surgical methods, the patients and their families will decide the treatment plan through consultation.

Prognosis of pelvic organ prolapse

Through the comprehensive treatment of female pelvic floor dysfunction diseases, most patients have achieved good treatment results and achieved high clinical objective and subjective cure rates. At present, the commonly used pelvic floor reconstruction surgery has a recurrence rate of less than 10%.

Pelvic organ prolapse prevention

Pelvic floor dysfunction is a degenerative disease, which should be based on prevention and combined with prevention and treatment.

Youth

Do a good job of family planning and avoid multiple births; strengthen the health care during puerperium during pregnancy, do regular prenatal checkups, pay attention to labor protection during pregnancy, especially in the third trimester, take appropriate rest, and do not participate in heavy physical labor. New birth method, timely treatment of delayed labor, difficult labor, reduce pelvic floor injury; pay attention to rest after birth, increase nutrition, do postpartum gymnastics, do abdominal and anus levator contraction exercises. Get out of bed early, but you should not do too much physical labor. You should also avoid standing, sitting and squatting for a long time.

Middle and old age

Begin doing middle-aged pelvic floor muscle exercises, treat constipation, chronic cough in a timely manner, and properly control weight. Exercises that reduce weight lifting and increase abdominal pressure should be minimized.

References:

1. Peking University's pelvic organ prolapse diagnosis and treatment guidelines (draft), Chinese Journal of Obstetrics and Gynecology, 2012, 13 (2): 155-157

2. Han Jinsong, Zhang Kun, Zhu Yili, etc. Clinical analysis of transvaginal mesh implantation for pelvic organ prolapse: Chinese Journal of Obstetrics and Gynecology, 2011: 46 (2): 101-104.

3. Han Jinsong. Comparison of traditional and new surgical methods in pelvic floor reconstruction: Chinese Journal of Practical Gynecology and Obstetrics, 2011: 27 (1): 5-8.