Andrew Siegel MD 10/22/2016
This is the second entry in a three-part series about pelvic organ prolapse. It is important to understand that the issue in POP is NOT with the pelvic organ per se, but with the support of that organ. POP is not the problem, but the result of the problem. The prolapsed organ is merely an “innocent passenger” in the POP process.
How Much Of A Vaginal Bulge Can POP Cause?
The extent of prolapse can vary from minimal to severe and can vary over the course of a day, depending on position and activity level. POP is more pronounced with with standing (vs. sitting or lying down) and with physical activities (vs. sedentary).
The simplest system for grading POP severity uses a scale of 1-4:
grade 1 (slight POP); grade 2 (POP to vaginal opening with straining); grade 3 (POP beyond vaginal opening with straining); grade 4 (POP beyond vaginal opening at all times).
Which Organs Does POP Affect?
POP can involve one or more of the pelvic organs including the following: urethra (urethral hypermobility); bladder (cystocele); rectum (rectocele); uterus (uterine prolapse); intestines (enterocele); the vagina itself (vaginal vault prolapse); and the perineum (perineal laxity).
The healthy, well-supported urethra has a “backboard” or “hammock” of support tissue that lies beneath it. With a sudden increase in abdominal pressure, the urethra is pushed downwards, but because of the backboard’s presence, the urethra gets pinched closed between the abdominal pressure above and the hammock below, allowing urinary control.
When the support structures of the urethra are weakened, a sudden increase in abdominal pressure (from a cough, sneeze, jump or other physical exertion) will push the urethra down and out of its normal position, a condition known as urethral hypermobility. With no effective “backboard” of support tissue under the urethra, stress urinary incontinence will often occur.
Urethral hyper-mobility causing stress urinary incontinence (the gush of urine) when this patient was asked to cough.
Descent of the bladder through a weakness in its supporting tissues gives rise to a cystocele, a.k.a. “dropped bladder,” “prolapsed bladder,” or “bladder hernia.”
A cystocele typically causes one or more of the following symptoms: a bulge or lump protruding into or even outside the vagina; the need for pushing the cystocele back in in order to urinate; obstructive urinary symptoms (a slow, weak stream that stops and starts and incomplete bladder emptying) due to the prolapsed bladder causing urethral kinking; urinary symptoms (frequent and urgent urinating); and vaginal pain and/or painful intercourse.
Descent of the rectum through a weakness in its supporting tissues gives rise to a rectocele, a.k.a. “dropped rectum,” “prolapsed rectum,” or “rectal hernia.” The rectum protrudes into the floor of the vagina. A rectocele typically causes one or more of the following symptoms: a bulge or lump protruding into the vagina, especially noticeable during bowel movements; a kink of the normally straight rectum causing difficulty with bowel movements and the need for vaginal “splinting” (straightening the kink with one’s fingers) to empty the bowels; incomplete emptying of the rectum; fecal incontinence; and vaginal pain and/or painful intercourse.
Rectocele with perineal laxity
Often accompanying a rectocele is perineal muscle laxity, a condition in which the superficial pelvic floor muscles (those located in the region between the vagina and anus) become flabby. Weakness in these muscles can cause the following anatomical changes: a widened and loose vaginal opening, decreased distance between the vagina and anus, and a change in the vaginal orientation such that the vagina assumes a more upwards orientation as opposed to its normal downwards angulation towards the sacral bones.
Women with vaginal laxity who are sexually active may complain of a loose or gaping vagina, making intercourse less satisfying for themselves and their partners. This may lead to difficulty achieving orgasm, difficulty retaining tampons, difficulty accommodating and retaining the penis with vaginal intercourse, the vagina filling with water while bathing and vaginal flatulence (passing air through the vagina). The perception of having a loose vagina can often lead to low self-esteem.
The peritoneum is a thin sac that contains the abdominal organs, including the small intestine. Descent of the peritoneal contents through a weakness in the supporting tissues at the innermost part of the vagina (the apex of the vagina) gives rise to an enterocele, a.k.a. “dropped small intestine,” “small intestine prolapse,” or “small intestine hernia.”
An enterocele typically causes one or more of the following symptoms: a bulge or lump protruding through the vagina, intestinal cramping due to small intestine trapped within the enterocele, and vaginal pressure/pain and/or painful intercourse.
Descent of the uterus and cervix because of weakness of their supporting structures results in uterine prolapse, a.k.a. “dropped uterus,” “prolapsed uterus,” or “uterine hernia.” Normally, the cervix is situated deeply in the vagina. As uterine prolapse progresses, the extent of descent into the vaginal canal will increase.
Uterine POP typically causes one or more of the following symptoms: a bulge or lump protruding from the vagina; difficulty urinating; the need to manually push back the uterus in order to urinate; urinary urgency and frequency; urinary incontinence; kidney obstruction because of the descent of the bladder and ureters (tubes that drain urine from the kidneys to the bladder) that are dragged down with the uterus, creating a kink of the ureters; vaginal pain with sitting and walking; painful intercourse; and spotting and/or bloody vaginal discharge from the externalized uterus, which becomes subject to trauma and abrasions from being out of position. The most extreme form of uterine POP is uterine “procidentia,” a situation in which the uterus is exteriorized at all times and, because of external exposure, has a tendency for ulceration and bleeding.
Severe uterine prolapse (procidentia) with ulcerative inflammation surrounding cervix
The most advanced stage of POP occurs when the support structures of the vagina are weakened to such an extent that the vaginal canal itself turns inside out. Vault prolapse, a.k.a. “dropped vaginal vault,” “prolapsed vaginal vault,”or “vaginal vault hernia,” is rarely an isolated event, but often occurs coincident with other forms of POP and most often is a consequence of hysterectomy. If the vagina is likened to an internal “sock,” vaginal vault prolapse is a condition in which the sock is turned inside out. When I explain vaginal vault prolapse to patients, I demonstrate it by turning a front pocket of my pants inside out.
To be continued…
Wishing you the best of health,
Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery. Much of the content of this entry was excerpted from his recently published book: The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health. For more info: http://www.TheKegelFix.com.
He has previously authored Male Pelvic Fitness: Optimizing Sexual & Urinary Health; Promiscuous Eating: Understanding And Ending Our Self-Destructive Relationship With Food; and Finding Your Own Fountain Of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity. Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro. Area and Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.
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Tags: Andrew Siegel MD, Arnold Kegel MD, cystocele, enterocele, pelvic organ prolapse, pelvic relaxation, prolapsed uterus, rectocele, stress urinary incontinence, urethral hypermobility, urology, vagina