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Explainer: what is pelvic organ prolapse?

Little is known about pelvic organ prolapse because its symptoms are incredibly embarrassing for women. Meghana Kulkarni

Millions of Australian women experience a pelvic organ prolapse, but they suffer in silence. This hidden epidemic is a well-kept secret and few people in the rest of the community know anything about the condition.

One in four Australian women have one or more symptoms of pelvic organ prolapse. The most common one is urinary incontinence. Half of all women over 50 who’ve had children will suffer urinary incontinence, mainly because of pelvic organ prolapse. Considering these statistics, three generations of women in a family may potentially be affected at any given time – the new mum, her mum and her grandmother.

What is it?

Pelvic organ prolapse is when the muscles and ligaments supporting a woman’s pelvic organs weaken and the organs (bladder, bowel and or uterus) in the area slip out of place (or prolapse) into the vagina. The major cause is vaginal birth, but ageing, heavy lifting, chronic constipation, chronic asthma and obesity exacerbate it. Giving birth by caesarean section doesn’t prevent pelvic organ prolapse or urinary incontinence because pregnancy itself is a major contributor.

Pelvic organ prolapse results from damage to the three support structures of the pelvic organs – the suspensory ligaments, pelvic floor muscles and fibromuscular tissue surrounding the vaginal walls. These support structures are injured by overstretching during pregnancy and tearing during the birthing process.

The nerves that enable the muscles to function can also be damaged in these processes. And using forceps during delivery, prolonged second-stage labour, large infant birth weight and episiotomy (cut to assist delivery) all contribute to the injury sustained during the birthing process as well.

The main symptoms of pelvic organ prolapse are urinary and bowel incontinence, sexual problems and an uncomfortable feeling of bulging in the vaginal area. These symptoms may be experienced during pregnancy, following childbirth or may only manifest many years later, particularly after menopause.

A secret shame

The reason so little is known about pelvic organ prolapse in the community is that these symptoms are incredibly embarrassing for women.

No one likes losing control of their bodily functions or discussing it with friends, let alone talking to the general public about it via the media. But the impact of incontinence on the quality of life and daily functioning can be severe. Indeed, it’s comparable to the effects of having a stroke or dementia.

Women suffer anxiety about not being able to get to a toilet when needed, or coughing or sneezing and wetting themselves in public. This can easily lead to social isolation as they retreat from everyday activities to the safety of their own home. (The advent of the smart phone has made life a little easier with “loo locator” applications.)

Prevention and treatment

Preventive measures include daily pelvic floor exercises and treatment can range from the use of a pessary (a device inserted into the vagina to support the uterus) to reconstructive surgical repair operations that provide support to vaginal walls, damaged pelvic floor muscles and over-stretched ligaments in more severe cases.

An Australian study showed 19% of women in the general population have a lifetime risk of having surgery for pelvic organ prolapse or incontinence. Up to one third of these women will have subsequent operations because of failed surgery.

To improve outcomes, meshes similar to those used in hernia operations have been adapted for repairing damage leading to pelvic organ prolapse. These provide improved support for pelvic organs but they’ve introduced a new set of problems – infection, exposure of the mesh into the vaginal wall, bladder or bowel and shrinkage of the mesh causing pain and painful sex. And they can require another operation to correct. Some companies have recently withdrawn their product from the market because of these unacceptable complications.

Non-permanent biological collagen-containing materials have also been used for pelvic organ prolapse surgery, but these often fail due to their degradation by normal body processes and repeat surgery is required. And, while permanent or non-permanent meshes provide structural support to the pelvic organs, they don’t repair the support structures damaged during pregnancy and childbirth or block the ageing process.

Steps in a promising direction

My research group is currently working with urogynaecologists and scientists at CSIRO to develop a tissue-engineering approach to repair the vaginal wall tissues damaged by processes leading to pelvic organ prolapse. Our work focuses on using a woman’s own mesenchymal stem cells (a type of adult stem cell found in bone marrow, fat, and in the uterine lining, which is known as endometrium). Endometrium is a highly regenerative tissue that grows each month and is shed at menstruation.

Mesenchymal stem cells can produce connective tissues cells – fat, bone, cartilage, smooth muscle, and tendon – and have healing properties when transplanted into the human body. They promote blood vessel growth and tissue repair, reduce inflammation, prevent excessive fibrosis, and promote adult stem cells in the body to proliferate and produce new tissue. All these processes help repair injured tissues.

Combining endometrial mesenchymal stem cells with new mesh materials to treat pelvic organ prolapse has the potential to regenerate damaged pelvic tissues and provide a more durable solution for the condition. It’s currently being tested in pre-clinical animal models and is most likely about five years away from being generally available.

This condition should not be suffered in silence and the more awareness raised about this common, but invisible problem, the sooner there will be better solutions available for women.

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