Evidence - Supracervical hysterectomy, cervicosacropexy with gyno-mesh, bilateral adnexectomy, and anterior colporrhaphy, laparoscopic

Genital prolapse refers to the descent of the internal female genital organs, particularly the vagina and uterus, due to a weakness or damage to the supportive and connective tissue in the pelvis. This condition is common and increases with age. With the demographic trend of an aging population, a further increase in prevalence is expected in the coming decades. A mild prolapse can remain asymptomatic and does not necessarily have to be considered pathological. However, in cases of significant descent, a variety of symptoms can occur, significantly affecting quality of life. In such cases, various conservative and surgical treatment options are available.

Epidemiological data on pelvic organ prolapse vary depending on the definition and examination method. In population studies, a prevalence of about 3–6% is reported when only women with noticeable symptomatic prolapse complaints are counted, whereas clinical examination shows that up to ~50% of women exhibit some degree of pelvic floor prolapse. In other words, pelvic organ prolapse (POP) is estimated to affect up to half of all women after childbirth and about one-third of women overall during their lifetime. Approximately 50% of all women are estimated to develop urogenital prolapse at some point, but only about 10–20% of those affected actually seek medical help.

The cumulative probability that a woman will need surgery for prolapse is about 7–19% (lifetime risk). This corresponds to approximately one in eight women undergoing a surgical procedure to correct a prolapse during their lifetime. The annual incidence of prolapse surgeries is reported to be about 1.5–1.8 per 1000 woman-years, peaking in the age group between 60 and 69 years. Due to increasing life expectancy and demographic changes, an overall increase in cases and surgical numbers is expected in the coming decades.

Reference:

1. Bhat M, Acharya S, Agur W. Vesico-vaginal fistula presenting as overactive bladder in a case of Gellhorn pessary for vault prolapse. BMJ Case Rep. 2021 Mar 3;14(3):e240331. doi: 10.1136/bcr-2020-240331. PMID: 33658219; PMCID: PMC7931760.
2. Galan LE, Bartolo S, De Graer C, Delplanque S, Lallemant M, Cosson M. Comparison of Early Postoperative Outcomes for Vaginal Anterior Sacrospinous Ligament Fixation with or without Transvaginal Mesh Insertion. J Clin Med. 2023 May 25;12(11):3667. doi: 10.3390/jcm12113667. PMID: 37297862; PMCID: PMC10253670.
3. ACOG Practice Bulletin No.185: Pelvic organ prolapse. Obstetrics and Gynecology 2017; 130(5): e234-e250
4. Barber M.D., Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int. Urogynecol. J. 2013;24:1783–1790. doi: 10.1007/s00192-013-2169-9.
5. Fialkow M.F., Newton K.M., Lentz G.M., Weiss N.S. Lifetime risk of surgical management for pelvic organ prolapse or urinary incontinence. Int. Urogynecol. J. 2008;19:437–440. doi: 10.1007/s00192-007-0459-9.
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7. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008; 300:1311.
8. Barber MD, Walters MD, Bump RC. Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol 2005; 193:103.

The cause of pelvic organ prolapse is a weakness or damage to the muscular and connective tissue support structures of the pelvic floor. Central to this is often a birth trauma: Repeated vaginal deliveries—especially complicated or very long births—can lead to overstretching and tears of the pelvic floor muscles (e.g., levator ani) and fascia, which permanently impairs the static stability of the pelvic floor. The most important risk factors therefore include multiparity (multiple pregnancies and vaginal births) and advanced age (age-related connective tissue weakness). Other contributing factors include obesity, chronically increased intra-abdominal pressure—such as from chronic cough (e.g., COPD) or chronic constipation—as well as heavy physical labor over many years. Previous surgeries in the pelvis (e.g., hysterectomy or other pelvic floor surgeries) also increase the risk of later genital prolapse, as they can weaken the integral support structure. However, this is not entirely consistent in studies. In addition to mechanical factors, constitutional and neurological aspects also play a role. A familial connective tissue weakness (genetic predisposition) or certain ethnic backgrounds can increase susceptibility to prolapse. For example, studies have observed a higher prevalence of prolapse in women of European descent compared to women of African descent. Neurological damage that impairs the innervation of the pelvic floor muscles (such as lesions of the pudendal nerves or spinal cord injuries) can also contribute to the pathogenesis. Overall, a genital prolapse usually arises multifactorially through the interaction of several risk factors on an individually variably resilient muscular and fascial support tissue.

Reference:

1. Bazi T et al.: Prevention of pelvic floor disorders: international urogynecological association research and development committee opinion. Int Urogynecol J 2016; 27(12): 1785-95
2. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008; 300:1311.
3. Sze EH, Sherard GB 3rd, Dolezal JM. Pregnancy, labor, delivery, and pelvic organ prolapse. Obstet Gynecol 2002; 100:981.
4. Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol 1997; 104:579.
5. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet 2007; 369:1027.
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A mild descent often proceeds asymptomatically and is often only discovered incidentally during gynecological examinations. However, as the descent progresses, characteristic symptoms appear. Most commonly, patients complain of a sensation of pressure and a foreign body in the lower abdomen or vagina – many describe the feeling of a "balloon" or a bulge that can extend to the vaginal entrance. This sensation typically intensifies when standing and in the evening, while it subsides when lying down.

Accompanying bladder dysfunctions may occur. These include a decrease in urinary stream strength, the feeling of incomplete bladder emptying, or a residual urine sensation. Occasionally, urinary incontinence (often stress incontinence) occurs, although paradoxically, this may initially be masked by the descent – a higher-grade prolapse can kink the urethra and thus conceal existing incontinence. Conversely, after surgical correction of a prolapse, previously hidden incontinence may become apparent. Some patients also report irritative symptoms such as frequent urination or recurrent urinary tract infections due to incomplete emptying.

Bowel-related symptoms are also possible, especially with a rectocele (descent of the posterior vaginal wall due to bulging of the rectum). A typical symptom is a sensation of obstruction during defecation: bowel movements are difficult, and the patient may need to strain or assist manually. The so-called "splinting" is a characteristic behavior where the woman presses with her fingers against the posterior vaginal wall or perineal tissue to facilitate bowel movements. Additionally, a feeling of incomplete evacuation or rectal pressure may occur. In severe cases, accompanying constipation is present.

Sexual dysfunctions can also be caused or exacerbated by a pronounced descent. Some women report a loss of sexual sensation or mechanical obstruction during intercourse, for example, if the bulge is bothersome. Less commonly, patients complain of pain during intercourse (dyspareunia) due to the descent – this is more likely to occur if there are already mucosal ulcerative changes or accompanying inflammations due to a far-protruding uterus/vaginal stump. Importantly, the extent of symptoms often correlates with the severity of the prolapse. Significant symptoms usually appear only from a prolapse stage II–III, when the tissue has descended to the level of the hymen or beyond. In cases of very far-protruding organs (total prolapse), complications such as pressure ulcers on exposed vaginal mucosa or – rarely – kidney obstruction (hydronephrosis due to ureteral kinking) may occur.

Reference:

1. Tan JS, Lukacz ES, Menefee SA, et al. Predictive value of prolapse symptoms: a large database study. Int Urogynecol J Pelvic Floor Dysfunct 2005; 16:203.
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3. Barber MD, Neubauer NL, Klein-Olarte V. Can we screen for pelvic organ prolapse without a physical examination in epidemiologic studies? Am J Obstet Gynecol 2006; 195:942.
4. Ellerkmann RM, Cundiff GW, Melick CF, et al. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol 2001; 185:1332.
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8. Mouritsen L, Larsen JP. Symptoms, bother and POPQ in women referred with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14:122.
9. Whitcomb EL, Lukacz ES, Lawrence JM, et al. Prevalence of defecatory dysfunction in women with and without pelvic floor disorders. J Pelvic Surg 2009; 15:179.
10. Weber AM, Walters MD, Schover LR, Mitchinson A. Sexual function in women with uterovaginal prolapse and urinary incontinence. Obstet Gynecol 1995; 85:483.
11. Barber MD, Visco AG, Wyman JF, et al. Sexual function in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol 2002; 99:281.

The treatment of prolapse primarily depends on the symptomatology rather than the objective findings. Asymptomatic or mildly symptomatic cases often do not require interventional therapy. Conservative measures are initially prioritized. These primarily include targeted pelvic floor training (physiotherapy) to strengthen the muscles and the use of pessaries. A pessary (e.g., ring or cube pessary) is inserted into the vagina and can mechanically prevent further descent of organs, often alleviating the sensation of pressure. Conservative therapies can improve symptoms and slow progression, but they require motivation and, in the case of pessaries, regular cleaning/replacement (every few months, usually by a physician). If conservative therapy is insufficient or the prolapse is very pronounced, surgical correction may be considered. According to current guidelines, surgery should generally only be performed for symptomatic prolapse. The choice of the appropriate procedure depends on various factors, particularly which compartments are affected, the severity of the prolapse, and the patient's needs (e.g., desire to preserve the uterus).

Reference:

1. Culligan PJ. Nonsurgical management of pelvic organ prolapse. Obstet Gynecol 2012; 119:852.
2. Hagen S, Stark D. Conservative prevention and management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2011; :CD003882.
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4. Hagen S, Stark D, Glazener C, et al. Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. Lancet 2014; 383:796.
5. Wiegersma M, Panman CM, Kollen BJ, et al. Effect of pelvic floor muscle training compared with watchful waiting in older women with symptomatic mild pelvic organ prolapse: randomised controlled trial in primary care. BMJ 2014; 349:g7378.
6. Li C, Gong Y, Wang B. The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis. Int Urogynecol J 2016; 27:981.
7. Sansone S, Sze C, Eidelberg A, et al. Role of Pessaries in the Treatment of Pelvic Organ Prolapse: A Systematic Review and Meta-analysis. Obstet Gynecol 2022; 140:613.
8. Klein J, Stoddard M, Rardin C, et al. The Role of Pessaries in the Treatment of Women With Stress Urinary Incontinence: A Systematic Review and Meta-Analysis. Female Pelvic Med Reconstr Surg 2022; 28:e171.