PELVIC ORGAN PROLAPSE

GENERAL SYMPTOM ASSESSMENT

Symptoms of POP are often not specific to the area that is prolapsing, and many women have no
symptoms. The classic symptoms of prolapse include vaginal heaviness and pressure, a vaginal bulge, pelvic pain,
or vaginal bleeding (from erosions of exposed vaginal epithelium). Back pain and pelvic pain are not reliably
associated with prolapse. If a woman with objective prolapse does not have any bothersome symptoms or evidence
of associated medical risks such as urinary retention or renal impairment from urethral or ureteral kinking, she does
not need treatment. Because more than one pelvic oor disorder is often present, urinary, bowel, and sexual
symptoms should be assessed in addition to prolapse symptoms in any woman with POP.

Urinary symptoms can include urinary incontinence, difficulty voiding, slow urinary stream, or a sensation
of incomplete bladder emptying. Bowel symptoms such as constipation, straining, incomplete evacuation, fecal
incontinence, or splinting (reducing the prolapse) to achieve bowel movements can be present. Sexual symptoms
may include discomfort, irritation, and decreased sexual desire. She should also be asked about how these
symptoms aect her quality of life, emotional health, and social interactions as well as whether they aect her ability
to do usual daily chores, exercise, and participate in social events. Validated, self-administered questionnaires are
available such as the Pelvic Organ Prolapse Quality of Life (P-QOL) scale and the Urinary Distress Inventory, which
cover these categories. Understanding the womans goals for treatment is important, because often there are
multiple symptoms in each of these areas that cause varying degrees of bother and distress.

SYMPTOMS AND SIGNS

Symptoms of POP include a sensation of fullness, pelvic pressure, vaginal bulge, and a feeling that organs
are falling out. With anterior vaginal wall prolapse, the woman may also report a feeling of incomplete emptying
with voiding, a slow urinary stream, or urinary urgency. The patient and the physician note a soft, bulging mass of
the anterior vaginal wall. In some patients this mass must be replaced manually before the patient can void. Strain,
cough, or prolonged standing often accentuates the bulge. Often POP symptoms are less bothersome in the
morning and worsen later in the day after upright activities. The mass may descend to or beyond the introitus.
Although urethroceles and cystoceles almost always occur in parous women, they have been noted in nulliparous
women who have poor structural supports. This is particularly true in women who have congenital malformations
or weaknesses of the endopelvic connective tissue and musculature of the pelvic oor. Most parous women
demonstrate some degree of cystocele, and when asymptomatic, they do not require therapy.

Women with prolapse often have concurrent urinary symptoms. Some women have stress incontinence
caused by urethral hypermobility or weak urethral sphincter, but others are continent despite a lack of urethral
support. Another group of women may have occult or latent stress incontinence (stress incontinence on prolapse
reduction) because their continence depends on urethral kinking or obstruction from severe prolapse. Treating the
prolapse with a pessary support or surgery could unkink the urethra and result in stress urinary incontinence. Sexual
function symptoms should be considered. Dyspareunia, vaginal dryness or irritation, and other difficulty with
intercourse may occur with POP in any compartment.
ANTERIOR VAGINAL PROLAPSE (CYSTOCELE)

The anterior vagina is the most common site of vaginal prolapse. Women with this type of defect
will describe symptoms of vaginal fullness, heaviness, pressure, and/or discomfort that often progress
over the course of the day and are most noticeable after prolonged standing or straining. Women may have
to apply manual pressure to empty their bladder completely. Other symptoms include stress urinary
incontinence (SUI), urinary urgency, and frequency. Significant anterior vaginal wall prolapse that
protrudes beyond the vaginal opening (hymen) can cause urethral obstruction caused by kinking,
resulting in urinary retention or incomplete bladder emptying.

POSTERIOR VAGINAL PROLAPSE (RECTOCELE AND ENTEROCELE)

Posterior vaginal defects occur when there is weakness in the rectovaginal septum.
Symptoms can be indistinguishable from other types of prolapse because the discomfort, pressure,
and the sense of a vaginal bulge are nonspecifc. When difficulties with bowel function and
defecation occur, lower posterior vaginal prolapse is likely. Straining or the need to manually splint for
complete bowel elimination may occur. Upper posterior vaginal wall prolapse is nearly always
associated with herniation of the pouch of Douglas, and because this is likely to contain loops
of bowel, it is called an enterocele.