P

elvic Organ Prolapse (POP) is the symptomatic descent of the anterior vaginal wall and bladder, the posterior vaginal wall and rectum, or the apex or vault of the vagina that results in utero-vaginal and vault prolapse respectively. It'€™s a disease more common in countries with rapidly ageing female populations, such as in Singapore.

Almost 30 percent of all hysterectomies for POP are done for women over 50 years old, as compared to only 7 percent in the 15-to-49 age group.

POP, in a way, is similar to a hernia, as it is also associated with the displacement of an organ from its normal position.

It is called a vault prolapse when there'€™s an eversion of the vagina in patients with a previous hysterectomy. When the uterus is displaced, it is an utero-vaginal prolapse; a cysto-urethrocoele, when the displacement is with the urethra and bladder; or a rectocoele when the displacement is with the rectum.

Additionally, patients with POP also suffer from urinary incontinence (UI), as both the problems have the same damage mechanism.

Pelvic organ prolapse occurs when there is some damage in supporting the fascial-ligamentous structures of the pelvis. This may be due to multiple pregnancies, assisted vaginal deliveries, menopause, or a previous pelvic surgery. The prolapse may worsen with conditions such as chronic coughs, asthma, constipation, carrying heavy weights and obesity.

Some patients with POP exhibit symptoms such as vaginal heaviness, vaginal discharge or bleeding, pelvic pain and discomfort, lower backache, difficulty or pain during sexual intercourse as well as difficulty in passing urine and walking in extreme cases.

In some cases, patients can feel and see the pelvic organ prolapse. Notably, some patients may remain completely asymptomatic.

Normally, the standard investigation for POP includes an assessment for UI, since the problems are interrelated.

A routine urine microscopy and culture to exclude infection, a pelvic ultrasound test to exclude gynaecological conditions such as ovarian cancer (which would require urgent treatment) and an ultrasound of the upper renal tract in severe POP cases, are part of the procedural diagnosis.

The doctors may also carry-out urodynamic studies '€” uroflowmetry, simple filling and voiding cystometry and urethral pressure profilometry '€” in cases with complex prolapse symptoms.

As 100 percent recovery from POP is impossible, prevention is important; but prolapse is still very common.

While there are both surgical interventions and conservative treatment options available, what is recommended for a particular woman depends on her age, prolapse severity, child-bearing wishes and other underlying medical conditions. There is no doubt though that for long-term relief, surgical interventions such as a vaginal hysterectomy, in case of utero-vaginal prolapse; or an anterior and posterior colporrhaphy, to treat rectocoele, are the best options.

In patients with severe vault prolapse (after the vaginal hysterectomy) or severe utero-vaginal prolapse, a sacrospinous ligament fixation attaches the top of the vagina to a ligament in the pelvis with non-absorbable sutures.

Sometimes a Manchester'€™s operation is done to remove the prolapsing cervix while retaining the uterus, if the patient so prefers.

These operations are usually done in combinations so that they have a synergistic effect in reducing prolapsed recurrence, especially when treating cysto-urethrocoele. Such surgeries require a reconstruction of the disrupted perineal body (perineorrhaphy), as a reduction of vaginal aperture diameter also reduces pressure transmission forces that predispose a person to prolapse.

Patients are also advised to avoid lifting heavy weights, to take care against constipation, and to not squat, as these may increase prolapse recurrence from pressure effects on the pelvic floor.

The surgery to treat POP has some complications include bleeding, infection at wound site and trauma to the adjacent bladder or rectum. But notably, these risks are very low (around 1 percent) when surgery is done by an experienced surgeon.

Once prolapse has occurred and the patient is not very keen on surgery, a vaginal pessary fitting (most common is a ring pessary) is recommended.

For pregnant women, non-surgical options include a popular treatment called Kegel exercises.

This is a kind of antenatal and postnatal pelvic floor exercise (PFE) activity, which prevents and reduces prolapse occurrence and urinary incontinence also.

Moreover, during pregnancy, it'€™s always advisable to consult an experienced obstetrician for reducing the risk of POP.

This may help in controlling constipation, monitoring weight increase and estimated fetal weight gain, as well as timing the delivery and deciding on the method of delivery to reduce the risk of pelvic floor injury.

The writer is a consultant obstetrician and gynaecologist sub-specializing in urogynaecology and pelvic reconstructive surgery at Gleneagles Hospital in Singapore. For more information, visit arthurtsengwhs.com.