Pelvic Organ Prolapse (Clinical)

Overview

Definitions^[1,4]

Pelvic organ prolapse Pelvic Organ Prolapse Pelvic organ prolapse (POP) is a general term that refers to herniation of 1 or more pelvic organs (e.g., bladder, uterus, rectum) into the vaginal canal, and potentially all the way through the introitus. Weakness and insufficiency of the pelvic floor may result in POP. Pelvic Organ Prolapse (POP): a general term referring to prolapse of 1 or more of the pelvic organs (e.g., bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess, uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy, rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy) into the vaginal canal

• Organs prolapse through the vaginal canal/orifice, pushing the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy with it → POP is defined by the vaginal wall that is prolapsing and the organs behind that wall
• Anterior compartment prolapse Anterior compartment prolapse A hernia-like condition in which the weakened pelvic muscles cause the urinary bladder to drop from its normal position. Fallen urinary bladder is more common in females with the bladder dropping into the vagina and less common in males with the bladder dropping into the scrotum. Pelvic Organ Prolapse:
  • Herniation Herniation Omphalocele of the anterior vaginal wall and bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess
  • Classically referred to as a cystocele Cystocele A hernia-like condition in which the weakened pelvic muscles cause the urinary bladder to drop from its normal position. Fallen urinary bladder is more common in females with the bladder dropping into the vagina and less common in males with the bladder dropping into the scrotum. Pelvic Organ Prolapse
• Posterior compartment prolapse Posterior compartment prolapse Herniation of the rectum into the vagina. Pelvic Organ Prolapse:
  • Herniation Herniation Omphalocele of the posterior vaginal wall and rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy
  • Classically referred to as a rectocele Rectocele Herniation of the rectum into the vagina. Pelvic Organ Prolapse
• Apical compartment prolapse Apical Compartment Prolapse Pelvic Organ Prolapse:
  • Herniation Herniation Omphalocele of the vaginal apex, which is either:
    • The uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy and cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy (normal anatomy)
    • The cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy (if the subject has had a supracervical hysterectomy)
    • Vaginal cuff (if the subject has had a total hysterectomy)
  • If the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy is present, the prolapse is referred to as uterine prolapse Uterine prolapse Downward displacement of the uterus. It is classified in various degrees: in the first degree the uterine cervix is within the vaginal orifice; in the second degree the cervix is outside the orifice; in the third degree the entire uterus is outside the orifice. Pelvic Organ Prolapse.
  • If the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy is absent, the intestine typically prolapses behind the vaginal cuff, classically known as an enterocele Enterocele Pelvic Organ Prolapse.
• Procidentia Procidentia Pelvic Organ Prolapse: a severe form of POP that includes herniation Herniation Omphalocele of the anterior, posterior, and apical vaginal compartments through the vaginal introitus

Visualizing POP

Visualizing POP, especially apical POP, can be difficult.

• Envision holding a sock up by the toe:
  • Your hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy is the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy.
  • The sock is the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy.
• The open part of the sock is secured to a fixed location:
  • The open part of the sock is the vaginal introitus.
  • The “fixed location” is the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy.
• Begin moving your hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy down → the lower position of your hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy represents apical/ uterine prolapse Uterine prolapse Downward displacement of the uterus. It is classified in various degrees: in the first degree the uterine cervix is within the vaginal orifice; in the second degree the cervix is outside the orifice; in the third degree the entire uterus is outside the orifice. Pelvic Organ Prolapse
• As you keep moving your hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy down through the sock opening, the sock begins turning inside out and is similar to how prolapsed organs can end up completely “outside” the body, yet still remain covered by vaginal mucosa.

Etiology^[1,4]

Prolapse is due to weakness and insufficiency of the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy, which normally keeps organs in place. Risk factors include:

• Multiple parity Parity The number of offspring a female has borne. It is contrasted with gravidity, which refers to the number of pregnancies, regardless of outcome. Pregnancy: Diagnosis, Physiology, and Care (risk increases with each additional birth)
• Vaginal delivery
• Advancing age
• Menopausal status
• Increased intraabdominal pressure:
  • Chronic cough
  • Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
  • Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
• Connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue: Histology abnormalities (e.g., Ehlers-Danlos syndrome Ehlers-Danlos syndrome Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited connective tissue disorders that are characterized by hyperextensible skin, hypermobile joints, and fragility of the skin and connective tissue. Ehlers-Danlos Syndrome)
• Family history Family History Adult Health Maintenance
• Hysterectomy (controversial)

Epidemiology^[1,8]

• The exact prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of uterine and vaginal prolapse is uncertain.
• Peak incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency: women aged 70–79 years
• Lifetime risk of women in the US undergoing surgery for POP: 13%
• Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of POP based on reported symptoms: 3%–6%
• Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of POP identified on exam: 40%–50%
• Take-home message: Many women with mild POP are asymptomatic and do not require management beyond reducing modifiable risk factors to prevent symptoms from developing (e.g., weight loss Weight loss Decrease in existing body weight. Bariatric Surgery, smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases cessation).

Surgical Anatomy and Pathology

Pelvic organs are supported by the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy, connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue: Histology, and the bony pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy. Additionally, the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy is supported by 3 levels of support along its length.

Pelvic diaphragm Pelvic diaphragm Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy

The most internal layer of the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy:

• Functions:
  • Provides structure to the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy, separating the internal pelvic cavity from the external perineum Perineum The body region lying between the genital area and the anus on the surface of the trunk, and to the shallow compartment lying deep to this area that is inferior to the pelvic diaphragm. The surface area is between the vulva and the anus in the female, and between the scrotum and the anus in the male. Vagina, Vulva, and Pelvic Floor: Anatomy
  • Resists intra-abdominal pressure
• Structure:
  • Muscles begin at the tendinous arch (below and parallel to the inferior margin of the pubic bones).
  • Muscles extend posteriorly toward the coccyx Coccyx The last bone in the vertebral column in tailless primates considered to be a vestigial tail-bone consisting of three to five fused vertebrae. Vertebral Column: Anatomy → “wrap around” the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy, vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy, and rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy, providing lateral support
  • Perineal body: the central tendon Central tendon Diaphragm: Anatomy and site of attachment for the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy muscles
• Muscles of the pelvic diaphragm Pelvic diaphragm Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy:
  • A group of muscles collectively known as the levator ani muscles Levator ani muscles Vagina, Vulva, and Pelvic Floor: Anatomy:
    • Puborectalis Puborectalis Vagina, Vulva, and Pelvic Floor: Anatomy: the innermost muscle, originating from the tendinous arch just below the pubic bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types and forming a sling around the rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy; in direct contact with the lateral vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy and the lateral and posterior rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy
    • Pubococcygeus Pubococcygeus Vagina, Vulva, and Pelvic Floor: Anatomy: the middle muscle, connecting the tendinous arch/pubic bones to the coccyx Coccyx The last bone in the vertebral column in tailless primates considered to be a vestigial tail-bone consisting of three to five fused vertebrae. Vertebral Column: Anatomy
    • Iliococcygeus Iliococcygeus Vagina, Vulva, and Pelvic Floor: Anatomy: the most lateral layer, connecting the ischial spines to the coccyx Coccyx The last bone in the vertebral column in tailless primates considered to be a vestigial tail-bone consisting of three to five fused vertebrae. Vertebral Column: Anatomy
  • Coccygeus Coccygeus Vagina, Vulva, and Pelvic Floor: Anatomy
• Other muscles of the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy:
  • Piriformis Piriformis Vagina, Vulva, and Pelvic Floor: Anatomy
  • Obturator internus Obturator internus Vagina, Vulva, and Pelvic Floor: Anatomy

Primary levels of vaginal support Levels of Vaginal Support Pelvic Organ Prolapse and associated pathology^[4]

• Level I support:
  • The most proximal level of support
  • Consists of the uterosacral ligaments Uterosacral ligaments Vagina, Vulva, and Pelvic Floor: Anatomy that suspend the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy and upper vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy to the sacrum Sacrum Five fused vertebrae forming a triangle-shaped structure at the back of the pelvis. It articulates superiorly with the lumbar vertebrae, inferiorly with the coccyx, and anteriorly with the ilium of the pelvis. The sacrum strengthens and stabilizes the pelvis. Vertebral Column: Anatomy, and the lateral pelvic wall
• Level II support:
  • Lateral connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue: Histology attachments along the length of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy
  • Paravaginal attachments to the endopelvic fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis of the levator ani muscles Levator ani muscles Vagina, Vulva, and Pelvic Floor: Anatomy surrounding the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy
• Level III support:
  • The most distal level of support
  • Consists of the perineum Perineum The body region lying between the genital area and the anus on the surface of the trunk, and to the shallow compartment lying deep to this area that is inferior to the pelvic diaphragm. The surface area is between the vulva and the anus in the female, and between the scrotum and the anus in the male. Vagina, Vulva, and Pelvic Floor: Anatomy and perineal muscles
  • Supports the distal 3rd of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy
• Pathology:
  • Loss of level I support → apical prolapse into the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy
  • Loss of level II support → most commonly results in anterior vaginal wall and bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess prolapse ( cystocele Cystocele A hernia-like condition in which the weakened pelvic muscles cause the urinary bladder to drop from its normal position. Fallen urinary bladder is more common in females with the bladder dropping into the vagina and less common in males with the bladder dropping into the scrotum. Pelvic Organ Prolapse)
  • Loss of level III support →
    • Anteriorly: urethral hypermobility and incontinence
    • Posteriorly: posterior vaginal wall and rectal prolapse Rectal prolapse Rectal prolapse, also known as rectal procidentia, is the protrusion of rectal tissue through the anus. The tissue may include just the mucosa or the full thickness of the rectal wall. Common risk factors include chronic straining, constipation, bowel motility disorders, and weakening of the pelvic floor muscles. Rectal Prolapse

Clinical Presentation

Individuals with POP typically present with:^[4,7,8]

• Vaginal symptoms:
  • Sensations of:
    • Vaginal fullness
    • Pressure
    • Bulge
    • “Something falling down”
  • Symptoms typically worsen with activity, Valsalva maneuver Valsalva maneuver Forced expiratory effort against a closed glottis. Rectal Prolapse, and/or at the end of the day.
• Urinary symptoms:
  • Incomplete emptying of urine
  • Difficulty in voiding urine
  • Urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence
• Rectal symptoms:
  • Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
  • Incomplete emptying
  • Splinting: placing fingers in the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy and pushing down in order to evacuate stool
  • Fecal urgency
  • Rectal fullness
• Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways symptoms:
  • Dyspareunia Dyspareunia Recurrent genital pain occurring during, before, or after sexual intercourse in either the male or the female. Primary Ovarian Insufficiency
  • Lower back and pelvic pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways that is exacerbated on activity
  • Vaginal pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways if the prolapse is severe and erosion Erosion Partial-thickness loss of the epidermis Generalized and Localized Rashes or ulcerations are present

Diagnosis and Classification

Diagnosis^[1,2,4]

• Based on clinical examination:
  • Visual inspection Inspection Dermatologic Examination
  • Speculum examination Speculum Examination Diagnostic Procedures in Gynecology: To assess POP, it is best to use only a single blade to examine the anterior and posterior walls separately.
  • Bimanual pelvic examination: helpful in assessing apical prolapse
  • Rectovaginal examination
  • Assess pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy muscle tone Muscle tone The state of activity or tension of a muscle beyond that related to its physical properties, that is, its active resistance to stretch. In skeletal muscle, tonus is dependent upon efferent innervation. Skeletal Muscle Contraction (with 1 or 2 fingers in the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy, have the patient squeeze).^[1]
• Examine the patient at rest and during the Valsalva maneuver Valsalva maneuver Forced expiratory effort against a closed glottis. Rectal Prolapse.
• Take note of:
  • Which portions of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy are prolapsing (e.g., anterior wall, posterior wall, apex)
  • How far the prolapse descends (use the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy as a reference point)
  • Rectal tone
  • Urethral mobility
• If significant prolapse is not appreciated lying down, examine the patient while they are standing up.^[1]
• Findings are reported using either:
  • Pelvic Organ Prolapse Pelvic Organ Prolapse Pelvic organ prolapse (POP) is a general term that refers to herniation of 1 or more pelvic organs (e.g., bladder, uterus, rectum) into the vaginal canal, and potentially all the way through the introitus. Weakness and insufficiency of the pelvic floor may result in POP. Pelvic Organ Prolapse Quantitation (POP-Q) staging Staging Methods which attempt to express in replicable terms the extent of the neoplasm in the patient. Grading, Staging, and Metastasis system
  • Baden-Walker grading system Baden-Walker Grading System Pelvic Organ Prolapse
• A majority of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with relatively mild POP are asymptomatic (POP discovered incidentally on exam). Because management is primarily aimed at relieving symptoms, it is important to ask about the presence of any of the following:^[1]
  • Symptoms bothersome enough to want treatment
  • Limited activity due to POP
  • Sexual dysfunction Sexual dysfunction Physiological disturbances in normal sexual performance in either the male or the female. Sexual Physiology (e.g., dyspareunia Dyspareunia Recurrent genital pain occurring during, before, or after sexual intercourse in either the male or the female. Primary Ovarian Insufficiency due to POP)
  • Urinary dysfunction (e.g., is voiding more difficult later in the day, when POP is more pronounced)
  • Defecatory dysfunction (e.g., Does the patient need to splint to defecate?)
• Assess the patient if they are experiencing stress urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence (SUI):
  • Ask the patient to cough while observing the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy for leaks.
  • Should be assessed when the prolapse has reduced (sometimes, especially anterior prolapse may actually improve SUI)
  • Consider urodynamics studies, especially if planning surgery, to see if a concurrent incontinence procedure may be indicated.

POP-Q staging system POP-Q staging system Pelvic Organ Prolapse^[1]

The American Urogynecologic Society (AUGS) and the Society of Gynecologic Surgeons (SGS) recommend using the POP-Q staging system POP-Q staging system Pelvic Organ Prolapse over the Baden-Walker system Baden-Walker System Pelvic Organ Prolapse because the former is the only validated method for the objective measurement of a prolapse.

• The POP-Q system is best for:
  • Tracking progression of prolapse over time
  • Assessing response to treatment
  • Standardizing research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest
• The POP-Q system is used to stage prolapse based on 9 measurements:
  • 6 of the measurements compare defined/fixed points in the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy to the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy during Valsalva maneuver Valsalva maneuver Forced expiratory effort against a closed glottis. Rectal Prolapse:
    • The hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy is defined as “0.”
    • Distance from the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy to each point is measured in centimeters during a Valsalva maneuver Valsalva maneuver Forced expiratory effort against a closed glottis. Rectal Prolapse.
    • Points proximal to the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy (toward the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy) are given negative values.
    • Points distal to the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy (toward the introitus) are given positive values.
  • 3 additional measurements are used to provide a more comprehensive picture.

Baden-Walker Grading System Baden-Walker Grading System Pelvic Organ Prolapse^[13]

• An easier but less precise system of assessing a prolapse
• Compares the maximal point of descent of the prolapse to the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy during valsalva
• All 3 compartments (anterior, posterior, and apex) should be assessed and can be graded separately
• Grading Grading Methods which attempt to express in replicable terms the level of cell differentiation in neoplasms as increasing anaplasia correlates with the aggressiveness of the neoplasm. Grading, Staging, and Metastasis:
  • Grade 0: no prolapse, normal position for each compartment
  • Grade 1: descent halfway to the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy
  • Grade 2: descent to the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy
  • Grade 3: descent halfway past the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy
  • Grade 4: maximum descent possible
• Note: Baden-Walker grades are approximately comparable to POP-Q stages.
• For clinicians managing POP, the POP-Q is preferred^[1,2]; for other clinicians (e.g., primary care, emergency physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship), however, it is reasonable to use the Baden-Walker system Baden-Walker System Pelvic Organ Prolapse.^[13]

Management

Management of POP is based on stage/grade, symptoms, and overall well-being of the subject. All cases should be offered conservative management. Some individuals with more severe symptoms may desire surgery.

Conservative management^[1,2,4]

• Reduce modifiable risk factors:
  • Weight loss Weight loss Decrease in existing body weight. Bariatric Surgery
  • Reduce straining with defecation Defecation The normal process of elimination of fecal material from the rectum. Gastrointestinal Motility (i.e., constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation) via dietary changes and medications.
  • Avoid smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases to reduce chronic cough.
• Kegel exercises Kegel Exercises Pelvic Organ Prolapse and pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy physical therapy Physical Therapy Becker Muscular Dystrophy (PFPT):
  • Pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy muscle training
  • Usually used as a primary prevention technique
  • Also aids AIDS Chronic HIV infection and depletion of CD4 cells eventually results in acquired immunodeficiency syndrome (AIDS), which can be diagnosed by the presence of certain opportunistic diseases called AIDS-defining conditions. These conditions include a wide spectrum of bacterial, viral, fungal, and parasitic infections as well as several malignancies and generalized conditions. HIV Infection and AIDS in controlling urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence
  • One-to-one PFPT is effective for improving stages I and II POP.^[2]
• Vaginal pessary Vaginal pessary Devices worn in the vagina to provide support to displaced uterus or rectum. Pessaries are used in conditions such as uterine prolapse; cystocele; or rectocele. Pelvic Organ Prolapse:
  • A medical grade silicone- or latex-based device that is inserted into the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy
  • Supports the pelvic organs and restores pelvic anatomy
  • Multiple shapes available (see image)
  • Fit in the office by a clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship:^[4]
    • Ensure that the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess and bowel are empty.
    • Place a “trial” pessary in the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy. 
    • Have the patient walk, bend, jump, etc ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (ETC). to ensure comfort and effectiveness.
    • Have the patient attempt to void, to ensure that micturition is not inhibited.
    • Goal is to fit the largest pessary that does not cause discomfort.
    • A finger should be able to pass between the pessary and the wall of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy.
  • Vaginal estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy cream is often used as an adjunct to prevent vaginal erosions Erosions Corneal Abrasions, Erosion, and Ulcers.
  • Can be removed by the individual at home as often as desired, or every 3‒6 months by a clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship in the office
  • Indications:
    • All individuals who have symptomatic POP
    • SUI
    • Poor surgical candidates
  • Complications:
    • Vaginal erosions Erosions Corneal Abrasions, Erosion, and Ulcers
    • Urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium

Surgical management^[1,2,4]

Indicated in symptomatic individuals if they express a desire for surgical correction. Note that unless the POP is causing urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium, the decision for surgery is driven primarily by the patient’s desires after undergoing counseling on risks/benefits/alternatives.

Refer patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship who desire surgical management to a urogynecologist (or general gynecologist with appropriate training).^[2]

Reconstructive surgery:^[1]

• Anterior repair ( anterior colporrhaphy Anterior Colporrhaphy Pelvic Organ Prolapse): strengthening the “ceiling” of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy, between the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy and the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess
• Posterior repair ( posterior colporrhaphy Posterior Colporrhaphy Pelvic Organ Prolapse): strengthening the “floor” of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy, between the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy and the rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy
• Suspensory procedures: to fix parts of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy, cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy, and/or uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy to the internal structures (usually involves permanent sutures and/or the use of a mesh) 
  • Sacrocolpopexy ( cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy to sacrum Sacrum Five fused vertebrae forming a triangle-shaped structure at the back of the pelvis. It articulates superiorly with the lumbar vertebrae, inferiorly with the coccyx, and anteriorly with the ilium of the pelvis. The sacrum strengthens and stabilizes the pelvis. Vertebral Column: Anatomy):
    • Requires a supracervical hysterectomy 
    • Typically considered the most effective suspensory procedure
    • Indications/candidates: high risk for recurrence (age < 60, stage III or IV POP, BMI BMI An indicator of body density as determined by the relationship of body weight to body height. Bmi=weight (kg)/height squared (m2). Bmi correlates with body fat (adipose tissue). Their relationship varies with age and gender. For adults, bmi falls into these categories: below 18. 5 (underweight); 18. 5-24. 9 (normal); 25. 0-29. 9 (overweight); 30. 0 and above (obese). Obesity > 26), shortened vaginal length, and intra-abdominal pathology
    • Often done robotically by urogynecologists
  • Hysteropexy (attaches the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy to the sacrospinous ligaments, anterior longitudinal ligament, or uterosacral ligaments Uterosacral ligaments Vagina, Vulva, and Pelvic Floor: Anatomy with sutures or mesh)
    • Benefits of hysteropexy compared to sacrocolpopexy: shorter operative time Operative time The duration of a surgical procedure in hours and minutes. Surgical Infections, lower incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency of mesh erosion Erosion Partial-thickness loss of the epidermis Generalized and Localized Rashes
    • Benefits of sacrocolpopexy: lower risk of mesh complications, lower risk of uterine and cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer, no uterus-related bleeding/ pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
  • Uterosacral ligament suspension (sutures shorten/tighten the uterosacral ligaments Uterosacral ligaments Vagina, Vulva, and Pelvic Floor: Anatomy)
  • Sacrospinous ligament fixation (sutures suspend the vaginal apex to the sacrospinous ligament, typically on the right side in order to avoid the colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy)

Obliterative surgery:

• Surgical obliteration/closing off the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy to prevent further prolapse (colpocleisis)
• Reserved for women who no longer desire vaginal penetration Penetration X-rays and who cannot tolerate more extensive surgeries

Complications of surgical management^[1,3] 

• Complications associated with the use of mesh:
  • Risk of complications are significantly higher when mesh (as opposed to native tissue) is used.
  • Around 12% of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship experience complications with mesh.
  • Often require repeat operations
  • Mesh complications include:
    • Erosion Erosion Partial-thickness loss of the epidermis Generalized and Localized Rashes and contracture into the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy, urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy, bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess, and/or rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy
    • Chronic pain Chronic pain Aching sensation that persists for more than a few months. It may or may not be associated with trauma or disease, and may persist after the initial injury has healed. Its localization, character, and timing are more vague than with acute pain. Pain Management
    • Small-bowel obstruction or ileus Ileus A condition caused by the lack of intestinal peristalsis or intestinal motility without any mechanical obstruction. This interference of the flow of intestinal contents often leads to intestinal obstruction. Ileus may be classified into postoperative, inflammatory, metabolic, neurogenic, and drug-induced. Small Bowel Obstruction
  • Because of these risks:
    • Transvaginal “mesh kits” are not recommended (taken off the market in the US around 2011 owing to unacceptably high risks for complications).^[1]
    • Synthetic mesh for POP should be used only in complex cases with recurrent prolapse (e.g., sacrocolpopexy) and by surgeons with advanced training in multidisciplinary referral centers.^[3]
• Risk of failure/high risk of recurrent POP (may be as high as 50% for some procedures)
• Injury to the surrounding organs (e.g., bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess, ureters Ureters One of a pair of thick-walled tubes that transports urine from the kidney pelvis to the urinary bladder. Urinary Tract: Anatomy, urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy, bowel)
• Bleeding
• Infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
• Fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula (rectovaginal or vesicovaginal)
• Sexual dysfunction Sexual dysfunction Physiological disturbances in normal sexual performance in either the male or the female. Sexual Physiology due to:
  • Shortened vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy/changes in anatomy
  • Restriction of the vaginal caliber (can potentially be managed with estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy cream and vaginal dilators)