Basic InformationDefinitionPelvic organ prolapse(POP) oruterine prolapserefers to the protrusion of the uterus into or out of the vaginal canal. In a first-degreeuterine prolapse, the cervix is visible when the perineum is depressed. In a second-degreeuterine prolapse, the uterine cervix has prolapsed through the vaginal introitus, with the fundus remaining within the pelvis proper. In a third-degreeuterine prolapse(i.e., completeuterine prolapse, uterine procidentia), the entire uterus is outside the introitus.Table 1-323compares the various types of prolapse.

TABLE 1-323--Types of Genital ProlapseOriginal Position of OrgansProlapseSymptoms (in addition to the general symptoms of discomfort, dragging, the feeling of a lump and, rarely, coital problems)

AnteriorUrethrocele

Cystocele

Urinary symptoms (stress incontinence, urinary frequency)

CentralCervix/uterus:

1st, 2nd, and 3rd degree

Procidentia

Bleeding and/or discharge from ulceration in association with procidentia

PosteriorRectocele

Enterocele

Bowel symptoms, particularly the feeling of incomplete evacuation and sometimes having to press the posterior wall backwards to pass stool

From Drife J, Magowan B:Clinical obstetrics and gynaecology,Philadelphia, 2004, Saunders.

SynonymsGenital prolapse

Uterine descensus

Uterine prolapse

POP

ICD-9CM CODES

Genital prolapse618.8Uterine descensus618.1Pelvic organ prolapse618.8

Epidemiology & DemographicsPrevalenceMost prevalent in postmenopausal multiparous women.Risk factorsPregnancy, especially POP symptoms during pregnancy

Labor

Vaginal childbirth

Obesity

Chronic coughing

Constipation

Pelvic tumors

Ascites

Strenuous physical exertion, especially during pregnancy

Maternal history of prolapse

Caucasian race

GeneticsIncreased incidence in women with spina bifida occulta.Physical Findings & Clinical PresentationPelvic pressure

Bearing-down sensation

Bilateral groin pain

Sacral backache

Coital difficulty

Protrusion from vagina

Spotting

Ulceration

Bleeding

Examination of patient in lithotomy, sitting, and standing positions and before, during, and after a maximum Valsalva effort

Erosion or ulceration of the cervix possible in the most dependent area of the protrusion

EtiologyVaginal childbirth and chronic increases in intraabdominal pressure leading to detachments, lacerations, and denervations of the vaginal support system

Further weakening of pelvic support system by hypoestrogenic atrophy

Direct injury to the levator ani, neurologic injury from stretching of the pudendal nerves

Some cases from congenital or inherited weaknesses within the pelvic support system

Neonataluterine prolapsemostly coexistent with congenital spinal defects

Ferri: Ferri's Clinical Advisor 2014,1st ed.Copyright 2013 Mosby, An Imprint of Elsevier

DiagnosisDifferential DiagnosisOccasionally, elongated cervix; body of the uterus remains undescended.

Diagnosis is based on history and physical examination. Currently there is only one genital tract prolapse classification system that has attained international acceptance and recognition: the patient pelvic organ prolapse quantification (POP-Q) (Boxes 1-43 and 1-44).

BOX 1-43Staging of Pelvic Organ Prolapse Based on POP-Q Examination

Stage 0No prolapse.

Stage IMost distal prolapse