Pelvic Organ Prolapse

 

Am Fam Physician. 2017 Aug 1;96(3):179-185.

  Patient information: See related handout on pelvic organ prolapse, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Pelvic organ prolapse is the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy). Prevalence increases with age. The cause of prolapse is multifactorial but is primarily associated with pregnancy and vaginal delivery, which lead to direct pelvic floor muscle and connective tissue injury. Hysterectomy, pelvic surgery, and conditions associated with sustained episodes of increased intra-abdominal pressure, including obesity, chronic cough, constipation, and repeated heavy lifting, also contribute to prolapse. Most patients with pelvic organ prolapse are asymptomatic. Symptoms become more bothersome as the bulge protrudes past the vaginal opening. Initial evaluation includes a history and systematic pelvic examination including assessment for urinary incontinence, bladder outlet obstruction, and fecal incontinence. Treatment options include observation, vaginal pessaries, and surgery. Most women can be successfully fit with a vaginal pessary. Available surgical options are reconstructive pelvic surgery with or without mesh augmentation and obliterative surgery.

Pelvic organ prolapse is defined by herniation of the anterior vaginal wall, posterior vaginal wall, uterus, or vaginal apex into the vagina; descent may occur in one or more structures.1 Prolapse of pelvic structures can cause a sensation of pelvic pressure or bulging through the vaginal opening and may be associated with urinary incontinence, voiding dysfunction, fecal incontinence, incomplete defecation, and sexual dysfunction.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Women with pelvic organ prolapse should be evaluated for other pelvic floor disorders such as stress urinary incontinence, overactive bladder, and fecal incontinence.

C

19

Women should be asked about symptoms of pelvic organ prolapse because they otherwise may not volunteer this information.

C

23

Most women should be offered a pessary as first-line treatment for pelvic organ prolapse.

C

27

Sexual function should be assessed before surgical repair of pelvic organ prolapse.

C

21, 22


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Women with pelvic organ prolapse should be evaluated for other pelvic floor disorders such as stress urinary incontinence, overactive bladder, and fecal incontinence.

C

19

Women should be asked about symptoms of pelvic organ prolapse because they otherwise may not volunteer this information.

C

23

Most women should be offered a pessary as first-line treatment for pelvic organ prolapse.

C

27

Sexual function should be assessed before surgical repair of pelvic organ prolapse.

C

21, 22


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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BEST PRACTICES IN GYNECOLOGY – RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not exclude pessaries as a treatment option for pelvic organ prolapse.

American Urogynecologic Society


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

BEST PRACTICES IN GYNECOLOGY – RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not exclude pessaries as a treatment option for pelvic organ prolapse.

American Urogynecologic Society


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

Epidemiology

Although pelvic organ prolapse can affect women of all ages, it more commonly occurs in older women. The prevalence of pelvic organ prolapse increases with age until a peak of 5% in 60- to 69-year-old women.2 Some degree of prolapse is present in 41% to 50% of women on physical examination,3 but only 3%

The Authors

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CHERYL B. IGLESIA, MD, is director of the Section of Female Pelvic Medicine and Reconstructive Surgery and a professor in the Departments of Obstetrics and Gynecology and Urology at Georgetown University School of Medicine, Washington, DC....

KATELYN R. SMITHLING, MD, is a clinical fellow in the Department of Obstetrics and Gynecology, Section of Female Pelvic Medicine and Reconstructive Surgery at Georgetown University School of Medicine.

Address correspondence to Cheryl B. Iglesia, MD, Georgetown University School of Medicine, 106 Irving Street NW, Ste. 405, South POB, Washington, DC 20010 (e-mail: Cheryl.iglesia@medstar.net). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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