Pelvic Organ Prolapse

This condition refers to the sagging or bulging of one or more organs in the pelvis. This includes the uterus, bladder, rectum, small intestines and the vagina. The underlying cause is neuromuscular, meaning injury to nerves, ligaments, and muscles with subsequent weakening of the pelvic support for these organs. Pelvic prolapse is much like hernias that can occur in other parts of the body. The following conditions may occur alone or together. The degree (or stage of prolapse) may vary from a small drop to a complete exposure outside the vagina. It is important to understand that the bladder and intestines are never actually exposed to the outside. They are pushing on the vaginal walls and it is the vaginal walls which can be visible.

  • Cystocele — bladder sags or herniates into the vagina
  • Rectocele — rectum sags or herniates into the vagina
  • Enterocele — small intestines sag or herniate into the vagina
  • Uterine prolapse — uterus sags or herniates into the vagina
  • Vaginal vault prolapse — top of the vagina sags or herniates into the vagina

Treatment Options

Non-Surgical Treatment

  1. Do nothing (live with your condition). It is very rare for pelvic prolapse to result in a medical condition that threatens your health. The main reason to pursue any sort of treatment is because it is bothering you in one way or another.
  2. Pessary. This is a silicone rubber device placed in the vagina to support the prolapse. Obtaining a good fit may require trial of several pessaries. It works best if you can learn to remove and insert it yourself, but it can be cared for in our clinic. Rare side effects include vaginal discharge, infection, bleeding and vaginal ulceration. There is no surgery required to insert it.
  3. Kegel exercises (pelvic floor exercises). These exercises can help in some cases of early prolapse. As with any physical therapy, success requires time, motivation and proper technique. It does not help in advanced cases except to possibly slow down the progress of prolapse.

Surgical Treatment

  1. Reconstructive Surgery: This involves restoring the weakened connective tissues which results in improved support of the prolapsed organs. This can be done vaginally or abdominally; there is no one best route for all patients. Many prolapses can be repaired with vaginal surgery. This has many advantages for the patient. There are fewer complications, no abdominal incision, and recovery time is much faster. In general, success rates are equal to that of abdominal surgery. For some patients, however, the abdominal route is definitely better and offers longer-lasting results. Abdominal procedures can also potentially be done using the laparoscope.
  2. Colpocleisis: In this surgery the vagina is closed so it is not appropriate for women who are sexually active or desire to be after surgery. In a colpocleisis, the vagina is closed to hold up the prolapse but the entrance is left open enough to allow normal urination. If the uterus is present a hysterectomy is NOT performed. This surgery is often very effective at relieving symptoms but it does not restore normal support or anatomy.

Additionally, surgery for prolapse may include one of the following:

A. Vaginally

  • Anterior colporrhaphy — repair of cystocele through a cut in the vagina
  • Posterior colporrhaphy — repair of rectocele through a cut in the vagina
  • Enterocele repair — repair of enterocele through a cut in the vagina
  • Vaginal vault suspension — uterosacral or sacrospinous ligament fixation of vaginal vault prolapse. These procedures involve attaching the top of the vagina to strong ligaments or structures in the pelvis.

In addition, many times a sling is also needed to prevent urinary incontinence, as demonstrated in the following video filmed at Brigham and Women’s Hospital: Minimally Invasive Mid-Urethral Sling Procedure. All these vaginal surgeries can be done using native tissue or less commonly with mesh.

B. Abdominally

  • Sacropexy — repair of the uterine or vaginal vault prolapse, utilizing a mesh to bridge the vagina to the tailbone. This can be done through a cut (or by laparoscopy) in your abdomen.
  • Paravaginal — repair of cystocele through a cut (or by laparoscopy) in your abdomen
  • Enterocele — repair of enterocele through a cut (or by laparoscopy) in your abdomen

C. Correction of uterine prolapse

You have the following options available with correction of the uterine prolapse:

  • No hysterectomy
  • Total hysterectomy (removal of uterus and cervix) – Watch Vaginal Hysterectomy for a demonstration of how a hysterectomy can be used as a treatment for uterine prolapse.
  • Partial (supracervical) hysterectomy (removal of uterus only - cervix left in place)
  • The hysterectomy can be done through the vagina or through the abdomen, or through laparoscopy.
  • Removal of your ovaries is also an option to consider if you have gone through menopause or you have risk factors for ovarian cancer.

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