Friday, 1 September 2017

Pelvic Organ Prolapse: Are You at Risk?

By Dr Fred Busch, Obstetrician and Gynaecologist

The Anatomy of a Woman's Pelvic Organs
(Source: Continence Foundation of Australia)

A woman's pelvic organs consist of the womb, bladder and rectum that are held in place by connective tissues such as the ligaments and fascia which help these organs to connect to the pelvis's side walls.  

These connective tissues hold the pelvic organs inside a woman's pelvis.  

Additionally, the pelvic floor muscles hold up the pelvic organs from below.  

If these connective tissues are stretched or torn or the pelvic floor muscles are weakened, the pelvic organs could bulge or sag down into the vagina which is known as the pelvic organ prolapse. 

Dr Fred Busch, Obstetrician and Gynaecologist, shares his views about the prevalence, symptoms, causes, implications, treatment and prevention of pelvic organ prolapse.

Pelvic Organ Prolapse

Pelvic organ prolapse is a significant health issue facing Australian women and, indeed, women worldwide. 
1 in 5 Australian women will require surgery for this condition in their lifetime. 

In the USA, surgery for pelvic organ prolapse is the most common in-hospital surgical procedure in women above the age of 70. 

The need and cost of surgery for this condition is likely to expand over time as our population ages.

Symptoms

The principal symptoms:

  • The awareness of a vaginal bulge or pressure which is typically less intense in the mornings after remaining lying down for a night’s sleep, or after lying down for a rest
  • The bulge or pressure typically gets worse as the day progresses due to being upright and active, and may cause discomfort

Associated symptoms may include:

  • Urinary problems - incontinence and bladder “irritability"
  • Bowel problems - inability to empty rectum properly
  • Discomfort with penetrative intimacy

The severity of symptoms does not correlate well with the stage of prolapse and some women with what would be considered significant prolapse on examination, may have relatively minor symptoms.

Causes

The condition most notably associated with pelvic organ prolapse is childbirth.

Contributing factors for pelvic organ prolapse other than pregnancy and childbirth may include:

  • Increased weight bearing including heavy manual labour, being overweight or obese
  • Chronic constipation
  • Chronic cough
  • Hysterectomy may lead to prolapse of the upper vagina in some women

There is a significant risk of vaginal delivery over caesarean delivery which appears to have a protective benefit. 

As an example, a case-control study showed a risk of prolapse for vaginal delivery of 93% compared to a risk for caesarean delivery of 2%. 

However, this protective benefit may wane over time with one survey of women 20 years following childbirth showing an incidence of symptomatic prolapse after vaginal delivery of 14.6% and 6.2% for caesarean delivery. 

Operative vaginal delivery, in particular forceps delivery, significantly increases the risk of prolapse. 

However, pregnancy itself, irrespective of the mode of childbirth, appears to have a negative effect on the female pelvic floor. 

The mechanisms by which the damage during pregnancy and childbirth occurs are not fully understood, but research suggests a combination of factors may be involved including muscle, soft tissue, and nerve damage, as well as a genetic predisposition to producing less strong connective tissue in the pelvic floor over time. 

The number of pregnancies is also significant with the first vaginal delivery causing the most injury, with small incremental increases in risk of prolapse with each subsequent vaginal delivery.

Implications

Should women therefore choose to have their babies by caesarean delivery?  

The answer to this question should not be categorically “yes” or “no”. 

The decision as to the mode of delivery should be made by consultation between the woman and her obstetrician.

While caesarean delivery is clearly protective against prolapse, it may come at a cost, particularly with multiple caesareans. 

While elective or planned caesarean delivery has become a relatively low-risk surgical procedure, the chief concern amongst obstetricians is the risk of placenta accreta in a subsequent pregnancy. 

This is a condition where the placenta can grow into the previous caesarean scar inside the womb.  

The placenta can therefore become firmly attached to the inner wall of the uterus which may lead to massive haemorrhage at the time of delivery of the baby. 

This may lead to the requirement of hysterectomy and transfusion of large amounts of blood at the time of caesarean to control the haemorrhage.  

This is potentially life-threatening.  The risk of placenta accreta increases especially after the third caesarean delivery.

Prevention

Preventative measures may include: 
  • Moderate exercise and a healthy diet to keep weight down
  • Avoiding constipation through adequate fluid intake
  • Adequate dietary fibre, and the use of appropriate laxatives
  • Seeking medical care for chest infections in a timely manner to avoid chronic cough
  • Cessation or reduction in smoking

Treatment

Treatment measures may include: 
  • Pelvic floor physiotherapy
  • Treatment measures for urinary and bowel dysfunction
  • Vaginal pessary
  • Surgery

Pelvic floor physiotherapy has been shown to be effective in clinical trials.  At least 57% of women will report benefit from this intervention.  

I recommend this as a first step for most women with prolapse since often this is all that is required to alleviate the symptoms of prolapse and provide and acceptable level of functioning.

The use of a vaginal pessary may be considered in women where physiotherapy alone has proven unsuccessful and where use of a pessary is appropriate.

Surgery should be reserved for those women in whom conservative measures have failed, or who decline conservative treatment.


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IMPORTANT: The information on this blog is for informational purposes only and not intended to be a substitute for professional medical advice, diagnosis or treatment in any manner. Always seek the advice of your doctor or other qualified health provider with any questions you may have concerning your health or anything related to it. 

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