Continuing Education Activity

Procidentia is the severe stage of pelvic organ prolapse. Pelvic organ prolapse is usually a non-life-threatening condition with the most common symptom described as a bulge-like sensation protruding from the vaginal vault. Prolapse symptoms can impact daily activity, body image, and sexual health. This activity reviews the evaluation and treatment options for pelvic organ prolapse and highlights the role of an interprofessional team in caring for patients with this condition.

Objectives:

• Identify the etiology of pelvic organ prolapse.
• Describe the physical exam staging of pelvic organ prolapse.
• Outline the non-surgical and surgical management considerations for patients with pelvic organ prolapse.
• Identify the importance of an interprofessional team approach to improve patient care and treatment in patients with complex pelvic floor dysfunction.

Introduction

Procidentia is a severe form of pelvic organ prolapse (POP) that includes herniation of the anterior, posterior, and apical vaginal compartments through the vaginal introitus. Pelvic organ prolapse can include all three compartments, such as in procidentia, or individual compartments. When the anterior vaginal compartment herniates through the vaginal introitus, it is a cystocele. When the posterior vaginal compartment is herniating through the vaginal introitus, it is a rectocele. When the apical vaginal compartment is herniating through the vaginal introitus, this area can include bowel or uterus, describing an enterocele or uterovaginal prolapse respectively.   

The first recorded documentation of pelvic organ prolapse dates back to 1550 BC in the Egyptian medical papyrus of herbal knowledge, Ebers Papyrus.[1] Historical management of prolapse varied, including acts of manual manipulating of the prolapsed organ, cleansing the prolapsed organ with oils and wines, and inhaling malodorous fumes.[1] Hippocrates also described a process termed succession, which was a maneuver that placed women upside down on a ladder while the ladder frame moved up and down with the hopes that gravity would restore the pelvic organs to their anatomical position.[1][2][3] There have even been multiple reports of primitive vaginal hysterectomies. The most commonly quoted was performed by Soranus of Rome during the 1st century when he completed a vaginal hysterectomy on a gangrenous uterus.[1][2] However, credit for the first vaginal hysterectomy goes to Capri during the beginning of the 16th century for performing the first partial vaginal hysterectomy for pelvic organ prolapse.[4]

Prolapse is not usually painful or life-threatening, but symptoms can impact daily activity, body image, and sexuality to the point of desperation as exemplified when a peasant woman in the 17th century took a sharp knife to her own uterine prolapse and cut what she thought was a polypoid growth from her vagina. Her bleeding eventually stopped, and reportedly she lived for many years with urinary incontinence likely from a vesicovaginal fistula.[4][5]

Over the 19th and 20th centuries, improvements in surgical instrumentation, anesthesia, and antibiotics decreased the morbidity rates of performing hysterectomies. This article covers the etiology, epidemiology, differential diagnosis, and treatment options for pelvic organ prolapse.

Etiology

Multiple medical conditions and risk factors have been cited as causes for pelvic organ prolapse. Defects in the pelvic anatomy, with enlarged uteri from leiomyoma and endometriosis, and pregnancy with vaginal delivery, have been reported to be associated risk factors for pelvic organ prolapse.[6][7] Extrinsic risk factors for pelvic organ prolapse included smoking and obesity.[8]

Epidemiology

In the Women’s Health Initiative Hormone Replacement Therapy clinical trial, a subset of older women were identified as having pelvic organ prolapse. The precise prevalence of pelvic organ prolapse is not known because there are different classification systems and women do not initially seek medical attention for prolapse.[9] However, about 1 in 10 women will undergo surgical intervention for pelvic organ prolapse by the age of 80 years old.[10] The prevalence of pelvic organ prolapse surgery varied from 6% to 18%. Prevalence for pelvic organ prolapse based on symptomology ranged from 3% to 6%, and upwards to 50% based upon vaginal examination.[9] Multiple studies have issued a consensus statement that pelvic organ prolapse needs to have a more precise classification system to help define and study this condition.

History and Physical

The most common symptom patients report is a feeling of fullness or a bulge protruding from the vagina. This usually occurs gradually and is noticed over time. Sometimes it is incidentally diagnosed on a physical exam at annually gynecological exams. Patients that have prolapse should also undergo assessment for any other urogynecological issues. Among those with prolapse, 40% will have concurrent stress urinary incontinence, 37% will have overactive bladder, and 50% will have fecal incontinence. Patients may report a dynamic change in their symptoms throughout the day. Most prolapse symptoms are less noticeable to the patient upon first rising, but after various levels of activity such as lifting, straining, or standing the bulging sensation may worsen. When procidentia occurs with complete uterine prolapse, chafing and epithelial erosions are also sometimes noted as the internal vaginal mucosa is now excessively exposed to friction.[6]

Evaluation

Diagnosis of prolapse has mainly been by physical exam. Laboratory and imaging studies are not routinely needed. Since 1996, the International Continence Society (ICS), the American Urogynecologic Society (AUG), and the Society of Gynecologic Surgeons (SGS) agreed on the Pelvic Organ Prolapse Quantification system (POP-Q) examination. Previously other conventional evaluation methods, including the Baden-Walker grading system, were in use.[11] Although the POP-Q test is hard to teach, it is a reproducible examination that has found application in both clinical and research practices. There are five stages of prolapse. The examiner measures specific points of the vaginal vault in relationship to the hymen during the POP-Q examination that help identify which portion of the pelvis is prolapsing.  

• Stage 0 – No prolapse demonstrated 
• Stage 1 – The most distal portion of the prolapse is more than 1 cm above the hymen level
• Stage 2 – The distal-most portion of the prolapse is between 1 cm above the hymen and 1cm below the hymen level
• Stage 3 – The distal-most portion of the prolapse is more than 1 cm below the hymen, but not completely everted
• Stage 4 – There is a complete eversion of the uterus

Procidentia is a stage 4 prolapse. Most women who become symptomatic from their prolapse are usually at stage 2 or higher.[12]

Treatment / Management

The general condition of prolapse, even to the extent of procidentia, is not life-threatening. The treatment has its basis in the severity of the individual patient’s symptomology. For those who have an incidental diagnosis of prolapse and are not symptomatic, observation and pelvic floor muscle training are reasonable options.[13] However, there is no guarantee that the prolapse will improve, stay the same, or worsen over time.  

For patients who are symptomatic, but do not wish to proceed with surgery or are not surgical candidates, pessaries have often been an option. Pessaries are usually silicone-based products fitted for a patient’s specific type of prolapse. There is a multitude of sizes and shapes. Examples for usage include young women desiring future pregnancies with symptomatic prolapse, elderly females with chronic medical issues that contraindicate anesthesia, patients wanting medical treatment, etc.[3]  

Surgical options depend on many factors including the stage of prolapse, vaginal length, hormonal status, desires for further coitus, concurrent urinary or bowel dysfunctions, etc.[2] There have been multiple studies comparing the differences in surgical techniques for pelvic floor repair with one multi-institutional study with women aged 70 to 80 years requesting surgical management having an overall comparable recovery time, anatomical success rate, and patient satisfaction with sacrocolpopexy, native tissue repair, and vaginal mesh repair.[14] The International Federation of Gynecology and Obstetrics (FIGO) working group studied different surgical procedures and their efficacy comparable to their cost-benefit profile. Pessary usage has the lowest complication rate and cost-benefit profile. For vaginal surgeries, the sacrospinous ligament fixation and uterosacral ligament suspension showed comparable results. For abdominal surgeries, the minimally invasive approach with sacrocolpopexy had good durability and quality of life with the least amount of complications.[15]

Differential Diagnosis

Pelvic organ prolapse is easily identifiable with a physical exam. However, certain concurrent conditions do need to be worked up before treatment, which is discussed below in the complications section. These conditions usually include the need for an extensive history of bladder, bowel, and sexual symptoms.

Prognosis

Prognosis with procidentia is good as it is a non-life threatening condition. Quality of life is the leading factor that brings most women in for intervention. Conservative treatment is usually the initial plan for the goal of minimizing any prolapse progression. The use of pessaries in postmenopausal women with advanced prolapse had improved quality of life with reduced vaginal symptomology.[16] Even long-term follow-up averaged two to five years after initial surgical interventions for pelvic organ prolapse showed continued improved quality of life and patient satisfaction.[17][18][19]

Complications

Prolapse may have associated complications usually involving bladder, bowel, or sexual health. 

Before proceeding with surgical intervention, bladder trials with a simple cystometrogram or urodynamic testing can evaluate for possible postoperative potential incontinence; this is primarily due to the unkinking of the urethra that occurs after reduction of the prolapse.[20] Regardless of any urinary incontinence symptoms, a bladder study is recommended in women with genitourinary prolapse to determine the necessity for incontinence surgery at the same time.[21] 

Bowel symptomology could present as either fecal incontinence or obstruction. Patients may state they need to insert a finger into the vagina and push the posterior vaginal vault or perineal body to aid in their defecation - this is called splinting and is likely due to the laxity in pelvic ligaments or damaged connective tissue preventing normal opening and closure of the anus.[22]  

Sexual health may also be affected by prolapse. Although prolapse alone should not be painful, there is an associated negative body image. This negative image not only affects women’s sexual health due to embarrassment but also can affect some women’s professional activities when they have to adjust or stop their activities due to discomfort.[5]

Deterrence and Patient Education

There are multiple organizations such as the International Urogynecological Association (IUGA) and the American Urogynecologic Society (AUGS) that have premade patient education pamphlets. These include printable information about different urogynecological testing and surgical procedures that may be necessary. Written instructions given about pessary information along with face-to-face consultations improved the confidence of patients to self-manage their pessaries.[23] This approach decreases the amount of vaginal discharge, smell, and time needed for continued in-office follow-up care. Although there have been image-guided models for patient education to help aid with consenting patients for pelvic organ prolapse surgery, using models is not superior to with or without standard verbal consent alone.[24][25]

Enhancing Healthcare Team Outcomes

Although prolapse, even at its most severe with procidentia, is not a life-threatening event. Further evaluation and treatment should be steered based on how bothersome the prolapse is. The workup for prolapse can be done by general gynecologists if there are no concurrent type urinary, bowel, or sexual health concerns. If there are concurrent symptoms, then multiple healthcare professionals should participate in the care of the patient due to the close anatomical approximation of urinary and gastrointestinal outlets. A joint pelvic floor interprofessional team consisting of a urogynecologist, a urologist, a physiotherapist specialized in women’s health, a colorectal surgeon, a geriatrician, and/or specialized nursing staff has been recommended by the National Institute for Health and Clinical Excellence (NICE) to manage patients with pelvic floor dysfunction, including prolapse. This team approach can help to standardize treatment and improve patient outcomes in complex patients. [Level 2][26][27]