Pelvic Organ Prolapse (POP)

What does it mean to have pelvic organ prolapse ?

Pelvic organ prolapse, often referred to as “fallen bladder”, is a problem of the connective tissue and support ligaments of the vagina and uterus. It may affect up to 40% of women and nearly 18% of women will have surgery for this problem at some time in their lives. While it is a benign (i.e. non-cancerous) condition, pelvic organ prolapse can be very uncomfortable and may also affect urinary and bowel habits. One of the most common complaints related to pelvic organ prolapse is noticing pressure or feeling a bulge in the vagina and some women will push this “bulge” back into the vagina to help urinate or have a bowel movement (this is called stenting). Not all women who have pelvic organ prolapse are symptomatic.

Pelvic organ prolapse is diagnosed and “staged” for severity based on a pelvic examination. Often women will bring this problem to the attention of their physician when they feel or see the vaginal wall bulging to or past the vaginal opening. Pelvic organ prolapse can also be diagnosed at the time of routine pelvic examination with a primary care physician (general physician or ob/gyn). While this condition may be seen on some radiologic studies, these generally are not necessary to accurately evaluate the problem. Your urogynecologist may ask to examine you both while laying down and standing if they have any questions regarding the severity of the problem. Your urgynecologist may ask to have some studies performed to see if pelvic organ prolapse affects other organs like the bladder or bowel.

Yes, there are several different types and some of the most common are listed below:

Cystocele: Also called a “fallen bladder”, this is a bulge or hernia from the top wall of the vagina and also called anterior wall prolapse. This is one of the most common types of prolapse.

Rectocele: This is a break in connective tissue on the bottom wall of the vagina that faces the rectum. This is also called posterior wall prolapse and associated with a bulge from the bottom of the vagina.

Vault prolapse or uterine prolapse: This is when the uterus (or vaginal vault – where the uterus used to be) is able to move down toward the vaginal opening to a significant degree. This usually suggests that support for the uterus or vaginal vault has broken down.

Urinary Incontinence/Overactive Bladder

Urinary incontinence is any loss of urine that occurs outside of urinating in the toilet. Women frequently describe this as embarrassing or bothersome to them. Leakage amount can vary from a few drops of urine noticed in undergarments to large amounts of urine that can overflow even the heaviest of absorbency pads. There is no amount of leakage that is considered “normal” and urine leakage is not considered a normal part of aging. Evaluation and treatment for urinary incontinence is generally based on patient desire for help with the problem.

There are several different types of urine leakage and your doctor may ask for some additional testing to help clarify the specific type and extent of urinary incontinence to help guide management. This evaluation may involve the following: pelvic examination, urine culture, bladder diary, cystoscopy, urodynamic testing, and possible imaging studies.

There are several different types of urinary incontinence and description of all types is beyond the scope of this educational handout. The predominant types of leakage are:

Stress incontinence: The most common reason for women to have urinary leakage. Generally described as leakage with coughing, exercise, sneezing, or changing position. This is generally an anatomical issue related to bladder neck or urethral support.

Urge incontinence: Leakage with an urge to urinate. This occurs because of an uncontrolled bladder contraction. Although less common than stress incontinence, urge incontinence is often described as more bothersome to the individual patient.

Mixed incontinence: A combination of both stress and urge incontinence.

Overactive Bladder, or OAB, refers to the feeling of an increased urgency to urinate or increased frequency of urination (over 8 times/day or over 2 times/night). These symptoms are commonly from excessive/uncontrolled detrusor contractions (bladder muscle). Smaller contractions may lead to urgency/frequency symptoms and larger contractions may lead to leakage (urge incontinence). Overactive bladder symptoms can be very bothersome to women as the urges to urinate often come when least expected/desired.

There are many potential sources of overactive bladder symptoms:

  • uncontrolled detrusor muscle activity/idiopathic
  • bladder cancer
  • urinary tract infections
  • IC or bladder pain syndrome
  • neurologic disease (Multiple Sclerosis or similar)
  • sleep apnea
  • levator muscle dysfunction
  • cystocele/prolapse
  • foreign body in bladder

Since there are several different potential sources for overactive bladder symptoms your doctor may require additional testing to help evaluate this issue and guide management. At a minimum this evaluation will include pelvic examination, urine culture, and bladder diaries but your physician may also recommend cystoscopy, urodynamic testing, medication trials, or neurologic studies to help understand and treat this problem.

Recurrent Urinary Tract Infections in Women

Urinary tract infections happen when the urine overgrows with certain types of bacteria. Common symptoms associated with urinary tract infections can include: urinary urgency, urinary frequency, blood in the urine, pain with urination, or urinary incontinence. As we age sometimes these symptoms can change to include mental status changes (confusion) or feeling tired all the time. Rarely, urinary tract infections can involve the kidney as well (called pyelonephritis) and be associated with back pain, fever, and sometimes kidney injury. Although urinary tract infections are fairly common, it is abnormal to have 3 or more urinary tract infections in a single year.

Someone who has three or more urinary tract infections in a single year is said to have “recurrent urinary tract infections” and may be offered further evaluation and considered for preventative treatment options.

Often a patient gives a urine sample to their health care provider and is told they have a urinary tract infection based on a urinalysis which looks for changes in the urine associated with an infection. Although a urinalysis is often correct, a urine culture is frequently needed to accurately diagnose someone with a urinary tract infection. Your health care provider may prefer catheterized urine specimens to ensure the urine sample is not contaminated during collection, this may be particularly important in women diagnosed with recurrent urinary tract infections.

Each person’s situation is unique; however, women with documented recurrent urinary tract infections or other risk factors may require further evaluation of the bladder and kidneys. This evaluation may include cystoscopy and renal ultrasound or CT scan.

Yes, it is not uncommon for someone presenting with symptoms of recurrent urinary tract infections to actually have a pelvic floor or bladder disorder such as overactive bladder, interstitial cystitis, or levator muscle spasm. Symptoms of these disorders can include urinary urgency, urinary frequency, pain with urination, and/or urinary incontinence. These disorders are more likely in women with recurrent symptoms but negative urine cultures.

Ways to prevent urinary tract infections vary but a few behavioral methods are presented below:

  •  Make sure to always keep your outer vaginal area clean and only wipe from front to back when cleaning after bowel movements.
  • If you currently use spermicide containing products (especially in association with diaphragm use) you may want to consider alternate contraception.
  • Urinating after sexual relations and maintaining good fluid intake throughout the day.

Hematuria in Women

Hematuria is the finding of blood in the urine. While some people are able to see blood in their urine, most patients are only made aware of blood in the urine after a urine sample is taken with their physician.

Hematuria is diagnosed based on urine testing. Your physician will take a specimen of your urine either through a clean catch specimen (urinating into a cup) or catheterized specimen (placing a very small tube into the bladder) to get a specimen

No, there are reasons why blood can be found in the urine that isn’t coming from the bladder or kidneys. Many physicians obtain urine specimens by having patients urinate into a cup (clean catch). However, sometimes this method will allow contamination of the sample with blood that is either from the vaginal, vulvar, or anal area. Your physician may obtain a catheterized specimen directly from the bladder to remove this possible source of contamination if they believe it is merited.

There are several medical problems that can cause hematuria and these can range from simple benign reasons (urinary tract infections or excessive exercise) to more complex issues (kidney stones, interstitial cystitis, or cancer). We are not always able to find out why each person has hematuria and the reasons for most cases of hematuria are not worrisome. The evaluation for hematuria focuses on making sure that more complex processes are not present.

Women with hematuria are usually evaluated with a combination of imaging of both the lower urinary tract (bladder) and upper urinary tracts (kidneys). This is typically performed with office cystoscopy (a small camera is passed into the bladder) to look at the lining of the bladder as well as either a CT scan or renal ultrasound to evaluate the kidneys. Your physician is also likely to perform a urine cytology to look for abnormal bladder or kidney cells that may be in the urine.

Some women have persistent findings of both blood and protein in the urine. This is sometimes associated with kidney diseases that may require evaluation with a Nephrologist (an internal medicine doctor that specializes in general medical diseases of the kidney).

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