Pelvic organ prolapse in women involves relaxation or weakening of the ligaments, connective tissue, and muscles of the pelvic floor, causing the bladder, urethra, small intestine, rectum, or uterus to bulge into the vagina.
Women may have a sensation of heaviness, fullness, or pressure in the pelvis, feel as if something is bulging out of their vagina, or have problems with urination or bowel movements.
Doctors do a pelvic examination and ask a woman to bear down so the doctor can detect abnormalities that occur only under pressure.
Pelvic muscle exercises and pessaries may help, but surgery may be needed.
Pelvic organ prolapse is a common gynecologic issue and becomes more common as women age.
The pelvic floor is a network of muscles, ligaments, and tissues that act like a hammock to support the organs of the pelvis: the uterus, vagina, bladder, urethra, and rectum. If the muscles become weak, ligaments are stretched, or nerves or other tissues are damaged, the internal organs in the pelvic area may drop down and protrude (prolapse) into the vagina. If the disorder is severe, the organs may prolapse all the way to the opening of the vagina and protrude outside the body.
Pelvic organ prolapse usually occurs in women with a combination of risk factors, including the following:
Having a baby, particularly if a woman had a prolonged second stage of labor (pushing stage), vaginal delivery with or without vacuum extractor or forceps, or a high-birthweight infant
Having obesity
Having an injury, as may occur during hysterectomy (removal of the uterus) or another surgical procedure
Increasing age
Frequently having increased intraabdominal pressure (for example, pressure due to constipation, lifting heavy items, or chronic respiratory disorders)
Being pregnant and having a vaginal delivery may weaken or stretch some of the supporting structures in the pelvis. Pelvic organ prolapse is more common among women who have had several vaginal deliveries, and the risk increases with each delivery. The pregnancy or the delivery may damage nerves, leading to muscle weakness. The risk of developing pelvic organ prolapse may be less with a cesarean delivery than with a vaginal delivery.
As women age, the supporting structures in the pelvis may weaken, even if a woman has never been pregnant. As a result, pelvic organ prolapse is more likely to develop.
Having a hysterectomy may also weaken the structures in the pelvis, increasing the risk of pelvic organ prolapse.
Increased pressure on the pelvic floor for a long time, usually many years, may also contribute to pelvic organ prolapse. Frequently straining of the pelvic area (for example, because of constipation), having a chronic cough, or frequently lifting heavy objects can increase this pressure.
Disorders of nerves to the pelvic floor and disorders of connective tissue may also contribute to pelvic organ prolapse. (Connective tissue is the tough, often fibrous tissue that is present in almost every organ, including muscles, and that provides support and elasticity.) Rarely, a woman may have a birth defect that affects this area or is born with weak pelvic tissues.
Dalili na Matatizo
Pelvic organ prolapse is essentially a hernia (an opening or weak area in tissue), through which organs protrude abnormally because supporting tissue is weakened.
The different types of pelvic organ prolapse are named according to the protruding organ.
Back wall of the vagina: Prolapse of the rectum (rectocele) or small intestine (enterocele)
Front wall of the vagina: Prolapse of the bladder (cystocele) or urethra (urethrocele)
Top of the vagina: Vaginal (apical) prolapse (the top of the vagina is called the apex)
Uterus: Prolapse of the uterus (uterine prolapse)
Many women have multiple sites of pelvic organ prolapse; a combination of prolapse of the bladder (cystocele), small intestine (enterocele), and rectum (rectocele) are particularly likely to occur together. A urethrocele and cystocele often occur together (called cystourethrocele).
In all types, the most common symptoms are a sensation of heaviness, fullness, or pressure in the pelvis or a feeling that something is bulging out of the vagina, or problems with incontinence (leakage) or retention (difficulty passing) urination or bowel movements.
When the Bottom Falls Out: Prolapse in the Pelvis
Symptoms tend to occur when women are standing or sitting upright, straining, or coughing and to disappear when they are lying down and relaxing. For some women, sexual activity is uncomfortable or painful. Women may feel embarrassed about sexual activity because of bulges in the vagina or incontinence of urine or stool.
Mild cases may not cause symptoms until a woman becomes older.
Damage to the pelvic floor may affect the urinary tract or bowel movements. As a result, women who have pelvic organ prolapse may have problems controlling urination, resulting in urine leaking out involuntarily (urinary incontinence) or problems completely emptying the bladder (urinary retention). They may have the same problems with bowel movements, with difficulty controlling the passage of gas or leakage of stool (anal incontinence) or have bowel movements that occur infrequently (constipation) or difficult completely passing a bowel movement.
Cystocele na cystourethrocele
A cystocele develops when the bladder drops down and protrudes into the front wall of the vagina. It results from weakening of the connective tissue and supporting structures around the bladder. When a urethrocele and cystocele occur together, they are called a cystourethrocele.
Women with either of these disorders may develop urinary incontinence or urinary retention.
Rectocele
A rectocele develops when the rectum drops down and protrudes into the back wall of the vagina. It results from weakening of the muscular wall of the rectum and the connective tissue around the rectum.
A rectocele can make having a bowel movement difficult and may cause constipation. Women may be unable to empty their bowels completely. Some women need to place a finger in their vagina and press against the back wall of the vagina (called splinting) to have a bowel movement.
Enterocele
An enterocele develops when the small intestine and the lining of the abdominal cavity (peritoneum) bulge downward between the vagina and the rectum. It occurs most often after the uterus has been surgically removed (hysterectomy). An enterocele results from weakening of the connective tissue and ligaments supporting the uterus or vagina.
An enterocele often causes no symptoms. But some women feel a sense of fullness or pressure or pain in the pelvis and may be unable to empty their bowels completely.
Kutokeza kwa uterasi
In prolapse of the uterus, the uterus drops down into the vagina. It usually results from weakening of the connective tissue and ligaments supporting the uterus. The uterus may bulge in the following ways:
Only into the upper part of the vagina
Down to the opening of the vagina
Partly through the opening
All the way through the opening, resulting in total uterine prolapse (procidentia)
How far down the uterus drops down determines how severe symptoms are.
At first, prolapse of the uterus may cause mild or no symptoms. When prolapses worsens, the first symptom most women report is feeling a bulge at the opening of the vagina. They may also have pain in the lower back or over the tailbone, difficulty having a bowel movement, and discomfort or pain during sexual activity, as well as a feeling of heaviness or pressure—a feeling that pelvic organs are dropping out.
Total uterine prolapse can cause pain during walking. If tissue of the cervix (the lower part of the uterus) protrudes past the opening of the vagina and is exposed to air or rubs on clothing, bleeding, a discharge, sores, or infection may develop.
Women may have problems controlling urination, resulting in urine leaking out involuntarily (urinary incontinence). Or women may not be able to empty their bladder completely or to urinate (urinary retention).
Constipation can occur.
Kutokeza kwa uke
In prolapse of the vagina, the upper part of the vagina drops down into the lower part, so that the vagina turns inside out. The upper part may drop part way through the vagina or all the way through, protruding outside the body and causing total vaginal prolapse.
Total vaginal prolapse may cause pain while sitting or walking. If vaginal tissue protrudes past the opening of the vagina and is exposed to air or rubs on clothing, bleeding, a discharge, sores, or infection may develop. Like prolapse of the uterus, prolapse of the vagina can cause problems with urination. Having a bowel movement may also be difficult.
Utambuzi wa Kutokeza kwa Kiungo cha Fupanyonga
Pelvic examination (while at rest and while bearing down)
Doctors usually diagnose pelvic organ prolapse by doing a pelvic examination. They use a speculum (an instrument that spreads the walls of the vagina apart) to see any bulges in the vagina or a lower position of the cervix (bottom part of the uterus). A doctor may insert 2 fingers into the vagina and press down on the abdomen to feel for vaginal bulges or prolapse of the uterus. They may also insert one finger in the vagina and one finger in the rectum at the same time to determine how severe a rectocele or enterocele is.
A woman may be asked to bear down (as when having a bowel movement) or to cough. She may be examined while standing with one foot on a stool. The resulting pressure in the pelvis from bearing down, coughing, and/or standing may make a pelvic organ prolapse more obvious.
Procedures to determine how well the bladder and rectum are functioning may be done if a woman has leakage of urine or stool (incontinence) or difficulty completely passing urine (urinary retention) or a bowel movement (constipation).
Matibabu ya Kutokeza kwa Kiungo cha Fupanyonga
Observation
Pelvic floor muscle exercises
A pessary
Surgery
Treatment of pelvic organ prolapse is based on a woman's symptoms. Treatment aims to improve quality of life.
Doctors start by closely monitoring a woman and her symptoms.
If symptoms are bothersome, treatment may include pelvic floor muscle exercises for less severe pelvic organ prolapse, a pessary, and, if symptoms are severe, surgery. If women do not have symptoms or symptoms are mild, no treatment is needed. However, follow-up visits are needed to monitor the progression of the prolapse.
Doctors also treat problems with completely emptying the bladder (urinary retention) or urinary incontinence.
Mazoezi
Pelvic floor muscle exercises, such as Kegel exercises, can lessen bothersome symptoms, including stress incontinence. Exercises are most helpful when prolapse is less severe.
These exercises help by strengthening the pelvic floor muscles. Kegel exercises target the muscles around the vagina, urethra, and rectum—the muscles used to stop a stream of urine. These muscles are tightly squeezed, held tight for about 1 or 2 seconds, then relaxed for about 10 seconds. Gradually, contractions are lengthened to about 10 seconds each. The exercise is repeated about 10 times in a row. Doing the exercises several times a day is recommended. Women can do Kegel exercises when sitting, standing, or lying down. (See National Health Service (NHS) England: Video: How to do pelvic floor exercises.)
Some women have difficulty contracting the correct muscles. To determine whether they are contracting the correct muscles, women can contract pelvic floor muscles two or three times while urinating. If they contract the correct muscles, the flow of urine stops in midstream. If women need additional help, pelvic floor physical therapy may be recommended.
Pelvic floor therapy includes techniques that make learning the exercises easier, such as the following:
Cone-shaped inserts placed in the vagina, which help women focus on contracting the correct muscle
Biofeedback devices, which may use special sensors that show pelvic floor muscle contractions on a computer screen
Electrical stimulation (a health care practitioner inserts a probe, which transmits an electrical current to make the correct muscle contract)
Pessaries
If prolapse is causing symptoms, a device called a pessary may be inserted into the vagina to support the pelvic organs. Pessaries are especially useful for women who are waiting for surgery or who do not want or cannot have surgery. The pessary can lessen symptoms but is not a cure.
A pessary is usually made of silicone. They may be shaped like a diaphragm, cube, or doughnut. Some can be inflated. A doctor fits the pessary to a woman by inserting and removing different sizes until the right size is found. In some countries, pessaries may be available over the counter.
A pessary must be periodically removed and cleaned with soap and water. Women are taught how to insert and remove the pessary for cleaning. If they prefer or if they are unable to clean and replace the pessary themselves, they may go to the doctor's office periodically to have the pessary cleaned. Some pessaries should be removed during vaginal sexual activity. Women should also leave the pessary out overnight at regular intervals as recommended by their doctor.
Pessaries sometimes irritate the vaginal tissues and may cause a foul-smelling vaginal discharge. The discharge can be prevented or controlled by removing the pessary, cleaning it, and leaving it out overnight, at least once or twice a week. Sometimes a different type of pessary may fit better and help limit irritation.
Women who use a pessary should see their doctor periodically as their doctor recommends.
Upasuaji
Surgery is done if symptoms persist after women have tried pelvic floor muscle exercises and a pessary. Surgery is also an option for women who do not wish to use a pessary. Surgery is usually done only after a woman has decided not to have any more children.
One of the following types of surgery is used:
Abdominal surgery: One or more incisions are made in the abdomen.
Vaginal surgery: Surgery is done through the vagina rather than the abdomen. In such cases, no external incision is needed.
Abdominal surgery includes the following:
Laparotomy: An incision that is several inches long is made in the abdomen.
Laparoscopic surgery: A viewing tube (laparoscope) and surgical instruments are inserted through several tiny incisions in the lower part of the abdomen.
The weakened area is located, and the tissues around it are built up to prevent the organ from dropping through the weakened area.
Vaginal surgery includes the following:
For rectoceles, enteroceles, cystoceles, and cystourethroceles, treatment involves
Repairing the tissues that normally support the vagina (procedures called colporrhaphy).
For severe prolapse of the uterus or vagina, treatment may include
Removal of the uterus, if still present (hysterectomy)
Repair of the tissues that support the uterus and vagina
Attachment of the upper part of the vagina (with stitches) to a nearby stable structure, such as a bone or strong ligament in the pelvis
Closure of the vagina (colpocleisis) after removal of the uterus or with the uterus in place (called the Le Fort procedure)
Closure of the vagina (colpocleisis) is an option for women who have severe vaginal prolapse and who do not plan to be sexually active. For this procedure, part of the vagina's lining is removed, and the vagina is stitched shut. Because this procedure can be done quickly and causes few complications, it may be a good choice for women who have conditions that make surgery risky (such as a heart disorder). Also, after closure, prolapse is unlikely to recur. However, sexual activity that involves vaginal penetration is no longer possible.
Recovery time depends on the type of surgery. Most women can gradually resume their normal physical activity over a period of a few weeks, depending on the surgery. Lifting heavy objects (more than 10 pounds) may interfere with healing and should be avoided for at least 6 weeks after surgery to correct pelvic organ prolapse.