1.3 Diagnosing POP
POP is a long since well-known condition and there have been several staging systems over the years. These staging systems are used to quantify the severity of POP. Today Pelvic Organ Prolapse Quantification system (POP-Q) is the one most frequently used by researchers. POP-Q was first used in 2002 and although often used there is still no fully universal choice among clinicians and researcher. The purpose of POP-Q is to have a system that can objectively describe, quantify and tell the stage of prolapse. By measuring six different defined points in the vagina the outcome is graded on a scale from 0 to 4 (see Table I) (8)
Table I. Pelvic Organ Prolapse Quantification system (POP-Q), stages of severity
Stage 0 No prolapse is demonstrated
Stage 1 The most distal portion of the prolapse is more than 1 cm above the level of the hymen
Stage 2 The most distal portion of the prolapse is 1 cm or less proximal or distal to the hymenal plane
Stage 3 The most distal portion of the prolapse protrudes more than 1 cm below the hymen but no farther than 2 cm less than the total vaginal length (not all of the vagina has prolapsed)
Stage 4 Vaginal eversion is essentially complete
1.4 Treating and coping methods
POP is not life threatening but can have serious effects on QoL, cause inactivity and have a negative effect on the general health of a woman (2). There are ways of treating and coping with POP. The different therapies can be divided into two groups, either surgical or conservative methods. POP surgery aims to strengthen or re-attach prolapsed organs in their original place. The re-stitching of prolapsed organs is often the primarily used surgical method (3). One in ten women is expected to have had POP surgery by the age of 80 (4). However, there is a recurrence rate of 58 % in women who have surgically treated POP (9). One third of women who have POP surgery undergo at least one more surgery (10). The second surgical option is often to insert a type of vaginal mesh to strengthen the pelvic floor itself. This is a fairly new technique. There have been reports of continued problems after the surgery such as: persistent pains, sexual problems, mesh exposure through vaginal tissue and occasional injury to nearby organs such as bowel and bladder (4). Pelvic floor surgery is an invasive treatment and can ironically enough cause damage to PFM. Surgery can therefore increase the risk of pelvic floor dysfunction (11). Surgeries can also increase the risk of infections, pain and inactivity, and not all women are eligible (4). Affected women who are planning on having more children are usually advised to wait until after their last pregnancy (12).
Although surgery is a common method for treating POP there are several conservative methods that can help patients (4). These methods strive to enable coping, boost the effects of surgery or treat the original cause of POP. Behavioral methods are administered to diagnosed or undiagnosed high-risk patients. This includes lifestyle adjustments and use of proper technique (coping strategies) when performing activities that increases abdominal pressure. Such strategies might be kneeling instead of squatting, avoiding heavy lifting and using “the knack”. “The knack” is a muscle contraction maneuver that is used before and during activities that increase abdominal pressure. It is a contraction of PFM and can be described as an attempt to stop urination. As previously mentioned these methods are coping strategies and will not treat POP (13). Other therapies with varying effects and target groups include: mechanical like pessaries, and hormonal strategies such as hormone replacement therapy (HRT) . Pessaries create a mechanical barrier that prevents the pelvic organs from prolapsing, while HRT is a type of estrogen treatment and is only available to postmenopausal women (4). Finally there is the option of physical therapy. One of the aims of physical therapy is to strengthen PFM. There are several types of training that claim to achieve this, such as yoga, Kegel exercises, Pilates, horseback riding, Ben Wa balls etc. Training that aim to strengthen PFM is in this review referred to as pelvic floor muscle training (PFMT). There has been little research done on the effect of PFMT programs and these programs compared to other medical therapies in short and long term.
1.5 Class, affordability and cost-effectiveness
POP, just like health in general is a class related issue (14). It is often related to stigma, shame and social isolation (2). Lack of treatment and the effects POP might have on QoL are often much higher in low- and middle-income countries. As mentioned above it is hard to establish a prevalence rate. A review from 2010 showed that the mean prevalence of POP in low- to lower middle-income countries was 19.7 % with a range between 3.4 – 56.4 % (15). However, we can determine that POP is a common health condition amongst women worldwide. There is a need to find safe, simple, cost-effective and affordable ways of treatment in order to reach as many women as possible (12).
To make an appointment with Anna Wallin specialist in women’s health please call the clinic on 020 8546 6464.