PELVIC ORGAN PROLAPSE

Pelvic organ prolapse ( POP ) is the abnormal descent or dropping down of one or more of the pelvic organs from their normal position, causing them to bulge into the vagina. These pelvic organs include the urinary bladder, urethra, uterus, small bowel and rectum

Treatment of Pelvic Organ Prolapse

      A detailed medical history, that includes your symptoms and history of your pregnancies and other medical problems will be taken. From your history, the doctor gets an idea of the severity of the prolapse. For example, your doctor will consider your age, symptoms of vaginal bulge and difficulty in having sex due to the bulge. Be open about your problems to help your doctor arrive at the best diagnosis

      Pelvic organ prolapse is typically diagnosed by a simple pelvic examination. For this a speculum may be used to visualise different parts of the vagina and determine which part is prolapsing and to what extent.

• Urodynamics - Bladder function study that assesses the urinary symptoms.
• Pelvic Ultrasound- To study the reproductive organs, bladder and muscles of the pelvic floor.
• Cystoscopy- To look inside the bladder for any anatomical abnormalities that could be contributing to the urinary symptoms.
• CT Scan of abdomen and pelvis.

The traditional anatomical site classification includes:

• Urethrocele
  Prolapse of the lower anterior ( front ) vaginal wall involving the urethra only.
• Cystocele
  Prolapse of the upper anterior ( front ) vaginal wall involving the bladder. Generally, there is also associated prolapse of the urethra and hence the term Cystourethrocele is used.
• Uterovaginal prolapse
  Prolapse of uterus, cervix and upper vagina.
• Enterocele
  Prolapse of upper posterior ( back ) wall of vagina usually containing loops of bowel.
• Rectocele
  Prolapse of lower posterior ( back ) wall of vagina involving the rectum bulging forwards into the vagina.

      Many women with pelvic organ prolapse do not have symptoms and may not require treatment. Therefore, if the prolapse is not causing discomfort or interfering with the things you enjoy doing, your doctor may suggest holding off on treatment and just keeping a watch. However, if the prolapse is causing pain, or problems with bladder/bowel function, or is interfering with your sexual activity, you may need treatment.

LIFESTYLE CHANGES :

• Weight loss : If you are overweight, even a 10% weight loss will significantly improve the symptoms of incontinence.
• Managing fluid intake : For urinary incontinence, restricting fluids after dinner can reduce trips to the bathroom at night. For those struggling with constipation, an increase in fluid intake is recommended.
• Changes in diet : For those with urinary incontinence, avoiding caffeine, energy drinks and artificial sweeteners helps. For those struggling with constipation, a fiber rich diet and stool softeners may help improve symptoms. At Healing Hands Clinic expert nutritionists will guide you regarding the same.
• Quit smoking
• Moderate physical activity : Regular physical activity helps to keep the bowel movement normal. However high intensity workout should be avoided as it can put pressure on the pelvic floor and increase the incontinence.
• Bladder training : This involves emptying the bladder at regular intervals and not waiting for the urge. This is because at times, the brain does not get a signal that the bladder is full until it's too late. Passing urine on a schedule may reduce leakage episodes. It is best to start by urinating every 60-90 minutes during the day. Extend this interval every few days till you start urinating every 21/2-3 hours. Bladder training can require months and needs motivation.

I. PELVIC FLOOR PHYSIOTHERAPY

Pelvic muscle exercises can improve pelvic floor muscle tone and therefore symptoms of urinary incontinence, although no improvement may be seen in the prolapse itself.

KEGELS EXERCISE : At Healing Hands Clinic, a dedicated Pelvic Floor Physiotherapist will train you in the right technique of performing this exercise. It should be noted that improvement in symptoms is finally a reflection of good exercise technique and dedication towards doing it regularly.

BIOFEEDBACK : This is a technique that gives information on how well pelvic muscles are contracting. The message or 'feedback' can help improve awareness and control of pelvic floor muscles.

II. PELVIC ORGAN PROLAPSE SUSPENSION ( P.O.P.S. ) SURGERY

     At Healing Hands Clinic, patients of pelvic organ prolapse are treated with this advanced technique made popular by the world renowned Colorectal surgeon, Dr.Antonio Longo ( Italy ). Dr. Porwal has mastered the technique from Dr. Longo himself, and he was the first to perform this surgery in India.

     P.O.P.S. is done for vaginal, bladder and rectal prolapse. In this procedure, a Y-shaped mesh is placed laparoscopically to lift the vaginal wall. Lifting of the vaginal wall corrects the associated bladder prolapse ( cystocele ) and rectal prolapse ( rectocele ). This procedure takes about 40-60 minutes and the patient is hospitalised for about 48 hours.

Advantages

• Correction of the rectocele provides relief from chronic constipation.
• Correction of cystocele provides relief from stress urinary incontinence.
• Lifting of the vaginal wall improves sexual life.

Disadvantages

• There may be non-specific dragging discomfort in the lower abdomen due to contraction of the mesh in the first 2-3 months.

Causes Of POP

      Pelvic organ prolapse occurs when the muscles and tissues in the area that hold up these organs in place are weakened. It is most commonly seen in women after childbearing and with increasing age.

• Childbirth - Multiple pregnancies, long or difficult vaginal delivery. The increased pressure of childbirth on the internal organs in the abdomen can lead to their prolapse.
• Old age, Post menopausal women - Due to weakening of tissues with age and dropping levels of the hormone, Oestrogen.
• Obesity - 40-75% increased risk of POP
• Heredity - You are more likely to have it if you have a family member ( mother/sister ) who has POP. This is because our genes decide the strength of our bones, muscles and tissues.
• Following hysterectomy - Removal of the uterus sometimes leaves other organs in the area with less support.
• Chronic coughing, chronic constipation - These conditions increase the abdominal pressure on the organs, pushing them down.
• Smoking
• Having large fibroids or pelvic cysts
• Repeated heavy lifting and intense repetitive activity such as Crossfit
• Injury to any part of the pelvic floor due to surgery, vaginal delivery, pelvic radiation or fracture of back/pelvis.
• Other conditions that cause tissues in the body to become weak
  eg. Marfan's syndrome, Ehlers Danlos syndrome etc.

Symptoms Of POP

     Pelvic organ prolapse is a common and distressing condition. Although many women with POP do not have symptoms in the early stages, when present, the symptoms are due to pressing of the uterus or other organs against the vaginal wall.
    In the earlier stages, symptoms include :

• Discomfort - Feeling of fullness, heaviness or pressure in the pelvic area. Sometimes there may be a feeling of pulling or stretching in the groin area or a low backache.
• A feeling as if something is actually falling out of the vagina . A bulge may be felt near the opening of the vagina with feeling of pressure in the pelvic area or lower abdomen.
• Spotting or bleeding from the vagina.
• Urinary symptoms - Leaking of urine, difficulty starting the stream of urine, frequent urinary tract infections.
• Difficult bowel movement with need to strain to pass stools.
  As the prolapse worsens, following symptoms may be seen :
• A bulging or heavy sensation in the vagina that worsens by the end of the day or during bowel movements. There may be a feeling of 'sitting on a ball'.
• During a bowel movement, there may be a need to push the stools out of the rectum by placing fingers in the vagina.
• Urinary symptoms - Difficulty starting to urinate or a weak or spraying stream of urine. Frequent urge to pass urine or a sensation of incomplete emptying of the bladder. At times there may be a need to lift up the bulging vagina to start urination.
• Lower back discomfort
• Painful intercourse
• Note : Symptoms of POP are made worse by standing, jumping and lifting weight, and are usually relieved by lying down.