pelvic organ prolapse

Abbreviation: POP
Protrusion of the pelvic organs into or through the vaginal canal. This condition is usually due to direct or indirect damage to the vagina and its pelvic support system. The damage may be related to stretching or laceration of the vaginal wall, hypoestrogenic atrophy, or injury to the nerves of the pelvic support structures. Synonym: vaginal hernia

Symptoms

Symptoms include a sensation of pelvic pressure, groin pain, coital difficulty, sacral backache, bloody vaginal discharge, difficult bowel movements, and urinary frequency, urgency, or incontinence.

Prophylaxis

Preventive measures include treatment of chronic respiratory disorders or constipation, estrogen replacement for menopausal women, weight control, smoking cessation, avoidance of strenuous occupational or recreational stresses to the pelvic support system, and pelvic muscle exercise to strengthen the pelvic diaphragm.

Treatment

Treatment may be nonsurgical (such as use of a vaginal pessary) or surgical, including reconstructive operations, vaginal hysterectomy, and cystocele or rectocele repair.

Pelvic Organ Prolapse

DRG Category:	748
Mean LOS:	1.7 days
Description:	SURGICAL: Female Reproductive System Reconstructive Procedures
DRG Category:	760
Mean LOS:	3.6 days
Description:	MEDICAL: Menstrual and Other Female Reproductive System Disorders With CC or Major CC

Pelvic organ prolapse (POP) is the abnormal descent from their normal position of organs in the pelvic cavity. The pelvic structures involved include the uterus (uterine prolapse) or vaginal apex (apical vaginal prolapse), anterior vagina (cystocele), or posterior vagina (rectocele). A cystocele is a structural problem of the genitourinary tract that occurs in women. The urinary bladder presses against a weakened anterior vaginal wall, causing the bladder to protrude into the vagina. The weakened vaginal wall is unable to support the weight of urine in the bladder, and this results in incomplete emptying of the bladder and cystitis. A rectocele is a defect in the rectovaginal septum, causing a protrusion of the rectum through the posterior vaginal wall. The rectum presses against a weakened posterior vaginal wall, causing the rectal wall to bulge into the vagina. The pressure against the weakened wall is intensified each time the woman strains to have a bowel movement; feces push up against the vaginal wall and intensify the protrusion. Frequently, a rectocele is associated with an enterocele, a herniation of the intestine through the cul-de-sac.

Causes

Pelvic floor defects occur as a result of childbirth when structures are torn or stretched or from pregnancy itself. Other causes are impaired nerve transmission to the muscles of the pelvic floor from conditions such as diabetes, genital atrophy from low estrogen levels, pelvic tumors, and sacral nerve disorders. Conditions associated with increases in intra-abdominal pressure such as obesity, constipation, or chronic pulmonary disease may lead to POP as well.

Genetic considerations

Genetic contributions are not currently known.

Gender, ethnic/racial, and life span considerations

The disorders tend to occur in middle-aged and elderly women who have had children, and incidence increases with age and parity. Ethnicity and race have no known effects on the risk for cystocele.

Global health considerations

In all regions of the globe, multiparous and elderly women have a high prevalence of POP.

Assessment

History

Ask about symptoms of POP, such as vaginal fullness or pressure, pain or discomfort during sexual intercourse, or lower back or abdominal pain. Patients with a cystocele often have a history of frequent and urgent urination, frequent urinary tract infections, difficulty emptying the bladder, and stress. Ask about the pattern and extent of incontinence: Does incontinence occur during times of stress, such as laughing and sneezing? Is it a constant, slow seepage? Is the amount such that the patient needs to use a peripad or adult diaper?

Patients with a rectocele have a history of constipation, hemorrhoids, pressure sensations, low back pain, difficulty with intravaginal intercourse, and difficulty controlling and evacuating the bowel. Symptoms may be worse when standing and lifting and are relieved somewhat when lying down. Obstetric history often reveals a forceps delivery. Some report that they are able to facilitate a bowel movement by applying digital pressure along the posterior vaginal wall when defecating to prevent the rectocele from protruding.

Physical examination

Upon inspection, the bulging of the bladder and/or rectum may be visualized when the patient is asked to bear down. This bulge may also be palpated. In addition, inspect the patient for hemorrhoids and assess sphincter tone. Levator ani muscles are tested by inserting two fingers in the vagina and asking the patient to tighten or close the introitus.

The International Continence Society (ICS) has proposed a classification using the following POP Quantification (POP-Q) system.

Table l1.
Stage	Description
0	No prolapse
I	Descent of the most distal prolapse to more than 1 cm above the level of the hymen
II	Descent between 1 cm above and 1 cm below the hymen
III	Descent beyond stage II but not complete
IV	Total or complete vaginal eversion

Psychosocial

Assess feelings regarding stress incontinence and the patient’s knowledge of the problem. Explore the effects on the patient’s social life, ability to travel, ability to meet occupational demands, and sexual function.

Diagnostic highlights

General Comments: No specific laboratory tests are indicated unless the patient has the symptoms of a urinary tract infection. The healthcare provider may evaluate blood urea nitrogen, creatinine, glucose, and calcium and may order magnetic resonance imaging, urodynamic testing, or cystoscopy.

Test	Normal Result	Abnormality With Condition	Explanation
Bimanual exam	No bulging or protrusions felt along anterior or posterior vaginal walls	Bulging of anterior vaginal wall felt with cystocele; bulging of posterior vaginal wall felt with rectocele	Cystoceles and rectoceles result in prominent protrusions into the vaginal canal
Transvaginal ultrasound	No bulging or protrusions into the vaginal wall	Detailed locations and extent of tissue changes can be visualized	Allows for visualization of identified changes of the endopelvic fascia

Primary nursing diagnosis

Diagnosis

Altered urinary elimination

Outcomes

Urinary continence; Knowledge: Treatment regimen; Symptom control; Muscle function

Interventions

Urinary incontinence care

Planning and implementation

Collaborative

Conservative management is recommended for POP. Mild symptoms of a POP may be relieved by Kegel exercises to strengthen the pelvic musculature. If the patient is postmenopausal, estrogen therapy may be initiated to prevent further atrophy of the vaginal wall. Sometimes, the bladder can be supported by use of a pessary, a device worn in the vagina that exerts pressure on the bladder neck area to support the bladder. Pessaries can cause vaginal irritation and ulceration and are better tolerated when the vaginal epithelium is well estrogenized. When the symptoms of cystoceles and rectoceles are severe, surgical intervention is indicated. For a cystocele, an anterior colporrhaphy (or anterior repair), which sutures the pubocervical fascia to support the bladder and urethra, is done. A posterior colporrhaphy (or posterior repair), which sutures the fascia and perineal muscles to support the perineum and rectum, is performed to correct a rectocele. A newer surgical technique for rectoceles involves the use of a dermal allograft to augment the defect repair.

Preoperative care specifically for posterior repairs includes giving laxatives and enemas to reduce bowel contents. If the new allograft technique is used, postmenopausal patients need to be told to apply estrogen cream for 3 to 4 weeks preoperatively to improve intraoperative handling and postoperative healing.

Postoperatively monitor the patient’s vaginal discharge, which should be minimal, as well as the patient’s pain level and response to analgesics. Sitz baths may be used for comfort. In an anterior repair, an indwelling urethral catheter is inserted and left in place for approximately 4 days. Encourage fluid intake to ensure adequate urine formation. After a posterior repair, stool softeners and low-residue diets are often given to prevent strain on the incision when defecating.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Stool softeners; laxatives	Varies with drug	Drug depends on patient and physician preference	Assist with bowel movement in patients with rectocele
Antibiotics	Varies with drug	Broad-spectrum antibiotic	Prophylaxis for infection related to surgery
Nonsalicylates; opioid analgesics	Varies with drug	Analgesics	Maintain comfort related to mild preoperative pain and more severe postoperative discomfort

Independent

Preventive measures include teaching the patient to do Kegel exercises 100 times a day for life to maintain the tone of the pubococcygeal muscle. Menopausal women should be encouraged to evaluate the appropriateness of estrogen replacement therapy, which can help strengthen the muscles around the vagina and bladder. If the patient has symptoms that are managed conservatively, teach the patient the use of a pessary—how to clean and store it, how to prevent infections—and to report any complications that may be associated with pessary use, including discomfort, leukorrhea, or vaginal irritation. Answer questions about treatment options and explain the procedures and possible complications.

Listen to the patient’s and her partner’s concerns and assist them in decision making about care. For additional support, have the patient speak to others who have undergone similar treatments.

Evidence-Based Practice and Health Policy

Haya, N., Segev, E., Younes, G., Goldschmidt, E., Auslender, R., & Abramov, Y. (2012). The effect of bladder fullness on evaluation of pelvic organ prolapse. International Journal of Gynaecology and Obstetrics, 118(1), 24–26.

Ensuring that patients empty their bladder prior to undergoing examination for staging of POP is critical to obtaining accurate measurements using POP-Q.
In a study in which 60 women with advanced POP were assessed with both empty and full bladders, empty bladders were associated with significantly higher POP-Q staging (p < 0.0001) and lower location points (p < 0.0001) when compared with full bladders.

Documentation guidelines

Level of comfort and response to pain medication
Physical response: Fluid intake and output, urinary continence, ability to have a bowel movement, amount and type of vaginal discharge
Presence of complications: Bleeding, inability to urinate after urethral catheter is removed, infection

Discharge and home healthcare guidelines

medications.

Instruct the patient on all medications, including the dosage, route, action, and adverse effects.

complications of surgery.

Instruct the patient to notify the physician if signs of infection or increased vaginal bleeding are noted. If patient is discharged with a catheter, be sure she understands that the catheter must remain patent and to notify the physician if the catheter fails to drain urine.

patient teaching.

Instruct the patient to avoid enemas, heavy lifting, prolonged standing, and sexual intercourse for approximately 6 weeks. Note that it is normal to have some loss of vaginal sensation for several months. Emphasize the importance of keeping follow-up visits.