Procidentia – Causes, Symptoms, Diagnosis, Treatment

Procidentia is a severe form of pelvic organ prolapse (POP) that includes herniation of the anterior, posterior, and apical vaginal compartments through the vaginal introitus. Pelvic organ prolapse can include all three compartments, such as in Providencia, or individual compartments. When the anterior vaginal compartment herniates through the vaginal introitus, this is a cystocele. When the posterior vaginal compartment is herniating through the vaginal introitus, this is a rectocele. When the apical vaginal compartment is herniating through the vaginal introitus, this area can include bowel or uterus, describing an enterocele or uterovaginal prolapse respectively.

The first recorded documentation of pelvic organ prolapse dates back to 1550 BC in the Egyptian medical papyrus of herbal knowledge, Ebers Papyrus.[rx]

Historical management of prolapse varied, including acts of manual manipulating of the prolapsed organ, cleansing the prolapsed organ with oils and wines, and inhaling malodorous fumes.[rx]

Hippocrates also described a process termed succession, which was a maneuver that placed women upside down on a ladder while the ladder frame moved up and down with the hopes that gravity would restore the pelvic organs to their anatomical position.[rx][rx][rx]

There have even been multiple reports of primitive vaginal hysterectomies. The most commonly quoted was performed by Soranus of Rome during the 1st century when he completed a vaginal hysterectomy on a gangrenous uterus.[rx][rx] However, credit for the first vaginal hysterectomy goes to Capri during the beginning of the 16th century for performing the first partial vaginal hysterectomy for pelvic organ prolapse.[rx]

Prolapse is not usually painful or life-threatening, but symptoms can impact daily activity, body image, and sexuality to the point of desperation as exemplified when a peasant women in the 17th century took a sharp knife to her own uterine prolapse and cut what she thought was a polypoid growth from her vagina. Her bleeding eventually stopped, and reportedly she lived for many years with urinary incontinence likely from a vesicovaginal fistula.[rx][rx]

Over the 19 and 20 century, improvements in surgical instrumentation, anesthesia, and antibiotics decreased the morbidity rates of performing hysterectomies. This article covers the etiology, epidemiology, differential diagnosis, and treatment options for pelvic organ prolapse.

Causes of Procidentia

Multiple medical conditions and risk factors have been cited as causes for pelvic organ prolapse. Defects in the pelvic anatomy, with enlarged uteri from leiomyoma and endometriosis, and pregnancy with vaginal delivery, have been reported to be an associated risk factor for pelvic organ prolapse.[rx][rx] Extrinsic risk factors for pelvic organ prolapse included smoking and obesity.[rx]

Symptoms of Procidentia

Symptoms of nonrelaxing pelvic floor dysfunction are associated with

• Avoiding dysfunction,
• Anorectal dysfunction,
• Sexual dysfunction, and pain.
• Symptoms tend to develop slowly and insidiously; for some patients, they may begin in childhood (eg, defecatory disorders).
• Difficulty evacuating stool or straining with bowel movements, a sense of incomplete evacuation, bloating, and constipation are bowel symptoms characteristic of non relaxing pelvic floor dysfunction.
• Urinary symptoms include frequency, hesitancy, urgency, dysuria, bladder pain, and sometimes urge incontinence. Insertional or deep dyspareunia, a pelvic ache after intercourse, low back pain radiating to the thighs or groin, and pelvic pain unrelated to intercourse are also common.
• It is important to inquire about the range of symptoms that may suggest nonrelaxing or hypertonic pelvic floor dysfunction in women who present with bowel, bladder, or sexual concerns.
• urinary issues, such as the urge to urinate or painful urination
• constipation or bowel strains
• lower back pain
• pain in the pelvic region, genitals, or rectum
• discomfort during sexual intercourse for women
• pressure in the pelvic region or rectum
• muscle spasms in the pelvis

Diagnosis of Procidentia

History and Physical

The most common symptom patients report is a feeling of fullness or a bulge protruding from the vagina; This usually occurs gradually and is noticed over time. Sometimes it is incidentally diagnosed on a physical exam at annually gynecological exams. Patients that have prolapse should also undergo assessment for any other urogynecological issues. Among those with prolapse, 40% will have concurrent stress urinary incontinence, 37% will have overactive bladder, and 50% will have fecal incontinence.  Patients may report a dynamic change in their symptoms throughout the day. Most prolapse symptoms are less noticeable to the patient upon first rising, but after various levels of activity such as lifting, straining, or standing the bulging sensation may worsen. When procidentia occurs with complete uterine prolapse, chafing and epithelial erosions are also sometimes noted as the internal vaginal mucosa is now excessively exposed to friction.[rx]

Evaluation

Diagnosis of prolapse has usually been by physical exam. Laboratory and imaging are not routinely needed. Since 1996, the International Continence Society (ICS), the American Urogynecologic Society (AUG), and the Society of Gynecologic Surgeons (SGS) agreed on the Pelvic Organ Prolapse Quantification system (POP-Q) examination. Previously other conventional evaluation methods, including the Baden-Walker Grading System, were in use.[rx] Although the POP-Q test is hard to teach, it is a reproducible examination that has found application in both clinical and research practices. There are five stages of prolapse.  The examiner measures specific points of the vaginal vault in relationship to the hymen during the POP-Q examination that help identify which portion of the pelvis is prolapsing.

• Stage 0 – No prolapse demonstrated
• Stage 1 – The most distal portion of the prolapse is more than 1cm above the hymen level
• Stage 2 – The distal-most portion of the prolapse is between 1cm above the hymen and 1cm below the hymen level
• Stage 3 – The distal-most portion of the prolapse is more than 1cm below the hymen, but not completely everted
• Stage 4 – There is a complete eversion of the uterus

Procidentia is a stage 4 prolapse. Most women who become symptomatic from their prolapse are usually at stage 2 or higher.[rx]

Treatment of Procidentia

The general condition of prolapse, even to the extent of Providencia, is not life-threatening. The treatment has its basis in the severity of the individual patient’s symptomology. For those who have an incidental diagnosis of prolapse and are not symptomatic, observation and pelvic floor muscle training are reasonable options.[rx] However, there is no guarantee that prolapse will improve, stay the same, or worsen over time.

For patients who are symptomatic, but do not wish to proceed with surgery or are not surgical candidates, pessaries have often been an option. Pessaries are usually silicone-based products fitted for a patient’s specific type of prolapse. There is a multitude of sizes and shapes. Examples for usage include young women desiring future pregnancies with symptomatic prolapse, elderly females with chronic medical issues that contraindicate anesthesia, patients wanting medical treatment, etc.[rx]

Surgical options depend on many factors including the stage of prolapse, vaginal length, hormonal status, desires for further coitus, concurrent urinary or bowel dysfunctions, etc.[rx] There have been multiple studies comparing the differences in surgical techniques for pelvic floor repair with one multi-institutional study with women aged 70 to 80 years requesting surgical management having an overall comparable recovery time, anatomical success rate, and patient satisfaction with sacrocolpopexy, native tissue repair, and vaginal mesh repair.[rx] The International Federation of Gynecology and Obstetrics (FIGO) Working Group studied different surgical procedures and their efficacy comparable to their cost-benefit profile. Pessary usage has the lowest complication rate and cost-benefit profile. For vaginal surgeries, the sacrospinous ligament fixation and uterosacral ligament suspension showed comparable results. For abdominal surgeries, the minimally invasive approach with sacrocolpopexy had good durability and quality of life with the least amount of complications.[rx]