Pelvic Organ Prolapse among Older Women

Emily Saks, MD, Fellow, Division of Urogynecology and Female Reproductive Surgery, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA.
Lily Arya, MD, Assistant Professor and Program Director, Division of Urogynecology and
Female Reproductive Surgery, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA.

Pelvic organ prolapse is a common condition among women, and its prevalence increases with age. Pelvic organ prolapse is multifactorial in etiology but ultimately results from a disruption in the pelvic floor muscles and their attachments. Patients may be asymptomatic or may report a variety of pelvic floor symptoms. Prolapse can be easily diagnosed through clinical examination. Treatment involves simple observation, pessary, or surgery.
Key words: pelvic organ prolapse, older women, pessary, vaginal surgery.

Introduction
Pelvic organ prolapse is a protrusion or herniation of pelvic structures such as the bladder, bowels, or uterus into the vaginal canal resulting from a weakness or damage to the pelvic support structures. As many as 50% of adult women over the age of 40 years are affected by pelvic organ prolapse,¹ and both the incidence and prevalence are known to increase with age.² Additionally, a woman carries an 11% lifetime risk of undergoing an operation for prolapse or urinary incontinence by age 80.³ The fasting growing segment of the U.S. population is age 85 years and older, and within the next 25 years, the number of women age 65 and over is expected to double.⁴ Accordingly, pelvic organ prolapse will be a progressively more common complaint among women, resulting in an increased need for pelvic floor dysfunction services. Although not a life-threatening condition, pelvic organ prolapse can cause distressing pelvic floor symptoms and may lead to a decreased quality of life and withdrawal from social activity.^5,6

Pathogenesis
The etiology of pelvic organ prolapse is not clear but appears to be multifactorial. Genetics and ethnic differences may play a significant role in a woman’s predisposition to developing prolapse.^2,7 Childbirth, with increasing parity, is considered to be one of the strongest factors in the development of prolapse.^2,8 This may be a result of direct damage to the muscle and fascia of the pelvis or of indirect weakness of the muscle caused by neurological injury. Increasing age and body mass index are also thought to be associated with an increased risk of pelvic organ prolapse.^2,8 Additionally, conditions that increase intra-abdominal pressure, such as chronic cough and chronic constipation,⁹ and heavy lifting¹⁰ may increase the risk of developing pelvic organ prolapse.
 

Pelvic organ support can be considered in two categories: pelvic muscles and endopelvic fascia (Figure 1). The pelvic floor is made up of the levator ani and coccygeal muscles. The levator ani is composed of three parts: the puborectal, pubococcygeal, and iliococcygeal muscles. These muscles create a hammock between the pubis and coccyx, attaching laterally along the pelvic sidewalls. The levator ani muscle is tonically contracted, providing a firm shelf posteriorly to support the pelvic contents and aiding with urinary and fecal continence. Endopelvic fascia is a loose network of connective tissue that surrounds and supports the pelvic organs and vagina. Condensations of the endopelvic fascia are known as the uterosacral and cardinal ligaments and the rectovaginal and vesicovaginal septa. These condensations help to keep the vagina in its normal position in the pelvis, directed posteriorly toward the sacrum.¹¹

The vagina is supported at three levels. The apex (level 1) is supported by the cardinal and uterosacral ligaments; failure results in uterine prolapse or vault prolapse posthysterectomy. The mid-vagina (level 2) is supported by the attachment of the vagina to