Andrew Siegel MD 10/29/2016
Note: This is the final entry in a 3-part series about pelvic organ prolapse.
How is POP diagnosed and evaluated?
The diagnosis of POP can usually be made by listening to the patient’s narrative: The typical complaint is “Doc, I’ve got a bulge coming out of my vagina when I stand up or strain and at times I need to push it back in.”
After listening to the patient’s history of the problem, the next step is a pelvic examination in stirrups. However, the problem with an exam in this position is that this is NOT the position in which POP typically manifests itself, since POP is a problem that is provoked by standing and exertion. For this reason, the exam must be performed with the patient straining forcefully enough to demonstrate the POP at its fullest extent.
A pelvic examination involves observation, a speculum exam, passage of a small catheter into the bladder and a digital exam. Each region of potential prolapse through the vagina—roof, apex, and floor—must be examined independently.
A useful analogy is to think of the vagina as an open box (see above), with the vaginal lips represented by the open flaps of the box. A cystocele (bladder prolapse) occurs when there is weakness of the roof of the box, a rectocele (rectal prolapse) when there is weakness of the floor of the box, and uterine prolapse or enterocele (intestinal prolapse) when there is weakness of the deep inner wall of the box.
Inspection will determine tissue health and the presence of a vaginal bulge with straining. After menopause, typical changes include thinning of the vaginal skin, redness, irritation, etc. The ridges and folds within the vagina that are typical in younger women tend to disappear after menopause.
Useful analogy: The normal vulva is shut like a closed clam. POP often causes the vaginal lips to gape like an open clam.
Since the vagina has top and bottom walls and since the bulge-like appearance of POP of the bladder or rectum look virtually identical—like a red rubber ball—it is imperative to use a speculum to sort out which organ is prolapsing and determine its extent. A one-bladed speculum is used to pull down the bottom wall of the vagina to observe the top wall for the presence of urethral hypermobility and cystocele, and likewise, to pull up the top wall to inspect for the presence of rectocele and perineal laxity. To examine for uterine prolapse and enterocele, both top and bottom walls must be pulled up and down, respectively, using two single-blade specula. Once the speculum is placed, the patient is asked to strain vigorously and comparisons are made between the extent of POP resting and straining, since prolapse is dynamic and will change with position and activity.
Image above shows vaginal exam at rest (mild prolapse)
Image above shows vaginal exam with straining (moderate prolapse)
Image above shows vaginal exam with more straining (more severe prolapse)
After the patient has emptied her bladder, a small catheter (a narrow hollow tube) is passed into the bladder to determine how much urine remains in the bladder, to submit a urine culture in the event that urinalysis suggests a urinary infection and to determine urethral angulation. With the catheter in place, the angle that the urethra makes with the horizontal is measured. The catheter is typically parallel with the horizontal at rest. The patient is asked to strain and the angulation is again measured, recording the change in urethral angulation that occurs between resting and straining. Urethral angulation with straining (hypermobility) is a sign of loss of urethral support, which often causes stress urinary incontinence (leakage with cough, strain and exercise).
Finally, a digital examination is performed to assess vaginal tone and pelvic muscle strength. A bimanual exam (combined internal and external exam in which the pelvic organs are felt between vaginal and external examining fingers) is done to check for the presence of pelvic masses. On pelvic exam it is usually fairly obvious whether or not a woman has had vaginal deliveries. With exception, the pelvic support and tone of the vagina in a woman who has not delivered vaginally can usually be described as “high and tight,” whereas support in a woman who has had multiple vaginal deliveries is generally “lower and looser.”
Depending upon circumstances, tests to further evaluate POP may be used, including an endoscopic inspection of the lining of the bladder and urethra (cystoscopy), sophisticated functional tests of bladder storage and emptying (urodynamics) and, on occasion, imaging tests (bladder fluoroscopy or pelvic MRI).
Image above is x-ray of bladder showing oval-shaped well-supported normal bladder.
Image above is x-ray of bladder showing tennis-racquet shaped bladder, which is high-grade cystocele.
How is POP treated?
First off, it is important to know that POP is a common condition and does not always need to be treated, particularly when it is minor and not causing symptoms that affect one’s quality of life.
There are three general options of managing POP: conservative; pessary and surgery (pelvic reconstruction).
Conservative treatment options for POP include pelvic floor muscle training Kegel); modification of activities that promote the POP (heavy lifting and high impact exercises); management of constipation and other circumstances that increase abdominal pressure; weight loss; smoking cessation; and consideration for hormone replacement since estrogen replacement can increase tissue integrity and suppleness.
A pessary is a mechanical device available in a variety of sizes and shapes that is inserted into the vagina where it acts as “strut” to help provide pelvic support.
Image above is an assortment of pessaries (Thank you Wikipedia, public domain)
The side effects of a pessary are vaginal infection and discharge, the inability to retain the pessary in proper position and stress urinary incontinence caused by the “unmasking” of the incontinence that occurs when the prolapsed bladder is splinted back into position by the pessary. Pessaries need to be removed periodically in order to clean them. Some are designed to permit sexual intercourse.
Studies comparing the use of pessaries with pelvic floor training in managing women with advanced POP have shown that both can significantly improve symptoms; however, pelvic floor muscle training has been shown to be more effective, specifically for bladder POP.
PFM Training (PFMT)
PFMT is useful under the circumstances of mild-moderate POP, for those who cannot or do not want to have surgery and for those whose minimal symptoms do not warrant more aggressive options. The goal of PFMT is to increase the strength, tone and endurance of the pelvic muscles that play a key role in the support of the pelvic organs. Weak pelvic muscles can be strengthened; however, if POP is due to connective tissue damage, PFMT will not remedy the injury, but will strengthen the pelvic muscles that can help compensate for the connective tissue impairment. PFMT is most effective in women with lesser degrees of POP and chances are that if your POP is moderate-severe, PFMT will be less effective. However, if not cured, the POP can still be improved, and that might be sufficient for you.
Numerous scientific studies have demonstrated the benefits of PFMT for POP, including improved pelvic muscle strength, pelvic support and a reduction in the severity and symptoms of POP. Improvements in pelvic support via PFMT are most notable with bladder POP as opposed to rectal or uterine POP. PFMT is also capable of preventing POP from developing when applied to a healthy female population without POP.
In symptomatic advanced POP, surgery is often necessary, particularly when quality of life has been significantly impacted. There are a number of considerations that go into the decision-making process regarding the specifics of the surgical procedure (pelvic reconstruction) to improve/cure the problem. These factors include which organ or organs are prolapsed; the extent and severity of the POP; the desire to have children in the future; the desire to be sexually active; age; and, if the POP involves a cystocele, the specific type of cystocele (since there are different approaches depending on the type). Surgery to repair POP can be performed vaginally or abdominally (open, laparoscopic or robotic), and can be done with or without mesh (synthetic netting or other biological materials used to reinforce the repair). The goal of surgery is restoration of normal anatomy with preservation of vaginal length, width and axis and improvement in symptoms with optimization of bladder, bowel and sexual function.
More than 300,000 surgical procedures for repair of POP are performed annually in the United States. An estimated 10-20% of women will undergo an operation for POP over the course of their lifetime.
Dr. Arnold Kegel—the gynecologist responsible for popularizing pelvic floor exercises—believed that surgical procedures for female incontinence and pelvic relaxation are facilitated by pre-operative and post-operative pelvic floor exercises. Like cardiac rehabilitation after cardiac surgery and physical rehabilitation after orthopedic procedures, PFMT after pelvic reconstruction surgery can help minimize recurrences. Pre-operative PFMT—as advocated by Kegel—can sometimes improve pelvic support to an extent such that surgery will not be necessary. At the very least, proficiency of the PFM learned pre-operatively (before surgical incisions are made and pelvic anatomy is altered) will make the process of post-operative rehabilitation that much easier.
Useful resource: Sherrie Palm is an advocate, champion and crusader for women’s pelvic health who has made great strides with respect to POP awareness, guidance and support. She is founder and director of the Association for Pelvic Organ Prolapse Support and author of “Pelvic Organ Prolapse: The Silent Epidemic.” Visit PelvicOrganProlapseSupport.org.
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, Kegel exercises, pelvic floor muscle, pelvic floor muscle exercises, pelvic floor muscle training, pelvic organ prolapse, pelvic reconstruction, pelvic relaxation, pessary, rectocele, Sherrie Palm, urethral hypermobility, vagina, vaginal bulge