What treatments are available for pelvic organ prolapse? Pelvic organ prolapse (POP) occurs when one or more of the organs in the pelvis slip from their normal position, which can cause them to bulge into the vagina and cause discomfort.1 This article will cover the treatment options that are available for those experiencing a prolapse, […]
Pelvic organ prolapse (POP) occurs when one or more of the organs in the pelvis slip from their normal position, which can cause them to bulge into the vagina and cause discomfort.1
This article will cover the treatment options that are available for those experiencing a prolapse, but our ‘What is pelvic organ prolapse?’ article covers causes and symptoms in more detail.
The pelvic floor, which comprises ligaments and muscles, normally holds the pelvic organs, such as the uterus, bladder and rectum, in place. A prolapse happens when these support structures are weakened by overstretching. The organs can shift from their natural position into the vagina and are sometimes severe enough to protrude outside the vagina.2
Prolapse is becoming a more common issue, which is believed to be due to extended life expectancies and issues from childbearing in low-resource areas.3 Although it is typically seen more in women, it can happen to men as well.4
It is not usually life-threatening but can affect quality of life by contributing to bladder, bowel and sexual dysfunction.5
To better understand why prolapses happen and how they can be treated, it is useful to first understand the role of the pelvic floor. It is made up of firm, supportive muscles which stretch across the bottom of the pelvis from the pubic bone at the front to the tailbone at the back, much like a trampoline. The bladder, vagina and rectum openings all pass through the pelvic floor, but the structure is held in place by the muscles. When passing urine or faeces, the muscles relax, but other than that they are supposed to hold tense.6
When it comes to diagnosing a POP, healthcare professionals will need to review the medical history of the patient and conduct an internal examination to discover the type of pelvic organ prolapse and its severity.7
Bladder symptoms, such as an immediate need to urinate or urinary incontinence from coughing and sneezing, may require further tests in hospital. This is to determine bladder function before treating the prolapse.7
A range of treatment options are available for patients suffering from a prolapse, each with their own risks and benefits. Doctors may want to begin by suggesting more conservative options, which include:
In more severe cases where conservative treatments have not been successful, surgery to remove symptoms can be offered.8
With a range of treatment options available, doctors need to take several factors into consideration before deciding which option is most suitable to recommend. These include:
Doctors may recommend trying conservative methods of treatment and management before advancing to surgery.2 This can be frustrating for some, as being diagnosed and living with a POP can be challenging. A ‘one-off’ solution may be more appealing than ongoing treatment, but a surgical procedure is invasive, and its success isn’t guaranteed.9
Furthermore, patients will have to undertake ongoing conservative treatment methods post-surgery, to reduce the chances of recurrence, meaning they are recommended in most cases anyway.2
It is worth noting that treatment options don’t need to be considered in isolation and surgery will be offered if it is required.
Lifestyle changes can help to relieve symptoms, may stop the POP from getting worse and can even prevent prolapse from occurring in the first place.8 They aim to reduce the added pressure on the pelvic floor muscles,10 which have weakened and hence are unable to hold the organs in place.2
Recommended lifestyle changes include:
This is because the pelvic floor acts as a hammock underneath the pelvic organs. Having a higher Body Mass Index (BMI) means that there is likely to be more body fat pushing down on the muscles, causing them to weaken.11
Constipation causes straining when using the toilet, which puts additional pressure on the pelvic floor muscles.12
The increased intra-abdominal pressure presses down on the pelvic floor.12
A change in exercise routine can be frustrating, but lower-impact exercises such as walking, pilates and swimming can ease the pressure on your pelvic floor.12
Double leg lifts and sit-ups should also be avoided for the same reason.6
In general, high-impact exercises, such as anything that requires both feet to be off the ground at the same time, can exacerbate a prolapse, so are best to be avoided.6
Smoking can cause a chronic cough, which puts additional strain on the pelvic floor.13
The pelvic floor can be strengthened like any other muscle so that it is able to hold the pelvic organs more effectively in place and possibly alleviate some of the symptoms of POP.2
‘Kegel exercises’ involve repeatedly tightening and relaxing the pelvic floor muscles so that they become stronger.14
It may be difficult at first as the muscle grow stronger, so doing them ‘little and often’ and lying down can help to make them easier. As the pelvic floor is strengthened, it is recommended to do a series of Kegel exercises 3 times a day and eventually transition into an upright position.12 Pelvic floor exercises require perseverance as it can take 3-6 months to see an improvement in symptoms.6
It is important to note that constantly bracing the pelvic floor muscles can worsen the problem and cause other issues, such as chronic pelvic pain.15
Pelvic floor relaxation can effectively manage POP and associated risk factors such as constipation. Relaxing the pelvic floor’s muscles fully gives them time to rest, recover and prepare to contract again. This method is often combined with pelvic floor exercises, allowing the exercises to be performed more effectively.15
Many women with POP are either in or have been through the menopause, which results in lower oestrogen levels.10 This can lead to vaginal atrophy and dryness,16 which can exacerbate the symptoms of POP and cause pain and discomfort.
Doctors may recommend oestrogen treatment to alleviate some symptoms, such as vaginal dryness or discomfort during sex. Oestrogen is available as a cream or tablet inserted into the vagina or as a vaginal ring which releases the hormone.8
Pessaries are removable devices that can be inserted to sit at the top of the vagina. They are designed to support the pelvic floor and assist in restoring the pelvic organs back to their natural position.2
There are several different types of pessaries, and which one is recommended will be based on factors such as prolapse type, anatomy and sexual activity. They are also available in different shapes and sizes, so different pessaries may need to be trialled to find one that is comfortable.2
Some types of pessaries need to be removed regularly, but others will require an appointment every 4-6 months to have it removed and replaced.2
Most women will be able to use a pessary2 and it can be a suitable option to manage symptoms in women who want children, do not want surgery or are waiting for surgery. On the other hand, some women may not be able to tolerate the feeling of a pessary, or their vaginal anatomy may be too short and narrow to fit a pessary.17
In women experiencing vaginal dryness and atrophy, pessaries can cause irritation since they sit on the wall of the vagina. In these cases, doctors may recommend hormone therapy with oestrogen before pessary use.10
Pessaries can be divided into two categories, support pessaries and space-filling pessaries.
The most commonly used type of pessary is a ring pessary, which is categorised as a support pessary. It is popular because it is easy to use by both patients and healthcare providers.18
In more advanced prolapses, space-filling pessaries may be more suitable. These can include Gellhorn, shelf, cube, donut and inflatable pessaries.18
POPYTM is a shelf pessary which can be used for more advanced prolapses, it is made from silicone and is a more flexible, comfortable option compared to other shelf pessaries.
Mediplus provides a range of pessaries to manage prolapse, which you can peruse by looking at our product page.
Doctors may recommend surgery to treat POP as part of treatment, but it is important to be aware that surgery is not guaranteed to succeed and carries an 11.1% lifetime risk of recurrence. Due to extended life expectancies, this is expected to increase in the future.9
POP surgery involves lifting the pelvic organs, such as the bladder, bowel and uterus, and stitching the tissues around to provide additional support. Surgery may also include a hysterectomy in which the uterus is removed.8 You may have heard of mesh repairs, but due to recent complications, this type of surgery isn’t currently offered routinely.19
It is important to acknowledge that POP only repairs the tissue bulge, rather than the underlying weakened tissue. This means that prolapse might be recurrent, which is why surgery should only be considered if other options haven’t managed to control or reduce symptoms.20
Recovery after surgery varies. Patients will normally need to stay in hospital for a few nights to recover but can then be discharged until a check-up with their doctor within 6 weeks. Full recovery can range from 4-6 weeks for open surgery and 1-2 weeks after laparoscopic surgery.21
Conservative treatment methods can complement surgery recovery and reduce the chances of prolapse recurrence. These include:
Reducing weight if overweight
Reducing constipation
Stopping smoking
Adjusting exercise routine
A pelvic organ prolapse diagnosis can be distressing, but there is a range of treatments available that can help to manage the symptoms and sometimes treatment isn’t even necessary.
Although it may seem like a quick fix, surgery isn’t always the right option, and in fact, a combination of techniques is likely to be the recommendation for approaching treatment.8
Mediplus provides a range of pessaries to support prolapse patients, including both support pessaries and space-filling pessaries. A ring pessary is the most commonly used pessary due to the ease it can be used by both the patient and healthcare provider.14 For more advanced prolapses, there are space-filling pessaries available including Gellhorn or shelf pessaries.
POPYTM is a shelf pessary which, made from silicone is a more flexible and comfortable option compared to other shelf pessaries.
You can see our full range of pessaries by visiting our product page.
References:
Anaesthesia
Gynaecology
OPERATING ROOM
UROLOGY