Brief Overview
Pelvic floor prolapse is also commonly referred to as pelvic organ prolapse (POP). It occurs when one or more pelvic organs (bladder, urethra, uterus, or rectum) depart from their usual anatomic alignment and bulge out against the vaginal vault. Prolapse can be so severe that the afflicted area extends into the vaginal canal. Underlying POP is a weakness of the pelvic organ-supporting pelvic floor muscles and tissue. According to Grzybowska et al. (2019) afflicts up to half of all mothers and results in various pelvic, bladder, colorectal, and sexual complaints. A pelvic exam can reveal the exact level of POP. Since treatment for urine or fecal symptoms is often integrated with a prescription for POP, a medical history is particularly helpful to elicit related symptoms. Asymptomatic POP may go away on its own without therapy. Its diagnosis, treatment, and management are based on evidence-based data as described below.
POP Pathophysiology
One of the most common and debilitating medical conditions among women is POP. Prolapse’s etiology is complex, and no single mechanism can explain everything that goes on during the disease process. POP’s pathophysiology is complicated and still being studied. Pathophysiology of POP has been linked to the genital tract and endopelvic smooth muscle (SM), which supports the pelvic viscera. An understanding of the pelvic floor subdivisions aids in comprehending POP pathophysiology.
The pubic symphysis ventrally, the perineal membrane caudally, the levator ani laterally, all border the anterior compartment. Levator ani muscles are found on either side and caudally of the sacrum in the posterior compartment. Ventrally, the rectovaginal fascia is an unfinished layer. The perineal body forms the ventrocaudal boundary. The ventrally reported limits of the middle compartment do not exist. The perineal body and the levator ani muscles are located caudally and laterally, respectively (Gao et al., 2019). There is a dorsal boundary made up of the rectovaginal fascia.
Premature descent of the anterior, rear, and/or apical vaginal compartment(s) with one or more pelvic organ(s) protruding into the vagina is classified as pelvic organ prolapse. Degradation of structural support for the pelvic organs causes these pathological alterations, which have a negative influence on women’s quality of life (Weintraub et al., 2020). Injury and degeneration to the muscles, neurotransmitters, and connective tissue that support the pelvic floor and its contents create these problems. POP may be identified from tightness or pressure in the pelvic region, a backache in the lower back, and excruciating sex (Weintraub et al., 2020). A physical examination may reveal the part of the pelvic floor bulging into the vagina.
Patients with POP may experience urination symptoms such as SUI, trouble voiding, the feeling that the bladder is not emptied enough, urinary frequency, urgency, or nocturia. Urinary symptoms can be hidden by certain types of POP. POP-related bowel symptoms can include defecation pain, fecal incontinence, or other forms of defecatory dysfunction (Weintraub et al., 2020). It’s not uncommon for a woman with a rectocele to say she defecates more easily if she presses between her vagina and rectum.
Primary Diagnosis
Pelvic organ prolapse is diagnosed by taking a medical history and performing a pelvic exam. When a patient has a full medical examination, a simple pelvic exam is usually enough to detect POP. The different portions of the vagina are examined with a Speculum to find out which part of the vagina is prolapsing and how much (Gao et al., 2019). These pelvic floor exercises are used to analyze how well your bladder works some tests are performed using a standard manner, such as checking to see if a person’s bladder leaks when it is reinserted during a physical exam. Other examinations could determine how quickly and completely the bladder empties. During your physical examination, you may also perform pelvic muscles strength tests to see how strong the patient’s pelvic floor and sphincter muscles are.
The muscles and ligaments that support the uterus, rectum, urethra, and bladder are put to the test during this procedure. According to Kershaw and Jha (2021), POP diagnosis also relies heavily on MRI and ultrasound technology. In severe cases, an MRI makes use of a magnetic field and radio waves to provide detailed images of the pelvis. In the end, ultrasound imaging utilizes high-frequency sound signals to produce images of the kidneys, bladder, and the muscles around the anus of a patient.
Differential Diagnoses
Although POP may seem rather unique in its clinical portrayal, there have been cases where POP has been misdiagnosed with other illnesses. Considerations while noticing bulging symptoms at an office visit include vaginal cysts, the extension of the cervix, and a big urethral diverticulum. Vaginal/Bartholin cysts are lumps found in the vaginal walls that seem to protrude from the surface. They are painful and cause difficulties walking and defecating, thereby making it easy to be confused with POP (Gao et al., 2019). Cervix extension is a condition closely related to POP since both are caused by childbirth as one major factor.
It is extremely rare for a urethral diverticulum (UD) to occur along the urinary canal’s tube, which is responsible for carrying urine (pee) out of the body. The majority of UD cases are female, and symptoms might include pain, recurrent UTIs, blood in the urine, and incontinence (Weintraub et al., 2020). These symptoms are similar to those resulting from POP, further explaining why the two may be confused with each other.
Evidence-Based Diagnosis Plan for POP
The prevalence and severity of POP among aged women can be limited through evidence-based diagnosis. Diagnosis is among the top activities in the POP management process and if done well, can effectively inform POP care. The evidence generated from past literature and studies can inform healthcare professionals about the need to develop new techniques of diagnosis. From the research done by Cundiff et al. (2018), the patient-physician relationship is a determining factor in eh quality of care.
The evidence-based diagnosis also limits the occurrence of errors and increases the effectiveness of the care plan. For this reason, POP diagnosis follows a prescribed sequence of activities all geared towards the quality of care for older women (Kershaw & Jha, 2021). First, communication is at the center of diagnosis and should be enforced at every stage. This means that before a physician can conduct any tests on the patient, they need to inform them about the condition and explain all possible diagnoses. Second, consent must be obtained before conducting any tests or prescribing any medication to patients. Lastly, every medical practitioner working with old women in POP diagnosis should be guided by the value of integrity and quality of care. Every step is taken with the patient in mind and every possible intervention considered that could facilitate recovery.
To eliminate the confusion between primary and differential diagnoses, the physician should record all symptoms noting how they relate to each other. According to Kershaw and Jha (2021), electronic records help in faster information recovery, in this case, retrieval of a patient’s medical history. From the medical history, all possibilities are ruled out and the best course of action taken. Re-tests are also done to prevent misdiagnosis, which could be fatal. Physical examinations, blood tests, and, in severe cases, MRI should be done and repeated before a doctor can give a final verdict of the illness.
Evidence-Based Management Plan
Pharmacology
In some cases, patients with POP will not receive treatment until their symptoms become unbearable. Conservative therapy is often prioritized before patients turn to surgery for additional support, especially for people with mild-to-moderate POP who wish to have a child but are physically fragile or otherwise unfit for surgery. Nonsurgical and nonpharmacological therapy, such as lifestyle changes, medical equipment, and physical therapies are classified as conservative interventions in the IUGA/ICS report (Gao et al., 2019). Weight loss and avoiding strenuous activities like heavy lifting or coughing are the most common lifestyle strategies. Support pessaries and space-filling pessaries are currently the most popular devices. Psychological treatments mostly consist of cognitive-behavioral therapy (CBT), pelvic floor exercises (PFT), bowel habit training (BHT), biofeedback, and electrical muscle stimulation (EMS), among other things.
Education
Evidence-based care is preceded by patient and nurses education to provide a comprehensive outlook of the problem and aid in the diagnosis, treatment, medical adherence, and, eventually, complete recovery. Patients need to be educated on the factors leading to POP and how they can avoid the risk factors. They need to understand that old age is one of the causes of POP and it cannot be prevented. With this knowledge, they will be confident when seeking medical intervention and cooperative in receiving the medication prescribed.
Medical practitioners also need to be educated on the need for effective, timely, and fact-based communication with patients. They need to learn that although they may have comprehensive knowledge about the condition, effective treatment depends on the patient-physician relationship (Weintraub et al., 2020). Again, they need to be equipped with up-to-date information on POP and technological interventions to aid in quick and effective diagnosis and treatment. Lastly, feedback should be maintained between patients and physicians to facilitate the implementation of change that will contribute to effective treatment.
Follow-up and Referrals
Follow-ups and referrals are two main areas that can ensure patients’ adherence to medication and facilitate recovery. In this case, it is important to consider people’s culture. For instance, when working with Muslim patients, it is important to know that they maintain distance between men and women. In this case, one may refer the patient to the appropriate caregiver in line with their cultural practices. Again, there are instances when a patient’s financial situation may limit them from getting comprehensive help from a given facility. Caregivers should always refer them to the most relevant facility within their means.
Evidence-Base Algorithm for POP Care
The proposed algorithm is based upon a thorough preoperative evaluation with a unified diagnosis among the specialists. It leads to the combination of various surgical procedures while taking into account the benefits and drawbacks that may affect the outcome (Cundiff et al., 2018). The suggested algorithm provides a surgical picture of complex pelvic floor problems that are integrated. It demonstrates how it is possible to combine surgical treatments for different compartments to achieve good morphological and functional results in the pelvic floor, increasing the patients’ quality of life.
Questions
- Q1. How can POP be misdiagnosed?
- Q2. How can patients be educated to facilitate their self-care and quick recovery?
- Q3. What information do patients and physicians need to facilitate the quality of POP care?
References
Cundiff, G., Quinlan, D., van Rensburg, J., & Slack, M. (2018). Foundation for an evidence-informed algorithm for treating pelvic floor mesh complications: a review. BJOG: An International Journal of Obstetrics & Gynaecology, 125(8), 1026-1037.
Gao, Y., Zhao, Z., Yang, Y., Zhang, M., Wu, J., & Miao, Y. (2019). Diagnostic value of pelvic floor ultrasonography for diagnosis of pelvic organ prolapse: a systematic review.International Urogynecology Journal, 31(1), 15-33.
Grzybowska, M., Futyma, K., & Wydra, D. (2019). Identification of the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire—IUGA Revised (PISQ-IR) Cutoff Scores for Impaired Sexual Function in Women with Pelvic Floor Disorders. Journal of Clinical Medicine, 9(1), 13.
Kershaw, V., & Jha, S. (2021). Pharmacological and Surgical Management. Sexual Function and Pelvic Floor Dysfunction, 167-182.
Weintraub, A., Glinter, H., & Marcus-Braun, N. (2020). Narrative review of the epidemiology, diagnosis and pathophysiology of pelvic organ prolapse.International Braz J Urol, 46(1), 5-14.