Prolapse

What Is Pelvic Organ Prolapse?

Pelvic organ prolapse is commonly known as the weakening of the pelvic floor.  The pelvic floor is a complex network of muscles and ligaments that support the organs that lie in the pelvis.  These organs include the vagina, uterus, bladder, and rectum.  Often pelvic organ prolapse is the result of weakening   muscles and is unfortunately something that happens to varying degrees with aging.  Additional contributing factors to pelvic organ prolapse, includes child birth, vaginal surgeries and body weight.  As the pelvic muscles weaken, the structures of the pelvis begin to descend into the vagina.  Depending on which side of the vagina falls, you can have the following types of prolapse:

  • Cystocele occurs when the bladder, which is normally positioned in front of the vagina, descends into the vagina.   Many patients refer to this as a “bladder drop”.
  • Enterocele occurs when the bowels and the top of the vagina fall down.
  • Rectocele occurs when the rectum, which is normally positioned in back of the vagina, shifts into the vagina.

Patients may have one or all three types of prolapse.  Patients may experience a variety of symptoms from prolapse such as abdominal/vaginal pressure and discomfort, urinary incontinence and difficulty urinating.  In extreme cases, patients may actually see a bulge coming from their vagina.  A rectocele may make it more difficult to have a bowel movement.  However, there are some patients who do not experience any symptoms, and are only diagnosed by their physician when addressing other concerns.

Treatment Options

There are several treatment options available including both non-surgical and surgical options.  The non-surgical treatment options often can temporary relieve symptoms, but tend not to see permanent relief of prolapse as with surgical repair.

Non-Surgical Treatments

Drug Therapies
Currently, there are no medications that have proven to be successful in treating prolapse.

Pelvic Floor Exercises
Pelvic floor exercises are designed to strengthen the pelvic muscles. The best known pelvic floor exercises are called Kegel exercises.  In general, these exercises do not help repair prolapse.  However, they can help prevent further prolapse and associated symptoms. These exercises strengthen the urinary sphincter muscle that helps prevent urine leakage (incontinence).  This is important because incontinence and prolapse often go together.

What does this treatment involve?

Pelvic floor exercises are taught by a physical therapist that is part of the Virginia Urology team.  The physicians and our patients have found that this provides a relaxed atmosphere where patients can focus on learning the pelvic floor exercises. Initially, appointments are generally held once per week. Once you feel comfortable with the exercises, you and your physical therapist may decide to decrease the number of visits.

Pessary
A pessary is a removable device placed in the vagina. Many women think of it as being similar to a diaphragm. It is designed to hold up the pelvic structures that have descended.  A pessary remains in the vagina at all times and is changed on a periodic basis.  Pessaries are often a good option for patients who want to avoid a surgical procedure, or whose health issues may increase the risk of surgery.

What does this treatment involve?

Patients must initially be fit by their doctor for a pessary in order to ensure a proper fit. To prevent infections, it is recommended that the pessary be changed and cleaned about once a month. This can be done by your doctor.  However, most women prefer to learn how to do this themselves so that they can do it at home.

    Surgical Treatments

    Surgical treatment options for prolapse vary depending on which of the three types you have.

    Cystocele Repair
    Figure 1. Mesh RepairCystoceles are repaired using a vaginal incision.  The bladder is then lifted back to its normal position.  Then, a layer of support is placed in between the bladder and vagina to prevent the bladder from shifting again.  In some cases, we use fascia, which is the strength layer that covers the outside of a person’s thigh.  This is taken from donors (cadavers).  Other times, we use a synthetic mesh that has support “arms” that wrap around the pelvic bone.

    Rectocele Repair
    Rectoceles are also repaired using a vaginal incision. The rectum is then shifted back to its normal position.  Then, a layer of support is placed in between the rectum and vagina to prevent the rectum from descending again.  In these cases we only use fascia, which is the strength layer that covers the outside of a person’s thigh. This is taken from donors (cadavers).

    Enterocele (Robotic Surgery)
    Enteroceles are repaired using a robot. While there are vaginal approaches, the gold standard (best success rates) is achieved by supporting the top of the vagina through the abdomen. A piece of synthetic mesh is sewn to the top of the vagina on one end. The other end of the mesh is anchored to a part of the hip bone using bone screws and this keeps the vagina held up.

    As described above, many patients have several types of prolapse and require more than one of these types of repairs.  In most cases, they are all done together in the same surgery setting. Importantly, prolapse is also commonly associated with incontinence.  In these cases, a sling is placed to prevent leakage.

    What does this surgical treatment involve?

    All types of prolapse repairs are performed in the hospital.  Patients remain in the hospital overnight for observation.  On the day of surgery, patients have a catheter in their bladder to help it rest.  A vaginal packing is also placed, to help the vaginal incisions heal.  Both the catheter and packing are removed the morning after surgery.  You may eat the evening of surgery and are encouraged to get out of bed and take a walk.  You will generally feel some discomfort for several days, and will be given medications to help ease pain.  While this is minimally invasive, it is still surgery!  However, most women feel well soon after surgery.  You may return to daily activities almost immediately, but we ask that you avoid physical activities for some time.  You may walk and drive the next day if you and your doctor feel comfortable with this decision.  You may return to work (office setting) in several days if you feel well.  However, we ask that you avoid heavy lifting (over 10 pounds), sports, sexual intercourse, and any strenuous activity for 6 weeks.  We will see you back in 6 weeks for a follow-up appointment to examine the progress of your healing.  Further appointments are made depending on how well things are healing.

    What are the success rates?

    With the constant advancements in technology, surgery for prolapse keeps getting better and increases the cure rate for prolapse in a majority of women.  It is important to note, that with any surgical procedure, there is no guarantee that the problem will be permanently fixed.  There are a small percentage of women who experience a return of the prolapse.  

    What are the possible complications?

    Your doctor will discuss a full list of complications with you.  Prolapse repair is a minimally invasive surgery with a low risk profile. However, all surgery carries risks. When a synthetic is used, sometimes that material can irritate the tissue around it. As a result, sometimes the vaginal skin overlying the sling may reopen. Sometimes the tissue may heal on its own with the help of a cream or your doctor may have to reclose the opening using local anesthesia. In extremely rare cases, the mesh may irritate and become incorporated into the bladder or urethra. This is a much more worrisome complication that usually requires surgery to remove the mesh. This is very rare, but the FDA recently issued suggestions that all doctors talk about the risks of mesh with their patients. A final risk specific to rectocele is that of painful intercourse. For some reason, the repair of the back of the vagina causes pain with sex in approximately 10% of patients. Most times this is temporary and can be resolved by an injection to the specific area of pain.

    What does this all mean?

    Overall, these surgeries are able to help a great number of women with prolapse.  In the past, there were limited treatment options that were often unsuccessful.  This left women having to just live with prolapse.  However with today’s technology and surgical advancements, women are now able to successfully face this problem.  Today, we are much better able to help the millions of women improve their quality of life.