Female Pelvic Prolapse Calls for a Multi-Disciplinary Approach

Pelvic organ prolapse (POP) affects up to 50% women in their lifetime, and the loss of tone that causes prolapse of one organ raises risks for prolapse in others as well. Like POP itself, multi-compartment pelvic organ prolapse is common, especially as women age, but the condition isn’t always investigated when a person seeks care for prolapse symptoms.

Rectal prolapse occurs when the rectum comes out through the anus. Pelvic organ prolapse occurs when the top of the vagina or uterus falls through the vaginal canal and bulges out of the vagina, or when the top wall of the vagina, which supports the bladder, or the bottom wall of the vagina, which supports the rectum, start to fall into the vagina. Pelvic organ prolapse typically is addressed by urogynecologists and female urologists, while rectal prolapse is addressed by colorectal surgeons. Since multi-compartment prolapse is common, a multidisciplinary approach is important.

At a clinic specializing in multidisciplinary care for multi-compartment pelvic floor prolapse, Cleveland Clinic physicians prioritize thorough patient histories, appropriate testing and accurate prolapse staging in order to optimize outcomes and improve patient quality of life. Urogynecologist Shannon Wallace, MD, who specializes in pelvic floor disorders at Cleveland Clinic’s Obstetrics and Gynecology Institute, describes the approach that she and colorectal surgeon Anna Spivak, DO, take with patients who have multi-compartment pelvic floor prolapse.

The first step is, of course, to identify the condition. "We think of the pelvis as a bowl,” says Dr. Wallace. “Tissue weakness there can be caused by age, vaginal delivery, obesity, connective-tissue disorders — there are lots of risk factors for prolapse. When you have weakening of these tissues, you can have any of pelvic organs fall.”

Prolapse-vulnerable areas are:

• the anterior vaginal wall
• the posterior vaginal wall
• the uterus
• the rectum

“Many different things can happen in the pelvis, and they present a little bit differently. How they present usually leads us into who they end up seeing,” Dr. Wallace says.

The vaginal bulge that can indicate bladder or anterior vaginal prolapse, as well as overactive bladder or incomplete bladder sensations, often send patients to a urogynecologist or a female urologist. Pressure that may accompany uterine prolapse also typically sends patients to a urogynecologist. The rectal wall can balloon into the vagina (rectocele) or slump down on itself (intussusception), which can cause patients to experience vaginal bulge, incomplete bowel evacuation and incontinence. If prolapse is severe, the rectum may protrude from the anus and patients can develop rectal prolapse. These patients tend to seek help from a urogynecologist, colorectal surgeon or gastroenterologist.

Historically, clinicians often have offered treatments appropriate for prolapse in one compartment without considering the rest of the pelvis, but that is changing.

“In the last 10 to 15 years, there has been a growing recognition that if you repair one compartment and you don't repair another, that other compartment could get worse,” says Dr. Wallace. “For example, if a colorectal surgeon sees rectal intussusception or rectal prolapse, they might do perineal repair or potentially an abdominal rectopexy with mesh or suture to lift everything up. But if there's undiagnosed uterine or bladder prolapse, that can get significantly worse after the surgery, because you're changing the forces in the pelvis. You can fix a bladder prolapse or fix a uterine prolapse but if you don't address a possible rectal prolapse, the patient’s defecatory symptoms can get worse.”

Screening has improved in both gynecologic and colorectal fields to determine the scope of needed repairs and whether to include clinicians from the other specialty, she adds, so that surgical repairs can be done together, when appropriate.

Multi-disciplinary care

Drs. Wallace and Spivak collaborate in cases referred by urogynecology or colorectal practitioners within Cleveland Clinic and across the country. “We do patient consults together, examine patients together, take patient histories together. We counsel patients together about their surgical options,” says Dr. Wallace. “The majority of the time, if they're appropriate candidates for multi-compartment surgery, we discuss with them the surgeries we do together. Sometimes they're candidates for more conservative management, such as with physical therapy, dietary changes and improved toileting habits or they may need different treatment options such as a sacral neuromodulation device or pessary. And then we each talk about that in relation to their symptoms.”

Care begins with a thorough history, including a focus on bowel-related issues.

"Optimization of bowel function is huge for our patients, because constipation itself is the biggest risk factor. We get a very important history of their bowel function and urinary function and then do an exam,” she says.

For more complex cases, the doctors may order x-ray defecography (see image) to capture rectal folds or anorectal manometry and assess how the anal and rectal muscles are working together.

“Most of the time we're looking for rectal intussusception. We're also looking for a large rectocele, as well as an enterocele, where the small bowel slips down between the vagina and the rectum,” Dr. Wallace says. “It can create a lot of pressure, but you can't see it on physical exam. That’s also true when the sigmoid falls in on itself, creating pelvic pressure, discomfort and obstructive defecation.”

If a patient has a history of constipation, and it is unclear whether it is caused by prolapse or slow-transit constipation, bowel-function tests may be ordered. For vaginal prolapse, the team measures the stages of vaginal prolapse. The team also may perform urinary stress incontinence, which can indicate whether the urethra is weak and should be addressed during surgery.

For most patients seeking surgical interventions for multi-compartment POP, Drs. Wallace and Spivak favor minimally invasive surgeries through the abdomen: ventral mesh rectopexy to repair rectal prolapse and sacrocolpopexy to address the gynecologic anatomy. Altemeier and Delorme surgeries, which use the perineum for access to repair rectal prolapse, often lead to recurrence, Dr. Wallace says. The procedures might be appropriate for patients who are frail, but for most healthy patients, the abdominal approach offers superior results with higher resolution of symptoms and reduction of recurrence.

Education and counseling

In general, says Dr. Wallace, the better educated clinicians are about multi-compartment POP, the better the outcomes are likely to be for their patients.

“It's a matter of re-educating everybody on screening patients for bowel symptoms, urinary symptoms and vaginal symptoms to make sure that the patient has been worked up appropriately before any sort of pelvic surgery is done,” Dr. Wallace says. “You don’t want to miss something.”

Patient education should include information about lifestyle and risk mitigation.

“Patient optimization for surgery is very important. Risk factors for prolapse recurrence or poorer outcomes are going to be obesity, diabetes and constipation. We try to counsel our patients about weight-loss strategies and getting their diabetes under good control,” she says. “As we get older, we get constipated. So we want to make sure you’re getting enough fiber and water. We strongly recommend daily fiber supplementation and good water intake to reduce straining and lower the risk of developing prolapse.”

In addition to risk, the team makes sure patients fully understand the potential outcomes of surgery. While the goal is to improve symptoms, patients might experience residual symptoms. If they do, other remedies are available, says Dr. Wallace.

“The big thing is to tell patients that while surgery may not be a 100% curative, it should improve your quality of life.”