Pelvic Floor Prolapse: Cause and Effect

Pelvic floor prolapse or pelvic organ prolapse (POP) ( Fig. 5.1 ) is a common but poorly understood condition affecting millions of women worldwide. In the United States, the lifetime risk of undergoing surgery for POP or urinary incontinence is estimated to be 11%, and nearly 30% of these patients require another operation for recurrence [1] . The Women’s Health Initiative (WHI) data revealed that approximately 40% of women had some form of POP [2] . This difference in rates of prolapse between surgical patients and patients being seen for routine gynecologic examinations reflects the often asymptomatic presentation of prolapse [3] . Understanding the progression of this disease may allow clinicians to apply more appropriate treatment to patients depending on the etiology of their prolapse and their symptoms. Despite the prevalence of POP, little is known regarding the mechanism for development and natural history of the disease. Much of this stems from the lack of a clear and standardized definition for POP, which limits our ability to study its etiologies. A conference on terminology assembled by the National Institutes of Health (NIH) recently focused on developing clear definitions for POP to foster more epidemiological research into the disease [4] . These studies are forthcoming, but with a 45% increase over 30 years in demand for services related to pelvic floor dysfunction, our understanding of its development will become important in meeting the treatment needs of the future [5] . Successful treatment will require the identification and management of risk factors that could potentially be involved in the development of POP. In order to recognize risk factors for POP, a thorough understanding of pelvic anatomy is needed. As the female pelvis evolved from quadruped ambulation to bipedalism, supportive structures adapted to support pelvic viscera and enable parturition (see Chapter 4, Three-Dimensional surgical anatomy). Activities and events that are shaped by a bipedal lifestyle can contribute to failures in the supportive structure of the pelvis that can lead to POP. Maintaining or rehabilitating levator muscle bulk and strength may be the key to preventing many cases of pelvic organ prolapse [6] . Just as humans evolve, so too do the signs and symptoms of POP. Research into the evolution of POP should focus on the anatomical disruptions predisposed to by specific risk factors and physical insults to the female pelvis. It is not uncommon for urinary incontinence, fecal incontinence, and POP to coexist because of their anatomical relationships and common risk factors ( Fig. 5.2 ) . In this chapter we will focus specifically on the cause and effect of pelvic organ prolapse.