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Nonsurgical Management of Pelvic Organ Prolapse

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Nonsurgical Management of Pelvic Organ Prolapse Clinical Expert Series Nonsurgical Management of Pelvic Organ Prolapse Patrick J. Culligan, MD Although surgical management of symptomatic pelvic organ prolapse (POP) is common and often necessary, conservative treatments such as pessaries, pelvic floor muscle training, or both can usually result in symptomatic improvement. When treating patients with POP, health care practitioners should focus primarily on identification and alleviation of POP-related symptoms. It is appropriate to offer nonsurgical management to most people with POP. This article reviews the objective and subjective evaluation and nonsurgical management of POP, emphasizing a simple, practical approach to pessary fitting and management. (Obstet Gynecol 2012;119:852–60) DOI: 10.1097/AOG.0b013e31824c0806 n the United States alone, millions of women are actually protrude beyond the opening of the vagina.3 Iaffected by pelvic organ prolapse (POP), the prev- The etiology of POP is multifactorial and compli- alence of which is expected to increase nearly 50% by cated. The main risk factors are vaginal childbirth, 2050.1 The strict definition of POP is any descent of frequent increases in intra-abdominal pressure (such the anterior vaginal wall (cystocele, urethrocele), the as occurs with heavy lifting or chronic constipation), vaginal apex (uterine or vaginal vault prolapse), the aging, and connective tissue abnormalities.2 posterior vaginal wall (rectocele, perineocele), or all of With at least 200,000 prolapse operations being these,2 but mere vaginal descent (ie, mild prolapse) in performed in the United States annually,4 gynecolo- the absence of symptoms does not require any treatment. gists may think of it as primarily a “surgical condi- Symptoms that are commonly associated with tion,” yet the vast majority of women with POP either POP include pelvic heaviness, vaginal bulging, in- choose conservative management or go without treat- complete bowel or bladder emptying, needing to ment altogether. Although minimally invasive surgical splint the posterior vaginal wall or perineum to defe- options exist for nearly every patient with POP, a large cate, or discomfort during sexual intercourse. It is proportion can be managed successfully with pessaries, important to note that most patients who exhibit just pelvic floor muscle exercises, or both. The choice be- mild or moderate POP do not experience any of these tween surgical compared with nonsurgical management symptoms until some aspect of their vaginal wall should be made by the patient once she understands the tradeoffs involved. From the Division of Urogynecology and Pelvic Reconstructive Surgery, Atlantic There are a variety of reasons that women with Health System, Morristown and Summit, New Jersey; and the Department of symptomatic prolapse might decline surgical manage- Obstetrics, Gynecology & Reproductive Science, Mount Sinai School of Medicine, New York, New York. ment. For example, they may be planning to become Continuing medical education for this article is available at http://links.lww. pregnant; they might not be able to comply with com/AOG/A287. postoperative restrictions as a result of job or parent- Corresponding author: Patrick J. Culligan, MD, 435 South Street Suite 370, ing responsibilities; they could have medical comor- Morristown, NY 07960; e-mail: [email protected]. bidities that would increase their perioperative risks; Financial Disclosure or they may view surgery as too risky or simply “not Dr. Culligan is a consultant and researcher with Intuitive Surgical, CR BARD, worth it.” Regardless of the ultimate treatment choice, and Boston Scientific, and a researcher for AMS. the initial work-up of POP does not change. © 2012 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. This article is intended to provide strategies for ISSN: 0029-7844/12 the evaluation and nonsurgical management of 852 VOL. 119, NO. 4, APRIL 2012 OBSTETRICS & GYNECOLOGY POP based on published evidence as well as clinical of prolapse, urinary and fecal incontinence, and pel- experience. vic discomfort, and allow them to quantify the extent to which their symptoms affect their quality of life. DIAGNOSTIC APPROACH When feasible, it is helpful for new patients to fill out Women with POP typically present in one of two symptom questionnaires before their actual office ways; either they notice a bulge on their own or they visit, because doing so can give them time to reflect are alerted to the condition by their gynecologist on and improve the accuracy of their answers. during an annual examination. When patients find Aside from administering validated questionnaires, the prolapse themselves, they usually make that dis- the health care practitioner can ask several specific covery while they are taking a shower or sitting on the questions to learn more details about the severity of the toilet. Often this scenario is preceded by a series of prolapse problem. A typical line of questioning might go unusually strenuous situations that caused the patient like this: “Does your bulge actually come out beyond to increase her intra-abdominal pressure (such as the the opening of the vagina, or is it just ‘right there’ at the need to move heavy boxes, a new exercise regimen, opening?” “When your vaginal bulge is at its largest, or a bout of prolonged severe coughing). The first- how big is it? To answer, can you compare it with the time discovery of a vaginal bulge understandably size of some other object like an egg or a golf ball or a frightens many women, who may even contact their baseball?” “Is it that big everyday or do you have some gynecologists for an emergency appointment. It is not good days and some bad days?” uncommon for these women to fear the worst such as As for the physical examination component, the cancer. Gynecologists can use these appointments to main goal is to verify that whatever you are seeing in reassure and educate their patients. Once a woman the examination room jives with the patient’s day-to- understands that the condition is not life-threatening day experience. To that end, it can be helpful to and that both surgical and nonsurgical treatment examine a patient while she is standing after the options exist, she will typically feel relieved and be supine prolapse examination is completed. This open to learning about these options. standing examination can be easily performed by Another common presenting scenario happens asking the patient to stand in front of you with her legs when the gynecologist is the one who discovers the slightly spread while you are seated on a low stool. prolapse during a routine examination and informs Then you can simply feel the various aspects of the the patient that she is developing a “dropped bladder” prolapse while she coughs or performs a Valsalva or some other type of prolapse. In this situation, the maneuver. This part of the examination tends to patient is usually asymptomatic or might have signs of make sense to patients because they usually experi- prolapse that she never connected to the condition ence their worst prolapse symptoms while standing. such as gradually no longer being able to retain a The best way to quantify POP in a standardized tampon. In some cases, rather than simply informing way (during the supine examination) is to use the Pelvic these patients that they may require surgery in the Organ Prolapse Quantification (POP-Q) system.2 Al- future, gynecologists could recommend pelvic floor though the POP-Q system may seem quite complicated muscle exercises either alone or in combination with at first, with a little practice, all POP-Q values can be a total body exercise program as an attempt to obtained within 30–60 seconds during a routine pelvic prevent worsening of the prolapse. Again, these “pro- examination. A full description of the POP-Q examina- lapse discovery” visits offer the gynecologist an op- tion is beyond the scope of this article. For more portunity to record the specific objective and sub- information about performing the POP-Q examination, jective prolapse-related signs and symptoms and you may read an easy-to-follow description by individualize the treatment options offered. It is Prietto et al6 or view a POP-Q video tutorial by also appropriate for the gynecologists in these visiting www.youtube.com/watch?vϭLplpznnhDmU. situations to let the patients know that they may After using the POP-Q system to describe the never experience significant POP symptoms and specific degree of prolapse found in the anterior, thus may never require any treatments at all. apical, and posterior compartments, the gynecologist When gathering the subjective data, several vali- can verify the degree of bother experienced by the dated questionnaires can be quite helpful. Two in patient. At this point, it is important to have the particular that address not only prolapse but all pelvic patient distinguish between “physical bother” and floor disorders are the Pelvic Floor Disorder Inven- “mental bother.” Doing so can be tricky, but it is very tory and the Pelvic Floor Impact Questionnaire.5 important. Some patients will deny any physical These forms allow patients to identify any symptoms symptoms yet still seek surgical correction of mild VOL. 119, NO. 4, APRIL 2012 Culligan Nonsurgical Management of Pelvic Organ Prolapse 853 POP because they are mentally troubled by knowing exercises. Of course, these options can be used simul- that they have “something wrong down there.” Other taneously or individually. patients are primarily bothered physically by their prolapse. Both groups of patients will say “yes” when Pessaries asked whether the prolapse “bothers” them. Women Pessaries can provide immediate relief of prolapse who are primarily bothered mentally, with little or no symptoms and can be appropriate for either tempo- physical bother, usually present fully intent on under- rary or long-term use.8 The most typical patients who going corrective surgery.
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