What is uterine prolapse and vaginal wall bulge
Uterine prolapse and vaginal wall bulge are two conditions, but they are usually combined because they often exist together and are collectively referred to as Pelvic Organ Prolapse (POP).
Prolapse (POP for short), and often need to be treated together.
This group of conditions and others, such as stress urinary incontinence, vaginal laxity, and anal incontinence, are often grouped together in a relatively new specialty, namely gynecologic urology.
When uterine prolapse occurs, a part of the uterus comes off from its original position and may be accompanied by a partial bulging of the vaginal wall, mainly in the anterior wall, mainly manifested by palpable sagging tissue in the vagina, similar to a ping-pong ball, with a sensation of falling. Severe cases may affect bladder and rectal function, manifested by difficulty in urination or defecation, and some people need to push the prolapsed uterus or vaginal wall back into the vagina before they can urinate or have a bowel movement. Many people have difficulty walking for long periods of time due to the prolapsed uterus or vaginal wall, which affects their ability to get out and about and their quality of life. The condition is usually light in the morning and worsens in the afternoon after activity.
According to statistics in the United States, POP is a condition that affects the quality of life of older adults, with roughly 7% of women needing surgery to correct prolapse during their lifetime. If incontinence is added, 11% of women have a lifetime chance of having surgery.
Second, what types of prolapse
Depending on the location of the prolapse, it can be distinguished as anterior vaginal wall bulge (because the anterior vaginal wall is the bladder and urethra, so there may be a combination of bladder bulge or vesicourethral bulge), posterior wall bulge (the posterior wall is behind the rectum and abdominal cavity, depending on the bowel protrusion, may be distinguished from rectal bulge and small bowel bulge), top prolapse (usually for uterine prolapse, if the hysterectomy has been done before, the dome may also occur The vault may also occur if there has been a previous hysterectomy).
Figure 1. anterior vaginal wall bulge (bladder bulge)
Figure 2. posterior vaginal wall bulge (rectal bulge)
Figure 3. prolapse of the uterus
III. Why uterine prolapse and vaginal wall bulge occur
Uterine prolapse and vaginal wall bulge occur in most people because of pregnancy and childbirth. During vaginal delivery, the fetus squeezes the pelvic wall, causing damage to the pelvic floor muscles and nerves, so uterine prolapse and vaginal wall bulge occur. Many people are concerned about whether a cesarean section should be performed routinely instead of a vaginal delivery, but this is only from the perspective of preventing pelvic floor prolapse, which is after all a surgical procedure and is not recommended because of the possibility of incisional endometriosis, scar pregnancy, and uterine rupture in the next pregnancy.
Another factor that causes uterine prolapse and vaginal wall bulge is menopause. After menopause, as estrogen decreases, collagen and muscle fibers atrophy, which can aggravate prolapse, which is one reason why estrogen therapy is also helpful to relieve prolapse and urinary incontinence. A rare factor is a congenital defect, which probably accounts for only about 2% of cases. Patients with some rare connective tissue diseases such as Marfan’s syndrome may be at greater risk of prolapse.
Fourth, how to distinguish the degree
Usually we distinguish the degree of prolapse according to the outermost part of the uterus or vaginal wall that falls out, where the hymen is 0, 1cm outside the hymen is +1 and 1cm inside the hymen is -1. If the lowest part is between -1 and +1, it is 2nd degree of prolapse, 1cm or more inside the hymen is 1st degree, and the prolapsed part is more than 1cm outside the hymen is 3rd degree. The degree of prolapse is 4 if the vaginal wall is completely prolapsed. The classification helps to understand the degree of severity of the condition and allows decisions to be made about treatment options. In general, degree 3 or higher will have significant symptoms and require surgery.
V. What are the conditions that may aggravate the disease
Chronic cough, constipation, and other conditions that increase abdominal pressure can aggravate constipation, and being overweight is also a risk factor.
If these factors are present, it may increase the risk of recurrence after surgery, and it is generally recommended that treatment be performed before surgery.
VI. How to treat
For mild prolapse with insignificant symptoms, surgical treatment is not required. You can first try pelvic floor exercises to strengthen the pelvic floor muscles by contracting them to relieve prolapse. Topical estrogen may also be considered in postmenopausal patients.
For mild to moderate vaginal wall bulge and uterine prolapse, erbium laser treatment can also be tried. The principle is that laser irradiation of the vaginal mucosal tissue causes collagen remodeling and contracture of the vaginal mucosa, relieving the degree of vaginal wall bulge and uterine prolapse, and improving vaginal laxity and urinary incontinence.
Figure 4 Vaginal laser treatment
A uterine support is a non-surgical treatment option (see the scientific article: “Uterine Support”), which serves to prevent the possibility of vaginal wall or uterine prolapse by placing a supporting ring inside the vagina. The uterine support is a simple and convenient treatment option and a very good one for patients of advanced age who are at risk of surgery or whose current situation is not suitable for surgery, except that the uterine support cannot treat the root of the prolapse. In addition, after the uterine support has been placed for a long time, ulcers may occur and need to be removed periodically, and regular follow-up visits with the doctor are required. The use of a uterine support prior to surgery can also help to identify patients with coexisting occult urinary incontinence (i.e., incontinence that is not manifested at the time of prolapse and develops after surgery to correct the prolapse).
Figure 5. uterine support
For prolapse of more than 3 degrees or symptomatic prolapse, surgical treatment can be considered, depending on the patient’s age, fertility requirements, and the presence of recurrent factors. In younger patients, Mann surgery can be considered, with partial amputation of the cervix and reinforcement of the ligaments, which can be done vaginally or laparoscopically. In older patients, depending on the exact location of the bulge, local vaginal wall repair or hysterectomy + ligamentous reinforcement may be performed, and in patients with 4th degree or recurrent cases, mesh placement and reinforcement may be considered. In severe cases, suspension of the uterus or vaginal wall onto the sacral periosteum is also a classic procedure. Vaginal closure can also be considered in advanced cases without sexual requirements, which can also lead to better results.
Figure 6: Diagram of anterior sacral vaginal fixation
There is no uniform way of surgery and individualized treatment is needed.
VII. Do you have to choose mesh implantation?
In the past 10 years or so, mesh implantation has been sought after by many doctors in China and is seen as a new treatment option for pelvic organ prolapse. In 2012, the FDA issued a warning about vaginal mesh implantation in the US and this year the FDA revised mesh implantation to a “high risk” procedure. This year the FDA revised the mesh implantation procedure to a “high risk” procedure. After 2012, PROLIF and PROSIMA, which previously held a significant market share in China, were withdrawn from the market. This series of changes has led more and more doctors to change their views on mesh implantation. In fact, since 2012, fewer and fewer mesh implant procedures have been performed in the United States.
The International Society of Gynecologic Urology published an expert consensus in 2013, suggesting that there is a clear benefit to using mesh only in patients with recurrent prolapse or in cases of 2nd degree or greater bulge combined with a risk of chronic cough, etc. Other bulges of 3rd degree or greater may only benefit with unclear results, but mesh surgery is particularly inappropriate in patients with posterior wall bulge or in younger patients.
Therefore, after the occurrence of prolapse, it is not necessary to use the mesh, the specific surgical approach also need to communicate with the doctor.
VIII. What are the risks of surgery?
Prolapse repair surgery mainly affects the surrounding adjacent organs, mainly the bladder and rectum. Urinary incontinence and prolapse are similar to sisters, usually with the possibility of a combined presence, and in some patients there is even no incontinence before the surgery and new incontinence after the surgery.
Risks of mesh implantation include exposure of the mesh after implantation, erosion into adjacent organs, causing new bladder irritation, etc. Secondary infection is also an aspect of the problem.
9. What to pay attention to before and after surgery
If there are factors that aggravate postoperative prolapse before surgery, prior correction should be considered, such as weight loss, relief of constipation and treatment of chronic cough. If you are menopausal, we usually use local vaginal estrogen for 2 weeks before surgery to thicken the local vaginal mucosa and continue to use it for a long time after surgery to help reduce recurrence. If there are ulcers in the vaginal wall or uterus, they should be treated before surgery. After the surgery, forceful movements with increased abdominal pressure should be avoided, sexual intercourse should be prohibited for 3 months, and heavy lifting of more than the weight of a hot water bottle should be avoided.
X. Is there a possibility of recurrence?
Yes, the exact probability of recurrence depends on the age and the protocol of the surgery. The chance of recurrence is relatively high for the repair surgery done with own tissues, with 25% of the patients having the possibility of recurrence, while the use of mesh is relatively small, with a 5-10% failure rate.
XI. How to deal with combined urinary incontinence
If urinary incontinence is found before surgery, it is usually necessary to perform corrective surgery for urinary incontinence at the same time during surgery, because usually the original incontinence will worsen after the prolapse is corrected, and some patients may not have it before surgery, but new incontinence appears after surgery.
XII. What if I still want to have children
If it is mild, you can consider doing pelvic floor exercises. Generally, surgery should be postponed until after the completion of childbirth, because another pregnancy and delivery may aggravate the prolapse and make the effect of surgery lost. If the symptoms are severe, you can also consider performing Mann surgery.