Makindo Medical Notes

Vaginal prolapse, also known as pelvic organ prolapse, occurs when the muscles and tissues supporting the pelvic organs weaken, causing one or more of the pelvic organs (bladder, uterus, rectum) to descend into or outside the vaginal canal.

Types of Vaginal Prolapse

• Cystocele (Bladder Prolapse): The bladder bulges into the anterior vaginal wall due to weakness in the supporting tissues.
• Rectocele (Rectal Prolapse): The rectum bulges into the posterior vaginal wall as a result of weakened connective tissues.
• Uterine Prolapse: The uterus descends into the vaginal canal when the pelvic floor muscles and ligaments weaken.
• Enterocele: The small intestine descends into the lower pelvic area and pushes into the vaginal wall.
• Vaginal Vault Prolapse: Prolapse of the top of the vagina (vaginal vault) post-hysterectomy.

Risk Factors

• Childbirth: Vaginal deliveries, especially if multiple, increase the risk due to pelvic floor muscle strain.
• Age: Advancing age, especially postmenopausal women, are at higher risk due to decreased estrogen levels and muscle weakening.
• Obesity: Increased intra-abdominal pressure weakens the pelvic floor over time.
• Chronic Cough or Constipation: Constant straining increases pressure on the pelvic floor.
• Pelvic Surgery: Surgeries like hysterectomy can compromise pelvic support structures.

Clinical Presentation

• Pelvic Pressure: A feeling of heaviness or pressure in the pelvis, particularly after prolonged standing or physical activity.
• Vaginal Bulge: Women may notice or feel a bulge or protrusion in the vaginal opening, especially with more advanced stages.
• Urinary Symptoms: Difficulty in urinating, urinary incontinence, frequent urinary tract infections (due to cystocele).
• Bowel Symptoms: Constipation, difficulty with bowel movements, or the need to apply pressure to the vagina or perineum to defecate (due to rectocele).
• Sexual Dysfunction: Pain during intercourse (dyspareunia) or reduced sexual satisfaction.

Diagnostic Evaluation

• Pelvic Examination: Visual and manual examination of the pelvic organs is performed to assess the degree and type of prolapse.
• POP-Q (Pelvic Organ Prolapse Quantification) System: A standardized scoring system used to stage the severity of prolapse.
• Ultrasound or MRI: Occasionally used for further imaging of pelvic structures if the diagnosis is unclear or to plan surgery.

Management Options

A. Conservative Management

• Pelvic Floor Exercises (Kegels): Strengthening the pelvic floor muscles can help mild cases and prevent worsening.
• Vaginal Pessary: A device inserted into the vagina to support the pelvic organs. Useful for women who are not surgical candidates or who prefer non-surgical treatment.
• Weight Loss and Lifestyle Modifications: Losing weight, treating chronic cough or constipation can alleviate symptoms and reduce intra-abdominal pressure.
• Hormone Replacement Therapy (HRT): Vaginal estrogen may help strengthen vaginal tissues in postmenopausal women.

B. Surgical Management

• Anterior or Posterior Vaginal Repair: Surgery to repair cystocele or rectocele by reinforcing the vaginal walls with sutures or mesh.
• Hysterectomy: Uterine prolapse may be treated by removing the uterus, particularly in women who no longer desire fertility.
• Sacrocolpopexy: A procedure to support the vaginal vault using mesh or the patient’s own tissues, often performed in women with vaginal vault prolapse post-hysterectomy.
• Colpocleisis: A surgery that closes off the vaginal canal in women who are no longer sexually active and wish for permanent relief from prolapse.

Complications

• Ulceration and Infection: Prolonged exposure of vaginal tissues outside the body can lead to ulceration and infection.
• Urinary Retention: Severe prolapse may compress the urethra and result in difficulty emptying the bladder.
• Chronic Constipation: Rectocele can lead to difficulty passing stools.

Follow-Up and Prevention

• Regular Follow-Up: Women using pessaries need regular follow-up to ensure proper fitting and to check for vaginal irritation or infection.
• Pelvic Floor Exercises: Continuing pelvic floor strengthening exercises post-treatment is recommended to maintain muscle tone.
• Weight Management: Maintaining a healthy weight reduces pressure on the pelvic organs.

Note: Early recognition and treatment of vaginal prolapse can improve quality of life and prevent complications. Both conservative and surgical management options are available depending on the severity and the patient's preferences.