Genital prolapse or pelvic floor dysfunction is a common problem that affects women of all ages, but many of them too are embarrassed to talk about it. It does not need to be a secret and effective treatment is available. Muscles, ligaments and fascia serve as the main support of the pelvic organs. The uterosacral and transverse cervical ligaments are the most important ligaments as they keep the uterus in position.
Causes of prolapse Damage to the support of the pelvic organs will predispose a person to prolapse.

Childbirth

Vaginal delivery has long been associated with pelvic floor prolapse due to the trauma and denervation of the muscles of the pelvic floor. Instrumental deliveries (forceps), large babies and prolonged labour play a significant role in the development of prolapse. The growing fetus and pressure over the nine months of pregnancy causes damage to the muscles of the pelvic floor. It has been proven that antenatal and post delivery pelvic floor exercises (Kegels) help to decrease the risk of prolapse.

Tissue disease

Women with connective tissue disorders like Marfan’s syndrome are predisposed to prolapse. Collagen is an important component of connective tissues. The low incidence of pelvic floor dysfunction in African women is due to their stronger connective tissues.

Iatrogenic factors

Poor surgical technique during a hysterectomy may also lead to prolapse. Chronic cough, respiratory disease, pelvic masses, constipation and obesity also increase the risk of prolapse.

Diagnosis

There is seldom need for special tests to confirm the diagnosis, but complications like incontinence require investigations to help with the grading of severity and possible treatment options.

Symptoms may be mild and asymptomatic or women may complain of a bulging mass in the vagina sometimes protruding outside the vagina. This may require manual replacement. This feeling is usually worse after long periods of upright activities. Prolapse may interfere with sexual intercourse, it can also cause backache and a dragging feeling in the vagina which may cause severe discomfort. Severe prolapse may lead to ulceration, and cause bleeding and infection. Other genitourinary symptoms include stress incontinence, poor stream and recurrent urinary tract infections. People with rectoceles may suffer from constipation that can only be relieved by digitations to empty the rectum.

Prolapse is a clinical diagnosis based on the patient’s symptoms and a proper examination by a doctor and may be more obvious while standing. For classification purposes the vagina is divided into three compartments, anterior (front), posterior (back) and middle (upper) compartments. The anterior compartment can have prolapse of the bladder or the urethra, while the rectum can prolapse posteriorly and the uterus or upper vagina if the uterus has been removed.

Management

Prolapse is only treated if it is symptomatic and should be considered a quality of life issue and not a life threatening issue.

Conservative management

Hormone replacement therapy is used to prepare the vagina for surgery; it is not used to reverse/cure the prolapse. However, pelvic floor exercises in conjunction with other modalities like surgery.

Vaginal pessaries are the most useful in the conservative treatment of prolapse. They are indicated for the frail, those patients waiting for surgery, treatment during pregnancy, an alternative to surgery (for women that have not completed their families), to determine if certain treatment may be beneficial and for the treatment of ulcers while waiting for surgery. These pessaries are made from a form of plastic. If it is too small or not correctly fitted it may “fall” out. In some women it can be used indefinitely as it solves the problem.

Surgery

This is the only permanent solution for most patients. Even with the best surgery there is a 20-30% recurrence rate. The different operations available are best discussed with your gynaecologist as there are many and they do not all have the same efficacy for everyone. The use of synthetic material like meshes has become popular but can be dangerous when used for the wrong situations. These meshes seem to have better success rates in women with recurrence.

Recurrence

With ongoing risk factors recurrence remains a problem, and patients need to be assessed for the correct procedure to be performed.

Conclusion

Prolapse can be completely asymptomatic in most women, but cause severe discomfort and distress in others. The best option will depend on the clinical findings of the prolapse combined with the wellness of the patient, and the abilities of the doctor doing the surgery.

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