Pelvic organ prolapse

In this episode of PodMD, experienced, Urogynaecolgist, Obstetrician and Gynaecologist Dr James Alexander will be discussing the topic of pelvic organ prolapse, including what pelvic organ prolapse is, how a patient would typically present, the treatment options available, the likelihood of recurrence, when to refer and more.

• Transcript
  Please note this is a machine generated transcription and may contain some errors.
  *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

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  Today I’d like to welcome to the PodMD studio Dr James Alexander.

  James is an experienced, Urogynaecolgist, Obstetrician and Gynaecologist, trained in Australia and specialising in pelvic floor disorders. James provides care in Sydney’s Northshore and the surrounding suburbs.

  James completed his basic Obstetrics and Gynaecology training in 2017 having trained at The Royal Hospital for Women, Port Macquarie Base Hospital and St George Hospital and went on to complete a year as the Gynaecological Oncology fellow at The Royal Hospital for Women. Following this, he commenced urogynaecology training and in 2022 obtained his fellowship in Urogynaecology after training at Monash Health & The Mercy Hospital for Women in Melbourne.

  *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
  If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

  James, thanks for talking with us on PodMD today.

  James: Thank you for having me.

  Question 1
  The topic of today’s discussion is pelvic organ prolapse. James, Can you describe for our listeners what pelvic organ prolapse is?

  James: Pelvic organ prolapse is the descent of the anterior or posterior walls of the vagina or the descent of the uterus or vault through the vagina. It can be mild to severe, and it is common. About 50% of women have some degree of prolapse during their lives although only a smaller proportion will be bothered enough to seek treatment.

  Mild prolapse is probably a prolapse that descends above the level of the introitus, a moderate prolapse comes to the introitus, and a severe prolapse descends beyond the introitus.

  Question 2
  How would a patient with pelvic organ prolapse typically present?

  James: Women will tend to present to their GP saying that they have a bulge or dragging sensation. Some will notice tissue protrusion beyond the vagina. Others will notice that they have trouble emptying their bladder and rectum and can only improve their symptoms by pushing on the relevant area of the vagina.

  Question 3
  What are the risks of the condition?

  James: Well the good news is on the whole, this is not a life threatening condition. But it can cause significant bother and contribute to discomfort, pain, Overactive bladder, urinary tract infection, voiding and defecatory difficulties, as well as dyspareunia

  Very severe prolapse such as procidentia can also cause ureteric obstruction leading to hydronephrosis.

  Question 4
  What are the treatment options?

  James: Mild to moderate prolapse symptoms can often be improved with supervised pelvic floor muscle therapy. This has been shown to reduced prolapse symptoms and improve bladder, bowel and sexual function. A good pelvic floor physio can be helpful here.

  Weight loss, optimising health and avoiding constipation are easy things to do and may improve symptoms.

  For many women a pessary may improve symptoms. These can be inserted by a trained medical professional but are also managed by accredited nurses and physiotherapists. Studies suggest most women choose not to use a pessary for longer than 12 months but about a quarter use them for the long term. I think they are particularly useful for those unsuitable for or wishing to avoid surgery, and also for women who only have symptoms occasionally, like during exercise, and can self-manage the pessary.

  Surgery is also an option, and very effective, however recurrence of symptoms over a period of years is common.

  Question 5
  Have there been any developments in treatment in the last years or are there any in trials or development now?

  James: There is early research looking at biosynthetic materials as an alternative to pelvic mesh but this is in the early days. We are looking at harvesting autologous fascia as an alternative to mesh but data on this remains preliminary.

  Laser therapy has not been proven to be effective at this stage.

  Question 6
  Are there any warning signs a GP or their patient can look out for?

  James: GPs and patients can be reassured that the natural history of prolapse is mostly slow and takes time to develop. Certainly referral to a local urogynaecologist or gynaecologist with an interest in pelvic floor disorders is reasonable at any stage.

  Question 7
  What is the likelihood of recurrence of the condition?

  James: Symptoms tend to recur after pessary removal, and pelvic floor muscle exercises are unlikely to resolve symptoms indefinitely, particularly for moderate-severe prolapse. Even after surgery, tissues may stretch and similar factors that caused the prolapse before may cause it again, so particularly for younger women, recurrence is not uncommon, though hopefully not as severe.

  Question 8
  When should a GP refer?

  James: IT probably depends on how much of an interest the GP has in pelvic organ prolapse. I think most would refer mild prolapse to a physiotherapist and that is very reasonable. Except for GPs comfortable fitting pessaries themselves, patients who are bothered by moderate to severe prolapse are suitable for referral.

  Question 9
  What role does the GP play in the treatment of the condition?

  James: I think recognising prolapse is helpful for women and providing education about treatment pathways. Women are often reassured by understanding that prolapse is common and that if asymptomatic does not require treatment. Also informing women that a mild prolapse wont become severe overnight is often helpful.

  Concluding Question
  Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on pelvic organ prolapse

  James:
  1. Prolapse is common, but only an issue if symptomatic for the patient
  2. Mild prolapse is often best managed conservatively
  3. Surgical management tends to be the pathway for those with persistent symptoms despite conservative management or those who prefer the surgical option.

  Thanks for your time and the insights you’ve provided.

  James: Thank you.