Postpartum Pelvic Organ Prolapse

Postpartum pelvic organ prolapse is descent of the bladder, uterus, rectum or vaginal vault toward or through the vaginal opening after birth, caused by stretching or injury to the pelvic floor muscles, ligaments and fascia. Some degree is found in up to 50 percent of women by examination at 6 weeks, but only a minority have symptoms. It matters because symptomatic prolapse affects bladder, bowel and sexual function, and many early prolapses improve in the first 6 to 12 months.

• Risk factors: vaginal birth, instrumental delivery, large baby, long second stage, multiparity, obesity, chronic cough, constipation, heavy lifting, family history.
• Anterior wall (cystocele) is the commonest type.
• Staged with POP-Q from 0 (no prolapse) to 4 (complete eversion).

Women report a feeling of heaviness, a vaginal bulge, dragging low back pain, incomplete emptying of the bladder or bowel, urinary leakage, and discomfort with intercourse. The bulge is worse at the end of the day.

• Visible bulge with straining.
• Splinting (pressing on the vagina) to pass urine or stool.
• Differential diagnosis: vaginal cyst, urethral diverticulum, Bartholin cyst, rectal prolapse, uterine inversion (early), cervical elongation, vaginal haematoma, fibroid polyp.
• Complications: urinary retention, urinary tract infection, vaginal ulceration, bleeding, incontinence, constipation, obstructed defaecation, sexual dysfunction, kidney obstruction in advanced prolapse.

The approach is pelvic examination and grading.

• Examination in the left lateral and standing positions with a split speculum, with the woman straining; grade each compartment (anterior, posterior, apical) by POP-Q.
• Pelvic floor muscle strength (Oxford scale 0 to 5); perineal body and sphincter integrity; rectal examination.
• Residual urine by ultrasound; urine dipstick and culture; renal ultrasound in advanced prolapse.
• Urodynamic tests where stress incontinence coexists and surgery is planned.

The principle is conservative care for the first year, with pessary and pelvic floor training, and surgery only after childbearing is complete.

• Supportive: pelvic floor muscle training (8 to 12 contractions held for 6 to 8 seconds, 3 times daily for at least 3 months); weight loss; avoid heavy lifting for 6 weeks and straining; treat constipation and cough; stop smoking; lie flat for rest periods in the day.
• Pharmacological: vaginal oestradiol 10 micrograms tablet at night for 2 weeks then twice weekly, long term, to improve tissue health and pessary tolerance; lactulose 15 mL oral 12-hourly; ispaghula husk 3.5 g oral 12-hourly with water; cefalexin 500 mg oral 6-hourly for 5 days for urinary infection.
• Procedures: ring pessary (size 3 to 5 cm, fitted by a trained provider) changed and cleaned every 3 to 6 months; replacement of prolapsed tissue and lubrication for ulcers; surgical repair (colporrhaphy, hysteropexy or sacrocolpopexy) after 12 months and after childbearing is complete, if symptoms persist despite conservative care.
• Special groups: women who want more children have conservative treatment and pessary only, and are advised on vaginal or caesarean birth in a later pregnancy; breastfeeding women use vaginal oestradiol at the lowest dose.
• Red flags: inability to pass urine, bladder or bowel obstruction, bleeding or ulceration, severe pain, kidney pain, irreducible prolapse, fever.
• Follow-up: review at 6 weeks, 3 months and 6 months with repeat POP-Q grading; referral to a urogynaecologist if symptoms persist at 12 months; pessary check every 3 to 6 months.