B18. Pelvic organ prolapse; therapy

Because many severe pelvic organ prolapses don’t cause the patient any bothersome symptoms or any symptoms at all, treatment is only indicated if the patient has bothersome symptoms.

Nonsurgical treatment

Nonsurgical treatment usually involves pessaries, local hormone support, and pelvic floor exercises.

Pessaries may be used as first line therapy. These are plastic or silicone devices which are inserted into the vagina to support its walls. There are two types of pessaries, those which are supportive and those which are space-filling, each with a variety of shapes. Supportive pessaries are the most common, and the most commonly used shape is the ring-shaped pessary.

Other shapes like donut, Gellhorn, and cube, are space-filling (and larger). This makes them more effective, but has the disadvantage of needing to be removed before intercourse.

Pessaries are kept in continously, only removed every few months by a gynaecologists to clean and inspect the vagina for complications (decubitus). Pessaries are effective in treating the symptoms.

Local hormonal support, by administration of vaginal suppositories, may also improve symptoms.

Pelvic floor exercise is important to strengthen the pelvic floor. It can be augmented with the use of vaginal cones, which provide weight resistance.

Surgical treatment

Surgery is effective and safe, and may also be the first choice of treatment for POP.

Many types of surgeries may be used, depending on the affected compartment and prolapsed organ. Because patients may have prolapse of multiple compartments or organs, multiple procedures may be necessary. These can be performed in the same procedure.

• Transvaginal procedures
  • Anterior colporrhaphy – for cystocoele
    • The anterior vaginal wall is reinforced
  • Posterior colporrhaphy – for rectocoele
    • The posterior vaginal wall is reinforced
  • Cervical amputation – for cervical prolapse
  • Manchester operation – for cystocoele, rectocoele, and cervical prolapse
    • Combination of anterior and posterior colporrhaphy and cervical amputation
  • Hysterectomy – for uterine prolapse
  • Spinal fixation – attachment of cervix or vaginal apex to connective tissues in the pelvic wall
• Laparoscopic procedures
  • Sacrocolpopexy –  fixation of the vaginal apex to the sacrul promontory by surgical mesh (hysterectomy is often performed simultaneously)
  • Ventral rectopexy – fixation of the rectum to the posterior abdominal wall with net