BRIAN LINDER: Hi. I'm Dr. Brian Linder, an Associate Professor of Urology and Obstetrics and Gynecology here at Mayo Clinic in Rochester. I'm excited to talk to you today about the evaluation and management options for pelvic organ prolapse. Pelvic organ prolapse is a common clinical entity that significantly impacts our patients' quality of life, secondary to pelvic pressure, a vaginal bulge, as well as urinary, bowel, or sexual dysfunction.
It's highly prevalent, with estimates that up to one in eight women will undergo surgical management for prolapse in their lifetime. Fortunately, there are a wide variety of treatment options, both surgical and non-surgical. Today, we'll talk about the presentation, evaluation, and management of this condition.
The diagnosis of prolapse is largely clinical, centering around a history and physical exam. A detailed history, including the duration of prolapse symptoms, degree of a vaginal bulge, and symptomatic bother, are helpful. Additionally, assessment for concomitant bowel, bladder, or sexual dysfunction is routinely performed, as these may coexist with prolapse.
A physical exam is how we confirm the diagnosis. Typically, the exam proceeds in a stepwise manner. And while there's no universal technique, it includes an assessment of the vulva, vaginal epithelium, pelvic floor muscles, extent and location of pelvic organ prolapse, urinary incontinence, and assessment of other pelvic organs, such as the adnexa.
When the diagnosis of prolapse is made, no additional testing is routinely required. Additional testing may be useful when patients note other pelvic floor symptoms, such as bladder or bowel dysfunction, or are planning surgery. For instance, urodynamic testing with assessment of a post-void residual may be helpful.
Regarding treatment options, prolapse is a benign condition. And therefore, treatment selection is based on symptoms, degree of bother, and in shared decision-making with the individual patient. Overall, treatment options for women with pelvic organ prolapse include observation, conservative measures, pessary use, or surgery. The degree of bother is a critical consideration in terms of managing prolapse. That is, while some women may have anatomic prolapse, it may not always be symptomatic. For those with asymptomatic prolapse, they can typically be reassured that prolapse can safely be managed conservatively and that rapid progression would be uncommon.
While it's an understudied topic, the available evidence suggests that prolapse may remain stable or gradually worsen over time. For instance, in one study of patients undergoing observation, 2/3 remained on observation at two years, while a third progressed to either using a pessary or surgery.
Additional conservative measures, such as pelvic floor physical therapy, may be helpful for those with mild symptoms, though, to a lesser extent, may impact the anatomic extent of a vaginal bulge. For those with bothersome symptoms who do not desire to undergo surgery, pessary placement is an effective intervention that can significantly improve prolapse-related symptoms.
A pessary is a device that's placed in the vaginal canal to support the prolapsed organs and return them to a more anatomic position. Among patients who prefer this treatment option, up to 90% can successfully be fitted with a pessary. For the initial placement, a pelvic exam is performed, and an appropriate size and shape of pessary is chosen.
When feasible, patients are taught to remove and reinsert the pessaries themselves. For those that are unable to do this, more continuous wear is utilized, with interval visits with a provider for pessary removal, cleaning, and maintenance. In appropriate candidates, topical estrogen can improve comfort with pessary use and help prevent ulcers from forming on the vaginal epithelium.
Surgery is indicated in patients with symptomatic prolapse who decline or have not had adequate success with nonsurgical management. Surgeries can be performed via vaginal, laparoscopic or robotic, or open approaches, each with their own unique risk and benefit profile. Ultimately, deciding between these is based on the compartments of prolapse involved, the extent of prolapse, medical and surgical comorbidities, differences in durability and risk between the surgeries, and in shared decision-making with the patient, factoring in their preferences.
As mentioned, one route of prolapse surgery is via the vagina. Here, there are no abdominal incisions, and the procedure is typically performed using the patient's own tissue, without the use of mesh. This type of native tissue repair is aimed at the prolapsing compartments-- that is, either the anterior, apical, or posterior compartments-- or a combination of these.
In general, native tissue vaginal prolapse surgeries are well-tolerated, with good long-term efficacy and low risk of major complications. For instance, in our own institutional experience managing apical prolapse using a native tissue transvaginal approach, the retreatment rate at five years was roughly 6% and, at 10 years, roughly 19%. A similar retreatment rate-- 6%, with a mean follow-up of 6-and-1/2 years-- was identified in a population-based study as well.
For patients interested in transvaginal surgery for advanced prolapse, but do not desire to maintain a vaginal canal, an obliterative procedure can be performed. These procedures are also known as colpocleisis. Similar to the previous surgery we discussed, they don't use mesh or a synthetic graft material. Rather, they use the patient's own tissue.
Essentially, these procedures approximate the anterior and posterior vaginal walls, closing the canal for future sexual function. The benefit of this type of surgery is a high success rate and fewer complications than other surgical options. But of course, this is only suitable for patients who are comfortable with closing the vaginal canal with regard to sexual function.
In addition to the native tissue transvaginal surgery we discussed, an additional option is the use of abdominal, laparoscopic, or robotic approach to prolapse surgery. The most common procedure performed in this fashion is a sacrocolpopexy. During this surgery, a y-shaped mesh is attached to the anterior and posterior vagina and secured to the anterior longitudinal ligament overlying the sacrum.
In contemporary series, these are most commonly performed in a laparoscopic or robotic manner, though an open approach is still utilized in some cases. Shown here is an example of a robotic sacrocolpopexy. The space over the sacrum and along the anterior and posterior vaginal walls have been dissected. The mesh is then attached to the anterior and posterior vaginal wall and then secured to the sacrum.
Compared to a native tissue transvaginal approach, sacrocolpopexy has its own advantages and disadvantages. An advantage of this route is that it's associated with lower prolapse recurrence rates than the native tissue transvaginal surgery. However, it adds the risk of using a synthetic mesh material. For instance, following sacrocolpopexy, there is a risk of vaginal mesh exposure, where the mesh protrudes through the vaginal epithelium and may need additional management.
While the use of mesh in surgeries for female pelvic floor disorders has been an area of controversy, it's important to note that the recent FDA notifications relate specifically to the use of mesh that's placed via a transvaginal route for prolapse, not specifically to sacrocolpopexy, though there are, as was mentioned, specific risks of mesh-related complications that still exist. A detailed conversation of these risks with the patient is important when counseling about surgical options, again to allow for shared decision-making based on patient preferences.
In summary, pelvic organ prolapse is a common condition affecting women that may be encountered by providers. Typically, patients with asymptomatic or mildly symptomatic prolapse could be managed with observation or conservative measures. For those with bothersome symptoms, nonsurgical and surgical options are available that are effective.
Ultimately, the appropriate prolapse management strategy is based on the patient's presentation and symptoms, with the choice of treatment made via shared decision-making with the individual patient. There's no one-size-fits-all treatment when it comes to prolapse. Thank you for your attention.
