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INTRODUCTION

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Pelvic organ prolapse (POP) is the downward descent of the female pelvic organs that results in a protrusion of the vagina and/or uterus. It usually involves descent of the bladder, uterus, or posthysterectomy vaginal cuff, and the small and/or large bowel. Vaginal delivery, hysterectomy, chronic straining, normal aging, and abnormalities of connective tissue or connective tissue repair predispose some women to disruption, stretching, or dysfunction of the levator ani complex and/or the connective tissue attachments of the vagina, resulting in prolapse. Women often present with multiple complaints including bladder, bowel, and pelvic symptoms. However, with the exception of vaginal bulging symptoms, none of these symptoms are specific to prolapse. Patients presenting with symptoms suggesting prolapse should undergo a history and pelvic examination. Radiographic evaluation is usually unnecessary. Many women with POP are asymptomatic and do not require treatment. When prolapse is symptomatic, options include observation, pessary use, and surgery. Surgical therapy for prolapse can be broadly categorized into reconstructive and obliterative techniques. Reconstructive techniques may be performed using an abdominal or vaginal approach. Although no effective strategy to prevent prolapse recurrence has been identified, weight loss, minimizing heavy lifting, treating constipation, modifying or reducing obstetrical risk factors, and maintaining or improving pelvic floor muscle strength through pelvic floor physical therapy can be considered.

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DEFINITION

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Key Point

  • Apical prolapse is the descent of uterus, cervix, or vaginal vault caused by a weakness of the top of the vagina.

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Apical prolapse is the descent of uterus, cervix, or vaginal vault caused by a weakness of the top of the vagina; the vagina begins to invert, just as a sock can be turned inside-out (Figure 14-1). Prolapse development is multifactorial, with vaginal childbirth and increasing body mass index as the most consistent risk factors (Table 14-1). Patients at a young age are at higher risk for prolapse recurrence following surgery and a lower overall risk from surgery compared with older women (Table 14-2).1-4

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FIGURE 14-1

Diagram of pelvic organ prolapse of the uterus and vagina.

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Table Graphic Jump Location
Table 14-1

Established and Potential Risk Factors for Pelvic Organ Prolapse

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Table Graphic Jump Location
Table 14-2

Risk Factors for Recurrent Pelvic Organ Prolapse following Surgery

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