Pelvic Organ Prolapse

Pelvic organ prolapse occurs when the muscles, ligaments and fascia (a network of supporting tissue) that hold the internal pelvic organs in their correct positions become weakened. This allows one or more of the organs to drop or “prolapse” into the vagina. The pelvic organs consist of the uterus, vagina, bowel and bladder.

Imagine the pelvic support structures as a trampoline mat help by springs in a frame. A prolapse may occur if:

  • There is a central weakness in the muscles or fascia, like a split or tear in the trampoline mat.
  • The ligaments become too stretched, like overstretched trampoline strings.
  • Ligaments and tissues tear away from the side of the pelvic walls, like the trampoline’s springs and webbing have torn away from the frame.

Many women have a minor degree of prolapse with only minor or no major symptoms that may not require surgical treatment. However, symptoms can be distressing, so about one woman in 10 with prolapse will seek surgical treatment.
Cause Of Prolapse

  • Pregnancy and childbirth are considered to be the main causes.
  • Age and menopause may cause further weakening of the pelvic support structures.
  • Obesity, chronic cough, chronic constipation, weight gain, heavy lifting, smoking and straining are risk factors.
  • Inherited weakness of pelvic floor connective tissues is a factor.

Symptoms of Pelvic Organ Prolapse

  • A heavy dragging sensation in the lower pelvic area.
  • Urinary problems such as repeated urinary infections, dribbling associated with poor stream, or a feeling of incomplete emptying may occur.
  • Difficulty in emptying the bowel properly.
  • Interference with sexual enjoyment.
  • Psychological difficulties due to embarrassment or low self-esteem.
  • Vaginal flatus (wind).
  • Sensation of a lump in the vagina.

Types of Prolapse

  • Prolapse of the front wall of the vagina: A cysto-urethrocele is the most common form of prolapse and occurs when both the bladder and urethra fall towards the vagina.
  • Prolapse of the back wall of the vagina: a rectocele occurs when the lower part of the bowel (rectum) bulges against the back wall of the vaginal canal.
  • Prolapse of the uterus: This occurs when the uterus drops into the vaginal canal. It is the second most common form of prolapse after a cysto-urethrocele.
  • Prolapse of the vaginal vault: Women who have had a hysterectomy can develop a prolapse of the vaginal vault, where the top part of the vagina collapses into itself and may fall outside the vaginal opening.

Principles of Surgical Treatment

The aim of surgery is to restore normal anatomy, correct bladder and bowel abnormalities, and restore normal sexual function. A thorough assessment of the damage will help the gynaecologist to plan the best type of surgery.

A variety of surgical procedures and techniques have been developed including surgery

  • Via the vagina
  • Using laparoscopic (keyhole) surgery
  • Through an incision in the abdominal wall (laparotomy).

MESH: Some surgical techniques use a strong mesh that is stitched into the damaged fascia to reinforce it. This mesh may be synthetic or derived from animal tissue.

Non Surgical Treatment

Prolapse is rarely a life-threatening condition. Some women will choose not to have any treatment if the prolapse is not causing any serious health problem. Others may opt for treatment with vaginal devices called pessaries, which will not cure the prolapse but may relieve some symptoms.

Before the Surgery

An internal pelvic examination is necessary, and a rectal examination may be recommended. Ultrasound assessment is often needed.

Urodynamic studies may be recommended, even if the patient has no urinary symptoms, as a prolapse can often mask symptoms of stress incontinence. Anal physiological studies may be needed if ano-rectal symptoms are present.

Anaesthesia

Pelvic prolapse surgery can be performed using regional anaesthesia (such as an epidural or spinal block), or general anaesthesia.

Recovery

Recovery depends on many factors including the patient’s age, general health, and especially the type of operation she has had. You can help yourself recover quickly by:

  • No heavy pushing, lifting or pulling for at least six weeks.
  • No vigorous exercise for at least six weeks.
  • Follow your doctor’s advice on driving and returning to work.
  • Be aware that pain medication can affect bowel habits.

Your doctor will check on your progress after surgery and answer any questions you may have. It may be possible to return to sexual activity between three to eight weeks following surgery.

Surgical Repair of Pelvic Organ Prolapse

  • Vaginal Prolapse Repair
    • Repair of posterior (back) vaginal wall prolapse: A posterior colporrhaphy is used to repair weakness in the back wall of the vagina that has caused a prolapse of the rectum or small intestine. An incision is made in the back wall of the vagina. The rectum and small intestine are pushed back into place.
    • Repair of anterior (front) vaginal wall prolapse: An anterior colporrhaphy is performed to repair a prolapse of the front wall of the vagina involving the bladder, the urethra or both. Synthetic or biological mesh may be used to reinforce weakened tissue, especially in the case of previous prolapse surgery. The use of mesh depends on the condition and the surgeon’s preference.
  • Uterine Prolapse Repair
    • Sacrohysteropexy: Surgery to suspend the uterus is a recently developed option.  Sutures or mesh may be used to hold and support the uterus in place.
    • Hysterectomy: In women who have completed child-bearing, a hysterectomy (removal of the uterus) is an effective way to solve prolapse of the uterus. However, it will not necessarily treat all prolapse and often needs to be combined with one or more of the other surgical procedures if the front and back walls have been prolapsing.
  • Vaginal-Vault Prolapse Repair
    • Sacrospinous Ligament Fixation: An incision is made in the back wall of the vagina, the sacrospinous ligament is found and stitches are inserted between this and the top of the vagina to improve support. Weakness in the fascia is strengthened with sutures or the insertion of mesh.

Possible Complications of Surgery

General risks of surgery

  • Cardiovascular risks
  • Infection of the wounds
  • Bleeding
  • Anaesthetic risks

Specific risks of pelvic prolapse surgery

  • The procedure fails in about five to 10 women in 100
  • Prolapse may reoccur in up to 30 of 100 women
  • Between one and five women in 100 may develop stress incontinence which was not present before the surgery
  • About 15 in 100 women may have difficulty passing urine after anterior repair
  • Urinary tract infection
  • Complications of the mesh affect around one in 10 to 20 women
  • Injury to the urethra or bladder during surgery which is undetected can cause a fistula (connecting channel between the bladder and vagina) and requires surgical repair. This affects about two women in every 1,000
  • Continuing incomplete bowel emptying after posterior prolapse repair
  • Painful intercourse for between one and five women in every 100
  • Damage to rectum and small intestine
  • During laparoscopy, a gas embolism (bubble of carbon dioxide in the blood) can rarely occur. It can be life threatening but usually can be treated quickly
  • Other rare complications include blood transfusion and damage to a ureter.

Pregnancy after pelvic floor prolapse repair:

To reduce the risk of labour and childbirth damaging the prolapse repair, women are usually advised to delay prolapse repair until after their families are complete. Women who become pregnant are usually advised to have a caesarean section for delivery.