Pelvic Organ Prolapse (POP)

Why Choose UCPA?

Our providers have dedicated their careers to helping patients with conditions of POP, as well as other problems in the pelvic area. We understand the complexities of POP — and that not all women’s vaginas are the same. We know when and how to fix it. Individualized care is the norm, and with something as complex as POP, individualized care is essential.

At UCPA we have specialists who are the leaders in our community and nationally. We offer providers who have received extra specialized fellowship training related to the care of patients with POP, incontinence, bladder/bowel dysfunction and other pelvic-related concerns. Some of our doctors have trained urologists in our community and beyond in the performance and use of advanced therapies, and act as a resource for them when they have problems or questions of their own. You should choose UCPA because we offer the most expert providers and offer the widest range of options, including conservative and advanced therapies. We will work with you to define your individual problem and come up with a specific plan that addresses your concerns.

What Is Pelvic Organ Prolapse?

POP is when the walls of the vagina have lost support and strength and ultimately fall down — sometimes out the vaginal opening. The organs behind those vaginal walls can then fall down with the walls and “herniate” out the vagina. Behind the front wall of the vagina is the bladder; behind the back wall of the vagina is the rectum; and at the top of the vaginal canal is the uterus, or in someone who has had a hysterectomy, the vaginal cuff or apex.

What Are The Symptoms Of POP?

The main symptom of significant POP is the feeling of a bulge at or out of the vaginal opening. Associated with prolapse can be the feeling of heaviness or pressure in the vagina, pelvic or lower back areas. Sometimes bleeding and discharge can be seen when the prolapse hangs out the vagina and rubs on underwear/pads. Other symptoms are usually related to the part of the vagina that is bulging.

A prolapsing bladder can cause some urinary voiding symptoms such as urinary urgency, frequency, and even incontinence — involuntary urinary leaking. In severe prolapse of the bladder, a “kinking” effect of the urethra can make it hard to void and empty the bladder. A slow stream might be noted, as well as an intermittent start-stop flow, or even having to push or strain in order to urinate.

A significant prolapsing rectum is associated with problems with bowel movements, such that stool gets trapped in the bulge and requires straining and “splinting” — pushing on the bulge — in order to defecate. This happens most commonly with poor quality stools such as small, hard pieces, but can also happen with softer, formed stools if the bulge is large enough.

What Causes POP?

POP doesn’t happen overnight, but usually progresses slowly over time. Any constant strain on the pelvic or vaginal area over time can result in POP. Primary examples include pregnancy and vaginal deliveries, other pelvic surgeries (such as hysterectomy), and high-impact activities that put a lot of strain on the pelvic area (running, jumping, pounding, heavy lifting, straining). When the ligaments (supportive structures) to the vagina and pelvic organs are weakened or disturbed, they can no longer support the vagina or the organs behind the vaginal walls. The process is very much like a hernia, except that the herniating or bulging process is happening in the vagina, rather than in the groin.

How Can POP Be Prevented?

Keeping the muscles in and around the vagina and pelvic area strong through a program of good core strengthening (Pilates, yoga) is most helpful for prevention. But sometimes, in the cases when the supportive ligaments have been damaged (traumatic vaginal delivery or hysterectomy), exercises can’t prevent the inevitable falling down or prolapsing process.

What Can Be Done About POP?

Observation – if it’s not associated with bothersome symptoms.

Pessary – a flexible vaginal insert that helps hold the prolapsing parts up in the vagina. Most optimal when a woman can manage the pessary herself, by taking it out 1-2 times/week overnight to decrease the chances of infections or erosion.

Surgery – to correct the defects and damaged areas in the vaginal/pelvic areas that are responsible for the prolapse.

Does All POP Need To Be Fixed?

NO! Just because a physician sees a bulge on vaginal exam, does not mean it needs to be fixed. Only POP that is associated with symptoms (bulge, urinary, bowel) should be addressed.

What Kind Of Surgical Options Are Available?

Under the surgical umbrella for POP repair there are a lot of options. The best way to correct one woman’s prolapse isn’t necessarily the best way to fix another woman’s prolapse. POP is a very complicated issue, since it can involve many compartments or organs in the vagina. It can also be associated with many different symptoms. Again, the main goal of surgery is to correct the symptom that is directly related to the POP.

Briefly, the options concerning the route of surgery include surgery done through the vagina (with no incisions on the outside) or surgery through the abdomen with an incision on the abdomen or with a few scattered small incisions for laparoscopic or robotic tools. The type of surgery depends on the compartment that needs to be fixed, the severity of the prolapse, the need for an incontinence surgery at the same setting.

Sometimes these procedures can be done with the patient’s own native tissue. But when the prolapse is large, and the remaining tissue is weak, a traditional native tissue repair doesn’t always last. Recurrence rates for symptomatic prolapse have been reported at 30-45% following traditional repairs — meaning that a second procedure will be necessary in the future to yet again fix the problem.

The addition of a synthetic material in the vagina is meant to decrease this chance for recurrence and provide the woman with a long-lasting repair. The material is a soft piece of mesh that gets incorporated into the vaginal tissue to provide it with strength, and therefore durability. It is the same mesh used for other hernias in the body (abdominal, groin) and has been used for many years. Whether or not mesh would be beneficial for your POP repair depends on many factors and requires extensive counseling; thus reinforcing the need to focus on very individualized care.

Finally, sacrocolpopexy, an abdominal surgery for prolapse, can be completed for POP. This procedure has been used since the 1950s and is considered “the gold standard” for pelvic prolapse repair, with success rates of 80 to > 90%. This procedure also utilizes a synthetic material in order to sustain your POP repair.

Rest assured you will be counseled thoroughly about the nature of your prolapse, the options available to fix it, and the advantages and disadvantages of the use of a synthetic material for your surgical repair.
Please ask your physician for education handouts regarding POP.