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Seminar

Pelvic organ prolapse


J Eric Jelovsek, Christopher Maher, Matthew D Barber

Pelvic organ prolapse is downward descent of female pelvic organs, including the bladder, uterus or post-hysterectomy vaginal cu, and the small or large bowel, resulting in protrusion of the vagina, uterus, or both. Prolapse development is multifactorial, with vaginal child birth, advancing age, and increasing body-mass index as the most consistent risk factors. Vaginal delivery, hysterectomy, chronic straining, normal ageing, and abnormalities of connective tissue or connective-tissue repair predispose some women to disruption, stretching, or dysfunction of the levator ani complex, connective-tissue attachments of the vagina, or both, resulting in prolapse. Patients generally present with several complaints, including bladder, bowel, and pelvic symptoms; however, with the exception of vaginal bulging, none is specic to prolapse. Women with symptoms suggestive of prolapse should undergo a pelvic examination and medical history check. Radiographic assessment is usually unnecessary. Many women with pelvic organ prolapse are asymptomatic and do not need treatment. When prolapse is symptomatic, options include observation, pessary use, and surgery. Surgical strategies for prolapse can be categorised broadly by reconstructive and obliterative techniques. Reconstructive procedures can be done by either an abdominal or vaginal approach. Although no eective prevention strategy for prolapse has been identied, considerations include weight loss, reduction of heavy lifting, treatment of constipation, modication or reduction of obstetric risk factors, and pelvic-oor physical therapy. Pelvic organ prolapse, also called urogenital prolapse, is downward descent of the pelvic organs that results in a protrusion of the vagina, uterus, or both.1 It is a disorder exclusive to women and can aect the anterior vaginal wall, posterior vaginal wall, and uterus or apex of the vagina, usually in some combination.2 Pelvic organ prolapse is distinct from rectal prolapse, in which the rectum protrudes through the anus, aecting both men and women. In 1997, more than 225 000 inpatient surgical procedures for pelvic organ prolapse were undertaken in the USA (227 per 10 000 women), at an estimated cost of more than US$1 billion.3,4 In the UK, the disorder accounts for 20% of women on the waiting list for major gynaecological surgery.5 Pelvic organ prolapse is the leading indication for hysterectomy in postmenopausal women and accounts for 1518% of procedures in all age-groups.6 It rarely results in severe morbidity or mortality; rather, it causes symptoms of the lower genital, urinary, and gastrointestinal tracts that can aect a womans daily activities and quality of life.7 The anterior vaginal wall is the most typical segment of the vagina to prolapse.8 This type of prolapse usually includes descent of the bladder: when the bladder protrudes, it is called a cystocoele (gure 1). Apical prolapse entails either the uterus or post-hysterectomy vaginal cu and can aect the small intestine (enterocoele), bladder, or colon (sigmoidocoele). Posterior vaginal wall prolapse concerns the rectum (rectocoele) but can also include the small or large bowel. Uterovaginal support can be measured with the pelvic organ prolapse quantitation system (table).9 In addition to describing precisely the degree of anterior, posterior, and apical vaginal-wall descent, this measure broadly classies uterovaginal support with a staging system that ranges from 0 (perfect support) to IV (total procidentia or complete vaginal eversion).

Lancet 2007; 369: 102738 Department of Obstetrics and Gynecology A81, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA (J E Jelovsek MD, M D Barber MD); and Wesley Urogynaecology Unit, The Wesley Hospital, Auchenower, QLD 4066, Australia (C Maher MBBS) Correspondence to: Dr J Eric Jelovsek jelovsj@ccf.org

Epidemiology
Despite the fact that pelvic organ prolapse is one of the most usual indications for gynaecological surgery, epidemiological studies of the incidence and prevalence of this disorder are rare.1,10 Most available work is either from clinical populations or of surgical registries or other similar databases to identify surgically treated prolapse.3,11,12 As far as we know, no epidemiological studies have been done of pelvic organ prolapse in community-based populations.1 Loss of vaginal or uterine support in women presenting for routine gynaecological care is seen in up to 4376% of patients, with 36% having descent beyond the hymen.13,14 In the Womens Health Initiative, 41% of women age 5079 years showed some amount of pelvic organ prolapse, including cystocoele in 34%, rectocoele in 19%, and uterine prolapse in 14%.8 In a multicentre study of 1006 women age 1883 years presenting for routine gynaecological care, 24% had normal support and 38% had stage I, 35% stage II, and 2% stage III pelvic organ prolapse.15 Thus, some loss of uterovaginal support is present in most adult women. There is no clear consensus, however, about what level of prolapse represents a variation of normal uterovaginal support and what represents disorder, although most people would agree that prolapse beyond the hymen is clinically signicant. Data for incidence of pelvic organ prolapse are restricted to studies of surgical intervention. The incidence of surgery
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Search strategy and selection criteria We searched the Cochrane Library, ACP Journal Club, and MEDLINE (195165 and 19502006) with the search term prolapse in combination with uterine prolapse. We largely selected publications from the past 5 years but did not exclude frequently referenced and highly regarded older reports. We also searched reference lists of articles identied by this search strategy and selected those we judged relevant. Review articles and book chapters are cited to provide readers with further details and references than this Seminar has room for.

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Figure 1: Photographs in lithotomy position and sagittal MRI showing vaginal-wall prolapse Prolapse might include (top to bottom): bladder (cystocele), small bowel (enterocele), or rectum (rectocele). Colour codes include purple (bladder), orange (vagina), brown (colon and rectum), and green (peritoneum). Stage 0 I II III IV Denition No prolapse The most distal portion of the prolapse is >1 cm above the level of the hymen The most distal portion of the prolapse is 1 cm proximal or distal to the hymen The most distal portion of the prolapse is >1 cm below the hymen but protrudes no further than 2 cm less than the total vaginal length Complete eversion of the total length of the vagina The distal portion protrudes at least the total vaginal length minus 2 cm beyond the hymen

Table: Five stages of pelvic organ support as dened by the pelvic organ prolapse quantitation system9

for prolapse is between 15 and 49 cases per 1000 women-years.3,11,12,16 A womans lifetime risk of surgery for pelvic organ prolapse by age 80 years is about 7%.16 The peak incidence of such surgery is in individuals age 6069 years (421 per 10 000 women). However, almost 58% of procedures are undertaken in people younger than 60 years.3 An estimated 13% of patients who have surgery will need a repeat operation within 5 years.16,17

Causes and risk factors


Many risk factors for pelvic organ prolapse have been suggested. The cause of this disorder is likely to be multifactorial, attributable to a combination of risk factors, varying from patient to patient.18 Vaginal childbirth, advancing age, and increasing body-mass index are the most consistent risk factors (panel 1),1 with
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vaginal childbirth being the one most frequently associated with prolapse. In the Oxford Family Planning Study,11 increasing vaginal parity was the strongest risk factor for pelvic organ prolapse in women younger than 60 years. Compared with nulliparous individuals, the relative risk of developing prolapse was 84 for a woman who had delivered two children and 109 (95% CI 47338) for someone with four or more children.11 The Womens Health Initiative noted that single childbirth was associated with raised odds of uterine prolapse (odds ratio 21; 95% CI 1727), cystocoele (22; 1827), and rectocele (19; 1722).8 Every additional delivery up to ve births increased the risk of worsening prolapse by 1020%.8 Similarly, in the Pelvic Organ Support study and the Progetto Menopausa Italia study, researchers showed that risk of pelvic organ prolapse rose with increasing parity.13,19 Caesarean section seems to protect against prolapse development whereas forceps delivery enhances risk.20,21 Findings of a cross-sectional study of 3050 women randomly selected from a large southern California health maintenance organisation showed that individuals who had undergone one or more vaginal deliveries had a signicantly greater risk of developing symptomatic pelvic organ prolapse than did those who had only caesarean sections (odds ratio 321; 95% CI 196526), after adjusting for age, parity, and obesity.21 The attributable risk of vaginal delivery for development of symptomatic prolapse, or the proportion that could have been prevented with a policy of routine elective caesarean section, was 46% in this population.21 Other obstetric factors that have been associated with an increased risk of pelvic organ prolapse, albeit less consistently, include high infant birthweight, delivery of a macrosomic infant, prolonged second stage of labour, and age younger than 25 years at rst delivery.15,20 Somewhat more controversial is whether pregnancy itself, distinct from mode of delivery, alters risk of pelvic organ prolapse. In one small case-control study, pregnancy was associated with worsening prolapse compared with non-pregnant controls matched for age and ethnic origin.22 A substantial proportion of pregnant nulliparous women show progression from stage 0 or I support in the rst trimester to stage I or II in the third trimester.23 This loss of vaginal support does not seem to return to baseline in the postpartum period. Despite the strong relation between obstetric factors and pelvic organ prolapse, most cases of symptomatic disorder arise a long time after vaginal childbirth, and most women who bear children do not have symptomatic prolapse.10 Both incidence and prevalence of pelvic organ prolapse increase with advancing age.1 In a cross-sectional study of 1004 US women aged 1883 years who presented for their yearly examination, the relative prevalence of this disorder rose by about 40% with every decade of life.13 In the Womens Health Initiative, women in the USA age 6069 years (odds ratio 12; 95% CI 1013) and 7079 years (14; 1216) had a higher risk of prolapse
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Panel 1: Established and potential risk factors for pelvic organ prolapse Established risk factors Vaginal delivery Advancing age Obesity Potential risk factors Obstetric factors Pregnancy (irrespective of mode of delivery) Forceps delivery Young age at rst delivery Prolonged second stage of labour Infant birthweight >4500 g Shape or orientation of bony pelvis Family history of pelvic organ prolapse Race or ethnic origin Occupations entailing heavy lifting Constipation Connective-tissue disorders Previous hysterectomy Selective oestrogen-receptor modulators

than did those age 5059 years.8 Similarly, ndings of a cross-sectional study of 21 449 menopausal Italian women showed an augmented risk of pelvic organ prolapse in individuals age 5255 years (13; 1115) and those 56 years or older (17; 1520) compared with those younger than 51 years.19 Surgery for prolapse is uncommon in people younger than 30 and older than 80 years; for women between these ages, incidence rises steadily.1,16 Increasing body-mass index also seems to have a role in development of pelvic organ prolapse. Women who are overweight (body-mass index 2530 kg/m; odds ratio 251; 95% CI 118535) and obese (>30 kg/m2; 256; 123535) are at high risk of developing this disorder.8,15 Similarly, individuals with a body-mass index of more than 26 kg/m2 are more likely (30; 1657) to undergo surgery for prolapse than are those with a lower value.20 Hysterectomy might heighten risk of subsequent pelvic organ prolapse; however, development of symptomatic prolapse typically happens many years after this procedure.11,16,20,24,25 In the Oxford Family Planning Study, incidence of surgery for prolapse in women who had undergone a previous hysterectomy was 29 per 1000 women-years versus 16 per 1000 women-years for the entire cohort.11 The cumulative risk of surgery for pelvic organ prolapse rose from 1% at 3 years after hysterectomy to 5% at 15 years. Risk was highest in individuals who had undergone previous hysterectomy for prolapse (158 per 1000 women-years). In a retrospective cohort study of 149 554 women age 20 years and older, the mean interval between hysterectomy and surgery for pelvic organ prolapse in those who developed the disorder was 193 years.16,17 Contrary to ndings of many other studies,
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the prevalence of prolapse for women with a uterus in the Womens Health Initiative was slightly higher than for those who had undergone hysterectomy, suggesting that previous prolapse of pelvic organs might have been repaired at the time of the procedure in this study population.8 Surgical technique at the time of hysterectomy, including performance of prophylactic culdoplasty, can lessen development of subsequent prolapse.26 Some evidence suggests that heritable or genetic factors can play a part in development of pelvic organ prolapse. In one study, a higher risk of prolapse was seen in women with a mother (odds ratio 32, 95% CI 1176) or sister (24, 1056) reporting prolapse.27 Data from the USA suggest that Hispanic and Asian women seem to have an increased risk of developing cystocoele (Hispanic, odds ratio 124, 95% CI 101154; and Asian, 218, 18264), and African-American women have a lower risk (063, 05079), compared with white individuals.8 The reasons for these ethnic dierences are unclear; however, some evidence indicates that African-American women have smaller pelvic outlets than do those of European descent.28 Although menopause is often cited as a risk factor for pelvic organ prolapse, most researchers studying hormonal status and prolapse fail to nd an association between oestrogen status and the disorder.11,19,27,29 In the Womens Health Initiative, a subgroup of 270 women who had not undergone hysterectomy and who were randomly assigned to receive either oral conjugated oestrogens and medroxyprogesterone or placebo were assessed for pelvic organ prolapse 6 years after treatment; no dierences were recorded between treatment groups.8 However, selective oestrogen-receptor modulators might be linked to prolapse and other pelvic-oor disorders.30,31 Repetitive straining, such as that seen in patients with chronic constipation or workers whose jobs entail heavy lifting, has also been associated with pelvic organ prolapse. Spence-Jones reported that straining at stool as a young adult was more typical in women with prolapse than in those without the disorder (61% vs 4%; p<0001).32 Individuals with stage II or greater pelvic organ prolapse had an increased risk of constipation (odds ratio 39; 95% CI 14119) compared with women with stage 0 or 1 prolapse.33 However, ndings of larger studies have disputed this association, and several groups have shown that neither overall stage of prolapse nor stage of the posterior vaginal wallestablished by the pelvic organ prolapse quantitation systemcorrelate with bowel function.3436 Additionally, women with only urinary incontinence and no prolapse seem to meet Rome II criteria for constipation with the same frequency as those with advanced pelvic organ prolapse.36 Housewives, who undertake more physical work, seem more likely to have prolapse (31; 1688) on multivariate regression than do professional managerial women.27 Similarly, people with occupations in which heavy lifting is entailed might have a high chance of undergoing surgical procedures for pelvic organ prolapse.37
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Pathophysiology
Anatomical support of pelvic viscera is mainly provided by the levator ani muscle complex and connective-tissue attachments of the pelvic organs (endopelvic fascia). Disruption or dysfunction of one or both of these components can lead to loss of support and, eventually, pelvic organ prolapse. The levator ani muscle complex consists of the pubococcygeus, the puborectalis, and iliococcygeus muscles.38 These muscles are tonically contracted at rest and act to close the genital hiatus and provide a stable platform for the pelvic viscera. Decline of normal levator ani toneby denervation or direct muscle traumaresults in an open urogenital hiatus, weakening of the horizontal orientation of the levator plate, and a bowl-like conguration.39,40 Such anatomical arrangements are more often seen in women with pelvic organ prolapse than in those with normal support.39 Visible defects in the pubovisceral and iliococcygeal areas of the levator ani muscle complex after a vaginal delivery have been noted on MRI in 20% of primiparous women, which are not seen in nulliparous individuals, suggesting that vaginal delivery contributes to development of pelvic organ prolapse through levator ani muscle injury.41,42 In addition to direct muscle trauma, neuropathic injury of the levator ani muscles can result from vaginal delivery. Weidner and colleagues undertook concentric-needle electromyography of the levator ani muscles in 58 primiparous women in their third trimester and at 6 weeks and 6 months postpartum and recorded evidence of neuromuscular dysfunction in 24% at 6 weeks and in 29% at 6 months.43 Women having vaginal delivery had a slightly greater proportion of defects at 6 months compared with those undergoing elective caesarean section, who had virtually no injury. Spontaneous delivery or caesarean section after labour was associated with greater dysfunction in the lateral levator ani whereas operative vaginal delivery had more damage to the medial levator ani. Chronic straining to achieve defecation has also been associated with pelvic muscle denervation.32,44,45 The excess straining and associated perineal descent is thought to cause stretch injury to the pudendal nerve and result in neuropathy.44 The endopelvic fascia is the connective-tissue network that envelops all organs of the pelvis and connects them loosely to the supportive musculature and bones of the pelvis. This network holds the vagina and uterus in their normal anatomical location yet allows for mobility of the viscera to permit storage of urine and stool, coitus, parturition, and defecation. Disruption or stretching of these connective-tissue attachments happens during vaginal delivery or hysterectomy, with chronic straining, or with normal ageing.40 Evidence suggests that abnormalities of connective tissue and connective-tissue repair might predispose some women to pelvic organ prolapse. Individuals with prolapse might have altered collagen metabolism, including a decrease in type I collagen and an increase in type III collagen.4648 Whether this alteration is a cause or eect of pelvic organ prolapse is unclear. Women
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with joint hypermobility have a higher prevalence of prolapse than do those with normal joint mobility.49 Similarly, individuals with connective-tissue disorders such as Ehlers-Danlos or Marfans syndrome are at enhanced risk of pelvic organ prolapse.50 Emerging data in genetic knockout mice show that abnormal elastin homeostasis might also contribute to development of the disorder through an abnormal tissue response to injury.51 The smooth muscle of the vaginal wall is also altered in women with pelvic organ prolapse. In these individuals, the vaginal wall consists of disorganised smooth-muscle bundles with a decreased fractional area of smooth muscle of the muscularis layer compared with controls with normal support (26% vs 48%; p<005).52,53 Histologically, nerve bundles and ganglia are also reduced in the muscularis layer.52 Currently, we do not know if these alterations in the smooth muscle of the vaginal wall have a role in development of pelvic organ prolapse or are the outcome of mechanical forces associated with the disorder.18 Variations in orientation and shape of the bony pelvis have been associated with development of pelvic organ prolapse. Specically, a loss of lumbar lordosis and a pelvic inlet that is less vertically oriented is more usual in women who develop genital prolapse than in those who do not.54,55 A less vertical orientation of the pelvic inlet is thought to result in alteration of intra-abdominal vector
Panel 2: Typical symptoms in women with pelvic organ prolapse Vaginal Sensation of a bulge or protrusion Seeing or feeling a bulge or protrusion Pressure Heaviness Urinary Incontinence Frequency Urgency Weak or prolonged urinary stream Hesitancy Feeling of incomplete emptying Manual reduction of prolapse to start or complete voiding Position change to start or complete voiding Bowel Incontinence of atus, or liquid or solid stool Feeling of incomplete emptying Straining during defecation Urgency to defecate Digital evacuation to complete defecation Splinting, or pushing on or around the vagina or perineum, to start or complete defecation Feeling of blockage or obstruction during defecation Sexual Dyspareunia

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Proportion with digital assistance for defecation (%)

forces that are usually directed anteriorly to the pubic symphysis such that a greater proportion is directed towards the pelvic viscera and their connective-tissue and muscular supports. Similarly, women with a wide transverse pelvic inlet seem to be at increased risk of pelvic organ prolapse.56,57 Some workers have postulated that a wider pelvic inlet provides a larger hiatus for abdominal pressure transmission to the pelvic oor, which over time leads to loss of pelvic visceral support.56 Variations in shape and orientation of the bony pelvis are also important factors that aect maternal soft-tissue damage and nerve injury during parturition.

100 Proportion with urinary splinting (%)

Stage 01

Stage 2

Stage 34

50

0 100

50

Clinical presentation
Women who develop pelvic organ prolapse can present either with one symptom, such as vaginal bulging or pelvic pressure, or with several complaints, including many bladder, bowel, and pelvic symptoms. Ellerkmann and colleagues assessed 237 women for pelvic organ prolapse and noted 63% with bulge symptoms, 73% urinary incontinence, 86% urinary urgency or frequency, 62% voiding dysfunction, and 31% faecal incontinence.58 Some prolapse-related symptoms are the result of the prolapsing vagina itself and some are caused by coexisting or associated dysfunction of the bladder, lower gastrointestinal tract, or pelvic oor. Panel 2 lists common symptoms in women with advanced pelvic organ prolapse. With the exception of vaginal bulging symptoms, none is specic to prolapse. Considerable overlap exists with other pelvic-oor disorders, and clinicians should be aware of other potential sources for the patients complaints. In general, only weak-to-moderate correlations exist between severity or stage of prolapse and presence of specic symptoms such as bulging, heaviness, and voiding dysfunction.14,5860 Several symptoms typically attributed to prolapse might, in fact, not be related. This fact is especially true for many bowel symptoms.34,59 The hymen seems to be an important cuto point for symptom development. Swift and coworkers assessed symptoms and pelvic-organ support in 477 women presenting for their annual gynaecological examination and reported that the number of pelvic-oor symptoms increased from an average of 05 for patients with stage I pelvic organ prolapse to 21 for those with the leading edge of the prolapse extended beyond the hymen.15 By contrast, prevalence of some symptoms, particularly stress urinary incontinence, declines as prolapse extends beyond the hymen, possibly from urethral obstruction.14,5861 Figure 2 shows the relation between extent of maximum prolapse and development of three commonly related symptoms.62 Bulge or herniation symptoms that have been attributed to worsening pelvic organ prolapse include a sensation of bulging or protrusion in the vagina, a sensation of something falling out of the vagina, seeing or feeling a vaginal or perineal bulge, pelvic pressure, fullness, and heaviness. Although many of these symptoms are correlated to some extent with presence and severity of
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0 100

Proportion with vaginal bulge (%)

50

0 3 2 1 0 1 2 3 Maximum POPQ measurement (cm)

Figure 2: Proportion of women reporting either a need to splint or push on or around the vagina to urinate (upper) or defecate (middle) or a feeling of a vaginal bulge (lower) Scale indicates maximum prolapsed portion of the vagina protruding proximal to (negative), at (zero), or distal to (positive) the vaginal hymen. Women with pelvic organ prolapse with the leading edge of the prolapse beyond the hymen (some stage II and all stage III) have augmented symptoms.15 POPQ=pelvic organ prolapse quantitation system. Reproduced from reference 62 with permission of Springer London.

prolapse, the only one that is acknowledged consistently by patients with severe prolapse is presence of a vaginal bulge that can be seen or felt.14,5860 Less specic symptoms such as pressure and heaviness have a much weaker relation to loss of vaginal support.14,5860 Lower urinary-tract complaints are frequent in women with pelvic organ prolapse. In some circumstances, loss of vaginal support directly aects bladder or urethral function, resulting in symptoms. In other cases, the relation between prolapse and lower urinary-tract dysfunction is less clear. The anterior vaginal wall supports the bladder and urethra.63 Loss of this support results in urethral hypermobility and cystocoele formation, which is thought to contribute to development of stress urinary incontinence.63,64 Therefore, the fact that pelvic organ prolapse and stress urinary incontinence sometimes coexist is not surprising, particularly when prolapse is mild. By contrast, women with pelvic organ prolapse that extends beyond the hymen are less likely to complain of stress incontinence and more likely to have symptoms of obstructed voiding, such as urinary hesitancy, intermittent ow, weak or prolonged stream, a feeling of incomplete emptying, need to manually reduce (splint) the prolapse to initiate or complete urination and, in rare cases, urinary retention.14,5861 The mechanism for urinary retention seems
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to be mechanical obstruction resulting from urethral kinking that arises with progressively worsening anterior vaginal prolapse. As many as 30% of women with stage III or IV prolapse have raised post-void residual volumes (>100 mL).65 Large posterior vaginal prolapse can also cause mechanical obstruction by direct urethral compression.66 Women with pelvic organ prolapse frequently complain of symptoms related to bowel dysfunction, including a feeling of incomplete emptying, straining, need to apply digital pressure to the vagina or perineum (splint) to start or complete defecation, urgency, and incontinence. In studies of the relation between bowel dysfunction and presence and severity of prolapse, researchers have reported either a weak correlation between posterior vaginal wall support and specic anorectal symptoms or no link at all.34,5860 The defecatory symptom that arises most consistently with respect to posterior vaginal prolapse is need to splint the vagina or perineum to defecate.5860 However, most women with rectocoeles do not have this symptom, and some without this disorder also use manual pressure to accomplish defecation.32,34 731% of women with pelvic organ prolapse report faecal incontinence.67,68 Although rectal prolapse is a recognised cause of faecal incontinence, vaginal prolapse is unlikely to contribute to development of faecal incontinence. Rather, faecal incontinence and pelvic organ prolapse sometimes coexist because they share common risk factors, such as neuropathic and muscular injury to the pelvic oor after vaginal delivery and the eects of ageing.10 People with pelvic organ prolapse have comparable rates of sexual activity to similarly aged individuals without the disorder.69 A third of sexually active women with pelvic organ prolapse complain that their prolapse interferes with sexual function.70,71 However, in a comparison of sexual function in individuals with and without prolapse, using a validated sexual-function questionnaire, no dierence was noted in frequency of intercourse, libido, vaginal dryness, dyspareunia, orgasmic function, or overall sexual function between the two groups.69 Furthermore, a high rate of sexual satisfaction (8184%) has been reported in women with pelvic organ prolapse who are in an intimate relationship.69,70 Although patients with pelvic organ prolapse sometimes attribute back and pelvic pain to their prolapse, very little evidence is available to show that the disorder causes pain.15,72 The complaint of pain in a woman with prolapse should prompt clinicians to search for other sources of the pain before attributing it to the disorder.

Assessment
Women presenting with symptoms suggestive of pelvic organ prolapse should undergo pelvic examination. This assessment should be done with the patient resting and straining while supine and standing to dene the extent of the prolapse and establish the segments of the vagina aected (anterior, posterior, or apical).9 A clinician should reproduce the maximum extent of prolapse that the
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woman has in their daily life. The extent of prolapse of the anterior vaginal wall can be assessed by placing either a Sims speculum or the posterior blade of a bivalve speculum in the vagina to retract the posterior vaginal wall. The woman is asked to strain and the extent of anterior vaginal prolapse is noted. The blade is then placed to retract the anterior vaginal wall and she strains again to reveal any posterior prolapse. A rectovaginal examination can be useful to identify presence of a rectocoele and establish the integrity of the perineal body. A bivalve speculum is inserted and the cervix orin women who have had a hysterectomyvaginal cu is identied to assess apical vaginal support. While the patient strains the speculum is slowly withdrawn and the descent of the vaginal apex is noted. In women with prolapse that protrudes beyond the hymen for a long duration, the vagina, cervix, or both can become hypertrophied and develop erosions (gure 3). A bimanual and rectal examination is undertaken to rule out coexistent gynaecological or rectal pathological ndings. Although several prolapse grading systems exist, the only system with international acceptance is the pelvic organ prolapse quantitation system.60 This examination denes systematically the amount of prolapse during a pelvic examination by measuring anterior, posterior, and apical segments of the vaginal wall in cm relative to a xed anatomical structurethe vaginal hymen. This assessment provides a highly reliable and reproducible staging system (table).73 Need for ancillary testing beyond a comprehensive history and physical examination depends largely on the patients presenting symptoms. Most women will need little additional testing. Those with pelvic organ prolapse who complain of lower urinary-tract symptoms should undergo urinalysis and post-void residual volume testing with a urethral catheter or bladder ultrasound. Urodynamic assessment should be planned in women with substantial urinary incontinence, irritative voiding symptoms, or voiding dysfunction. Although urodynamics are currently being used to predict postoperative urinary incontinence, ndings of a randomised trial have disputed the usefulness of this test as a predictor of altering surgical management.74 Similarly, anal manometry, defecography, or both should be considered in individuals with substantial defecatory symptoms, and endoanal ultrasound should be contemplated in those with faecal incontinence when an anal sphincter defect is suspected. Generally, radiographic assessment to establish extent or characteristics of a patients prolapse is unnecessary. Some workers have advocated use of imaging procedures such as contrast radiography or dynamic MRI to describe the location of pelvic-support defects before attempting surgical repair.75 However, a scarcity of standardised radiological criteria currently exists for diagnosis of pelvic organ prolapse, and the clinical benet of such radiographic imaging has yet to be dened. Currently, such imaging studies are used mainly for research.
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Management
Loss of normal vaginal support can be seen to some extent in as many as 4376% of women14,15 When this loss of support becomes a condition that causes patients to seek care and for doctors to oer treatment depends largely on development and severity of associated symptoms. Current management options for women with symptomatic pelvic organ prolapse include observation, pessary use, and surgery.

Observation
Women with advanced prolapse can have few symptoms and report little or no bother as a result of the disorder. This situation is especially true for individuals with prolapse that is mild and does not extend beyond the hymen. In these cases, observation or watchful waiting is perfectly appropriate. Although several groups of researchers have studied associations between prolapse and lifestyle factors, to date, the role of lifestyle modications in prevention or treatment of prolapse has not been investigated. Pelvic-oor muscle training is an eective treatment for urinary and faecal incontinence; however, its role in management of pelvic organ prolapse has yet to be established.76 Findings of one study do suggest that daily pelvic-oor muscle strengthening can slow progression of anterior prolapse in elderly women.77 Individuals with advanced prolapse, who choose observation, should be examined periodically to identify development of new symptoms or disorders that might prompt treatment. Obstructed urination or defecation, vaginal erosions that do not resolve with conservative management, or hydronephrosis from chronic ureteral kinking are all indications for treatment, even in women with few symptoms of prolapse.

Figure 3: Complete uterovaginal prolapse with cornication of cervix and two linear erosions of posterior vaginal mucosa Erosions of vaginal mucosa can develop in women with prolapse that protrudes beyond the hymen for a long duration.

Pessary
Pessary use is the only currently available, non-surgical intervention for women with pelvic organ prolapse. These devices are inserted into the vagina to reduce prolapse inside the vagina, to provide support to related pelvic structures, and to relieve pressure on the bladder and bowel.76 Pessaries have been used to treat women with prolapse since the beginning of recorded history. In 400 BC, Hippocrates described reduction of prolapse by putting half a pomegranate soaked in wine into the vagina. Since that time, hundreds of dierent types of vaginal pessaries have been described made of various materials both organic and inert. Today, fewer than 20 dierent pessary types are available, and all are made of silicone or plastic. The most frequently used are the ring, ring with support, Gelhorn, and donut pessaries (gure 4).78 Historically, use of these devices has been reserved for patients with symptomatic pelvic organ prolapse who decline surgery, who are poor surgical candidates because of medical comorbidities, or who need temporary relief of pregnancy-related prolapse or incontinence. Unfortunately, most available data for pessary use are restricted to case reports of pessary complications. Published work on the
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appropriate indications, proper management, and eectiveness of pessaries for treatment of pelvic organ prolapse are scarce.76,79 In the 2004 Cochrane review of these devices, no randomised trials of pessary use in women with prolapse were identied.79 Despite this absence, 86% of gynaecologists and 98% of urogynaecologists use pessaries in their practice.78,80 All available pessary types are oered in various sizes. When tting a pessary, several factors are considered, including nature and extent of the prolapse and the patients cognitive status, manual dexterity, and level of sexual activity. The size of the vagina is estimated and the appropriate size and shape of pessary is inserted such that the prolapse is eectively reduced and the woman is comfortable with the device in place. The doctor should be able to sweep his or her nger between the pessary and the walls of the vagina. The patient should be asked to undertake various activities, including standing, walking, doing a Valsalva manoeuvre, and bending, to ensure that the pessary is retained. She should also be able to void without diculty with the pessary in place before leaving the clinic. Generally, a ring pessary, which is easy to insert and remove, is a good rst choice. In a prospective study of 110 women, Wu and colleagues were able to successfully t a pessary in 74% of patients.81 Of these, 96% received a ring pessary. If a device of this type cannot be successfully inserted, trial and error is usually necessary to nd the correct pessary size and shape for an individual patient.
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Figure 4: Various pessary types (Top left to right) Marland with support, Ring with support, Donut, Shaatz, Gelhorn, and Smith-Hodge with support.

No clear consensus exists on how frequently patients should be examined after a successful pessary tting. Manufacturers, on the package insert information, generally recommend follow-up visits every 46 weeks. Wu and coworkers followed up patients every 3 months for the rst year after tting and every 6 months in subsequent years with no serious complications, suggesting that pessaries can be managed safely with fewer visits.81 Women who can eectively remove and reinsert their pessary need less frequent follow-up than do those who cannot. Vaginal oestrogen cream should be considered in patients with vaginal atrophy. At every follow-up visit, the patient should be asked about development of new symptoms and the vagina inspected for irritation and erosions. If erosion develops, the pessary should be removed and vaginal oestrogen cream applied until the ulcer is healed. The device can then be replaced, although a reduction in pessary size, a change in shape, or both should be considered. If the erosion does not heal, biopsy should be planned. The most typical side-eect of pessary use is vaginal discharge and odour. Serious complications reported with use of these devices include vesicovaginal and rectovaginal stulas, faecal impaction, hydronephrosis, and urosepsis. However, almost all these side-eects arose with pessaries that were neglectedfurther emphasising the need for regular follow-up in women managed in this manner.8284 About half of patients successfully tted with a pessary will continue with their use beyond a year.81,85 Factors associated with pessary use for more than 1 year include age older than 65 years, severe comorbidity, and maintenance of urinary continence.86

Surgery
Women with symptomatic pelvic organ prolapse who fail or decline pessary treatment are candidates for surgery. Surgical treatment for the disorder can be categorised broadly into reconstructive and obliterative techniques. Reconstructive surgery for prolapse aims to correct the prolapsed vagina while maintaining (or improving) vaginal
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sexual function and relieving any associated pelvic symptoms. Surgery can be undertaken by either an abdominal or vaginal route. Although precise estimates of the proportion of procedures undertaken by each route are not available, ndings of epidemiological studies of national or insurance databases suggest that the preferred route for most prolapse surgery is vaginal, with as many as 8090% of operations done this way.3,12,16 Prolapse of an isolated segment of vagina can arise but is uncommon. Typically, several vaginal segments are aected. As a result, surgical repair of prolapse usually needs some combination of resuspension of the anterior, apical, or posterior vaginal wall. Two frequent approaches for correction of apical prolapse include abdominal sacral colpopexy, which suspends the upper vagina from the sacral promontory with synthetic mesh, and vaginal sacrospinous ligament suspension, which attaches either the upper vagina or cervix to the ligament between the ischial spine and the sacrum transvaginally. These two procedures have been compared in three randomised controlled trials8789 and a Cochrane review,90 and conclusions were that abdominal sacral colpopexy was associated with lower recurrent prolapse but a longer operating time and length of admission and greater morbidity and cost than vaginal sacrospinous ligament suspension. In another study, the laparoscopic approach seemed to be as successful as the open technique, with slightly longer operating time but greatly reduced blood loss and admission.91 Although hysterectomy is sometimes undertaken concomitantly at the time of sacral colpopexy, there seems to be an increased risk of postoperative mesh erosion into the vagina.87,88,9294 Alternatives to hysterectomy at the time of abdominal prolapse repair include subtotal hysterectomy and sacral mesh hysteropexy, in which the cervical stump and cervix, respectively, are suspended from the sacrum. Other transvaginal apical suspension procedures include iliococcygeus ligament xation, high uterosacral ligament suspension, and McCall culdoplasty.95 Anterior colporrhaphy is a surgical technique to repair anterior vaginal prolapse, which entails central plication of the bromuscular layer of the anterior vaginal wall. The success rate of this procedure ranges from 80100% in cases series to only 4060% in randomised trials.9699 Paravaginal defect repairs comprise reapproximation of vaginal tissue that has torn from the lateral supporting arcus tendineous fascia pelvis to correct anterior vaginal prolapse. Paravaginal repair has a 67100% success rate for treatment of anterior vaginal prolapse, although the vaginal approach has a high complication rate.100105 Posterior colporrhaphy, described by Francis and Jecoate, plicates the levator ani muscle and is highly eective in treatment of posterior vaginal-wall prolapse but is associated with unacceptably high rates of dyspareunia.106108 To reduce this side-eect, many gynaecologists have undertaken midline fascial plication or site-specic repairs with success rates of 80100%.108113 Abramov and colleagues reported a signicantly higher recurrence rate of rectocoeles after
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defect-specic repair compared with midline fascial plication (32% vs 13%, p=0015).114 Findings of a randomised trial comparing three techniques for treatment of rectocele showed that midline fascial plication and site-specic rectocele repair provide superior anatomical outcomes to site-specic rectocoele augmented with a porcine xenograft, with similar functional outcomes between the groups.115 Despite widespread use of mesh in surgery to correct prolapse, very few safety and eectiveness data have been published. Use of mesh has become popular in pelvic surgery largely owing to the original work of Ulmsten and Petros on the integral theory that has formed the basis for the revolution with suburethral tapes in continence surgery over the past decade.116 Posterior intravaginal slingplasty uses a multilament polypropylene mesh to suspend the upper vagina via a novel transgluteal approach.117 Meschia and colleagues compared vaginal sacrospinous colpopexy with posterior intravaginal slingplasty and noted at 2 years that both techniques were equally eective at correction of prolapse. The total vaginal mesh procedure aims to correct prolapse of the apical, anterior, and posterior vaginal wall by passing a polypropylene mesh with two arms through the obturator foramen anteriorly and one arm is passed posteriorly around the ischial spine at the vaginal apex via a transgluteal approach. Cosson and colleagues reported a 95% success rate in 687 patients at 36 month follow-up, with a mesh erosion rate of 67% and mesh shrinkage of 28%.118 These researchers stressed the importance of avoiding simultaneous hysterectomy and shortening the length of vaginal incisions to reduce complications such as mesh erosions and granulomas.119 Addition of mesh in the posterior vaginal wall either seems to be of no benet or has a high complication rate.99,120123 Use of absorbable or biological grafts has arisen from a desire to obtain the benet of permanent synthetic grafts without the risk of erosion. Polyglactin 910 mesh reduces the rate of recurrent cystocele compared with traditional anterior colporrhaphy.90,98,99 However, data are mixed with respect to use of donor allograft and xenograft material, including porcine dermis and small intestine submucosa.124126 At present, potentially high success rates resulting from use of some mesh products are accompanied by a high complication rate. Side-eects associated with use of mesh in the vagina include mesh erosion (gure 5) and infection that results in pain, dyspareunia, and recurrent vaginal discharge, requiring removal of the mesh.103,121,122,127131 In 2005, at the World Health Organizations 3rd International Consultation on Incontinence, researchers concluded that because of its high potential morbidity, mesh placed transvaginally should only be used in well-designed clinical trials and not in general practice until more data is available.74 Obliterative surgery, such as total colpocleisis or LeForts partial colpocleisis, corrects pelvic organ prolapse by moving pelvic viscera back into the pelvis and closing o
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the vaginal canal either partly or totally.132 Obliterative procedures are less frequently undertaken in Europe, Asia, and Australia compared with the USA and are usually reserved for women who are elderly, medically compromised, and no longer sexually active. The purported advantages of obliterative surgery in this population are shortened operative time, decreased perioperative morbidity, and a very low prolapse recurrence risk. The obvious disadvantage is elimination of the potential for vaginal intercourse. In a systematic review of colpocleisis, workers noted that although colpocleisis seems to be nearly 100% eective for correction of pelvic organ prolapse, little is known about improvement or deterioration of pelvic symptoms.133 Findings of a prospective study showed a substantial improvement in health-related quality of life without alteration in body image in a group of carefully selected women with stage III or IV pelvic organ prolapse who received obliterative vaginal surgery.134 Preoperative counselling is essential when choosing between the obliterative and reconstructive options. Women and, if applicable, their spouses must be completely comfortable with the prospect of losing vaginal sexual function before an obliterative operation can be considered.

Prevention
Limited data are available for prevention strategies for pelvic organ prolapse. Potential approaches include lifestyle changes that reduce modiable risk factors, such as weight loss, avoidance of heavy-lifting occupations, and treatment of constipation. Unfortunately, as far as we know, no studies have been done to assess these changes or anything similar. Modication or reduction of obstetric risk factors also oers the potential to prevent subsequent prolapse.40 Similar to lifestyle changes, much more evidence is needed in this area. Some researchers have advocated for elective caesarean section as a way to reduce

Figure 5: Mesh erosion of posterior vaginal wall

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risk of subsequent pelvic organ prolapse.135 However, until specic criteria allow providers to ascertain who would and would not benet from this intervention, it is unlikely to become an eective strategy for prevention. Another potential preventive approach is maintenance or improvement of pelvic-oor muscle strength via a physical therapy (Kegal exercise) programme. Kegal exercises are an eective treatment for urinary incontinence and other pelvic-oor disorders. Their role in the prevention of pelvic organ prolapse is not yet established.136
Conict of interest statement We declare that we have no conict of interest. Acknowledgments We thank Sandip Vasavada for the MRI images and Cindy L Amundsen for the rectocele image. References 1 Hunskaar S, Burgio K, Clark A, et al. Epidemiology of urinary and fecal incontinence and pelvic organ prolapse. In: Abrams P, Cordozo L, Koury S, Wein A, eds. Third international consultation on incontinence, 1st edn. Paris: Health Publication, 2005. 2 Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Am J Obstet Gynecol 2002; 187: 11626. 3 Brown JS, Waetjen LE, Subak LL, Thom DH, Van den Eeden S, Vittingho E. Pelvic organ prolapse surgery in the United States, 1997. Am J Obstet Gynecol 2002; 186: 71216. 4 Subak LL, Waetjen LE, van den Eeden S, Thom DH, Vittingho E, Brown JS. Cost of pelvic organ prolapse surgery in the United States. Obstet Gynecol 2001; 98: 64651. 5 Cordozo L. Prolapse. In: Whiteld CR, ed. Dewhurses textbook of obstetrics and gynaecology for postgraduates. Oxford: Blackwell Science, 1995: p 64252. 6 Kesharvarz H, Hillis SD, Kieke BA, Marchbanks PA. Hysterectomy surveillanceUnited States 19941999. MMWR Surveill Summ 2002; 51 (SS05): 18. 7 Jelovsek JE, Barber MD. Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life. Am J Obstet Gynecol 2006; 194: 145561. 8 Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the Womens Health Initiative: gravity and gravidity. Am J Obstet Gynecol 2002; 186: 116066. 9 Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic oor dysfunction. Am J Obstet Gynecol 1996; 175: 1017. 10 Bump RC, Norton PA. Epidemiology and natural history of pelvic oor dysfunction. Obstet Gynecol Clin North Am 1998; 25: 72346. 11 Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford family planning association study. BJOG 1997; 104: 57985. 12 Boyles SH, Weber AM, Meyn L. Procedures for urinary incontinence in the United States, 19791997. Am J Obstet Gynecol 2003; 189: 7075. 13 Swift S, Woodman P, OBoyle A, et al. Pelvic Organ Support Study (POSST): the distribution, clinical denition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol 2005; 192: 795806. 14 Samuelsson EC, Arne Victor FT, Tibblin G, Svardsudd KF. Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. Am J Obstet Gynecol 1999; 180: 299305. 15 Swift SE, Tate SB, Nicholas J. Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse? Am J Obstet Gynecol 2003; 189: 37277. 16 Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997; 89: 50106. 17 Clark AL, Gregory T, Smith VJ, Edwards R. Epidemiologic evaluation of reoperation for surgically treated pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 2003; 189: 126167.

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