Pelvic organ prolapse (POP) in women is a highly prevalent condition that involves herniation of the pelvic organs through the vaginal walls. It can be described as anterior, middle or posterior compartment prolapse.1
The aetiology of POP is usually multifactorial, but risk factors (RF) such as age, history of vaginal delivery,2 connective tissue abnormalities, pelvic surgeries such as hysterectomy and diseases that lead to increased intra-abdominal pressure such as obesity or chronic constipation contribute to its development.3
The clinical presentation is highly variable, ranging from asymptomatic (the most common) to a feeling of heaviness or the appearance of a lump in the perineal area, urinary or faecal incontinence and sexual dysfunction. Symptom severity is more conditioned by the position than by the stage of the prolapse4,5 and is dynamic, influenced by the level of physical activity or the degree of bladder or rectal repletion.3
Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited renal disease with an incidence of one in 400–1000 live births; its presentation typically consists of the development and progressive growth of cysts throughout the renal parenchyma.6
The development of renal cysts in ADPKD begins in the embryonic stage and they continue to increase in size throughout the individual's life.7
In March 2017, tolvaptan (TVP) treatment was approved by the European Medicines Agency (EMA) for the treatment of ADPKD in patients meeting criteria for rapid progression in order to slow the course of the disease.
The increase in renal volume leads to an increase in intra-abdominal pressure that weakens the pelvic floor muscles, and is more prominent in patients with large renal volumes.
In addition, the high volumes of diuresis secondary to TVP treatment in these patients lead to bladder distension, which contributes to the weakening of this musculature.
For this reason, we decided to analyse the prevalence of pelvic organ prolapse (POP) symptomatology in patients with ADPKD classified as rapid progressors and undergoing treatment with TVP.
In our series, of the total number of patients treated with TVP, seven were women, of whom three (43%) had POP symptoms. The most common symptomatology was the appearance of a genital mass and/or urinary incontinence. The average age of the patients was 42 years. Two patients were multiparous, mean body mass index was 31 (20–44), one of them had pelvic surgery (hysterectomy) as a risk factor and a history of cystocele and rectocele.
All three patients were on maximum dose TVP treatment (120mg/day) with a mean diuresis volume of 6liters (6–6) and a mean urinary osmolality of 265 mOsm/kg (190–387).
Rehabilitation treatment led by the pelvic floor unit was effective in one patient. For the other two patients, the dose of TVP had to be lowered, and the drug had to be discontinued in one of them due to lack of improvement and limiting symptomatology.
These results suggest that the occurrence of POP may be common in women receiving TVP, with obesity being a risk factor for POP, as well as having a history of POP.
Asymptomatic status prior to initiation of TVP treatment does not rule out subclinical disease, which may be precipitated by increased bladder volume. Targeted anamnesis may be sufficient for screening prior to the start of treatment, as well as during follow-up, although more attention should be paid to patients with a history of POP or risk factors such as those discussed above.
In women with predisposing risk factors for developing POP, assessment and follow-up by the pelvic floor unit would be advisable from the start of treatment with tolvaptan.
In addition, personalised treatment should be considered, with the possibility of adjusting the drug dose according to urinary osmolality,8 which could be useful in limiting the aquaretic effect and its complications in patients with risk factors for POP.
