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Pelvic Organ Prolapse

The network of muscles, ligaments, and skin in and around a woman’s vagina acts as a complex support structure that holds pelvic organs, tissues, and structures in place. This support network includes the skin and muscles of the vagina walls (a network of tissues called the fascia). Various parts of this support system may eventually weaken or break, causing a common condition called pelvic organ prolapse.
 
Pelvic organ prolapse is a condition in which structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself may begin to prolapse, or fall, out of their normal positions. Without medical treatment or surgery, these structures may eventually fall farther into the vagina or even through the vaginal opening if their supports weaken enough.
 
The symptoms that result from pelvic organ prolapse commonly affect sexual functions and bodily functions such as urination and defecation. Pelvic pressure and discomfort are also common symptoms.
 
The following are types of pelvic organ prolapse: 

  • Rectocele (prolapse of the rectum). This involves a prolapse of the back wall of the vagina (rectovaginal fascia). When this wall weakens, the rectal wall pushes against the vaginal wall, creating a bulge. This bulge may become especially noticeable during bowel movements. 
  • Cystocele (prolapse of the bladder, bladder drop). This can occur when the front wall of the vagina (pubocervical fascia) prolapses. As a result, the bladder may prolapse into the vagina. When this condition occurs, the urethra usually prolapses, as well. A urethral prolapse is also called a urethrocele. When both the bladder and urethra prolapse, this condition is known as a cystourethrocele. Urinary stress incontinence (urine leakage during coughing, sneezing, or exercise, for example) is a common symptom of this condition. 
  • Enterocele (herniated small bowel). The weakening of the upper vaginal supports can cause this type of prolapse. This condition primarily occurs following a hysterectomy. An enterocele results when the front and back walls of the vagina separate, allowing the intestines to push against the vaginal skin.
  • Prolapsed uterus (womb). This involves a weakening of a group of ligaments called the uterosacral ligaments at the top of the vagina. This causes the uterus to fall, which commonly causes both the front and back walls of the vagina to weaken, as well. The following are stages of uterine prolapse:
    • First-degree prolapse: The uterus droops into the upper portion of the vagina.
    • Second-degree prolapse: The uterus falls into the lower part of the vagina.
    • Third-degree prolapse: The cervix, which is located at the bottom of the uterus, sags to the vaginal opening and may protrude outside the body.
    • Fourth-degree prolapse: The entire uterus protrudes entirely outside the vagina. This condition is also called procidentia, or complete prolapse. 
  • Vaginal vault prolapse. This type of prolapse may occur following a hysterectomy, which involves the removal of the uterus. Because the uterus provides support for the top of the vagina, this condition is common after a hysterectomy, with upwards of 10% of women developing some degree of vaginal vault prolapse after undergoing one. In vaginal vault prolapse, the top of the vagina falls toward the vaginal opening. This may cause the walls of the vagina to weaken as well. This could progress and the top of the vagina may protrude out of the body through the vaginal opening, effectively turning the vagina inside out. A vaginal vault prolapse often accompanies an enterocele. 

Approximately 30%-40% of women develop some presentation of pelvic organ prolapse in their lifetime, usually following menopause, childbirth, or a hysterectomy. Most women who develop this condition are older than 40 years. Many women who develop symptoms of a prolapse do not seek medical help because of embarrassment or other reasons. Some women who develop a prolapse do not experience symptoms.

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