The POP surprise of the pelvic organs
A prolapse is any descent into the pelvic floor or perineum of part of the bladder, uterus, rectum, or bowel loops through the vagina. It is a common condition that up to 40% of multiparous women can suffer from, that is, women who have had several births.
In addition to the logical alarm, the first effect that occurs in women is the fear of suspecting that it may be a malignant tumor.
«But it is not cancer, just a benign physical process that must always be studied in depth», he highlights.
Patients face a pathology that causes very uncomfortable sensations depending on the intensity of the prolapse: they notice heaviness, something that rubs against them when walking or sitting, without ruling out the possibility of seeing blood or secretions in their underwear.
“There are women in whom the prolapse is barely perceptible; in others it may be felt or seen with the help of a mirror; and some see it and touch it, even having to insert it to be able to urinate or defecate », she specifies.
“The prolapse not only causes urinary or faecal incontinence, voiding difficulty or constipation, but also hinders or causes pain in sexual intercourse.”
Dr. Carmen González Enguita
Pelvic organ prolapse (POP) thus becomes a problem that also concerns other medical specialties, such as gynecology, coloproctology and pelvic floor rehabilitation or physiotherapy.
The origin of pelvic organ prolapse
The main risk factors involved in the appearance of prolapse will be determined by the age of the patient, since they are more frequent after menopause, even more so in the stage of senility.
“Hormonal changes in menopause affect the support capacity of tissues and aging causes muscle weakness,” explains the urologist and surgeon at Jiménez Díaz.
Multiple births will influence, with greater assessment if they have been traumatic; the obesity; the physical work carried out throughout his life; and also the poor quality of the tissues of their physiology.
“Collagen diseases are sometimes family (genetic), or acquired,” he clarifies.
Therefore, we can see that there are:
Predisposing Factors: being a woman, neurological and anatomical factors, muscular pathology, collagen physiology and environmental factors.
Stimulating Factors: childbirth, neurological or muscular injury, tissue fracture, radical surgery or pelvic floor radiation. They incite or cause the prolapse to happen.
Promoting Factors: obesity, smoking, chronic cough, lung diseases, menopause, infections, certain medications, constipation, certain professions, recreation and leisure activities. They promote their appearance.
Decompensating Factors: aging, dementia, weakness, being sick and also some medications. They cause a destabilizing situation that favors their appearance.
“Its origin is basically multifactorial, with which we can be before defective tissues, subjected to normal abdominal pressure, or normal tissues subjected to high abdominal pressure, chronically,” he explains.
Dr. González Enguita uses the simile of the hammock to explain it to her patients
“The bones, the muscles with their fasciae and the ligaments of the pelvis form a ‘hammock’ in the lower part of the abdomen, in the pelvic area.
This hammock supports and sustains viscera such as the intestinal loops, the uterus or the bottom of the vaginal sac in the case of hysterectomy -removed uterus-, the bladder and the rectum, preventing them from exiting the body.
If our imaginary hammock does not have the right tension (too much or too little), its support will be compromised. And even more, if in the center of that hammock there is a hole larger than usual (which would correspond to the vaginal hiatus), with the addition that the fabric of the hammock is very deteriorated, the visceral support will clearly be inefficient. .
Continuing with the example of our hammock, it would also be as if we tried to stand on said fabric.
In this way, a rope that would hold our arms tied to the palm trees would increase the chances of staying upright in the hammock. If these ropes were to lose tension or break, it would be very likely that we would fall to the ground sooner rather than later.
The set of circumstances that cause POP, natural or provoked, determine that these structures can be weakened and the organs that support them descend and can be displaced from their normal anatomical situation.
«The organs prolapse, but they are not the protagonists. In general, the bladder, uterus, or rectum are healthy. The cause is in the ligaments, the fasciae that keep them in place, which acts as support and sustenance”, emphasizes the specialist.
Two women talk over coffee sitting on a street bench in the Poblenou neighborhood of Barcelona. EFE/Marta Perez
Diagnosis of the POP woman
Pelvic organ prolapse is a global problem that affects the entire pelvic floor, and even if POP predominates in one compartment, for example the anterior one, and it is the bladder that descends, all three compartments must always be well explored.
“Looking for causes and solutions, we may find that there are anatomical and functional alterations either in the middle compartment, where the uterus is, or in the posterior compartment, where the rectum is located,” he mentions.
To which specialist should a woman go to diagnose and treat this POP pathology?
«It is very curious -he highlights-, because although the first contact is usually in gynecologyfrom that consultation many patients are oriented towards the urology if what predominates is the descent of the bladder (cystocele) and towards coloproctology if what predominates is the prolapse of the rectum (rectocele).
Sometimes, the gateway for these patients to the health system are the Health Care Units. pelvic floor that have the Rehabilitation and Physiotherapy Services.
“But the most important thing is to go to a specialist who has the appropriate training so that they can make an assessment and have a global vision of the pathology,” advises Dr. González Enguita.
The experts in this pathology reiterate over and over again that there is never a single organic defect or damage, but that the problems caused by POP are multiple, and therefore the vision must be comprehensive.
For a good diagnosis of the origin of the prolapse, a detailed medical history must be taken, followed by a very good physical examination.
«The clinical history, anamnesis, allows us to know in depth the woman’s past, fundamentally at the gynecological level, pregnancies and childbirth. Also, the symptoms produced by the prolapse and how they affect the patient’s quality of life, identify possible alterations in the functioning of the way of urinating, defecating or problems with sexual relations.
Dr. Carmen González Enguita
Physical examination enables the observation and palpation of the organs that are involved in the prolapse. At this time, the strength of the pelvic floor muscles is also evaluated.
“With a full bladder, and an urge to urinate, the woman should be examined to determine if POP is accompanied by urine loss. Sometimes, despite the fact that the patient has told us that she does not leak urine, when reducing the prolapse manually we discover that she does leak urine. It is what we call an occult urinary incontinence, ”she describes.
The conclusion is, therefore, multidisciplinary: health personnel from different medical specialties, interrelated, who approach the same problem from different points of view.
«The objective is none other than to improve the quality of life of women by assessing all the converging aspects that guide to the best treatment. We must solve as soon as possible the anatomical changes and the dysfunctionality of the organs affected by the prolapse».Doctor and surgeon Carmen González Enguita, head of the Urology Service of the Fundación Jiménez Díaz University Hospital
In chapter II of pelvic organ prolapse we will talk about POP treatments
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