What is pelvic organ prolapse?
This condition is when one or more pelvic organs bulge out of the vagina or form a hernia. The pelvic organs include the uterus, vagina, intestines and bladder. Prolapse of the pelvic organs occurs when the muscles, ligaments and fascia (a mesh of supporting tissues) that keep these tissues in the correct position become weak. Li Yanxia, Department of Obstetrics and Gynecology, The First Hospital of Guangzhou Medical University
Symptoms include.
1. feeling a dragging sensation in the vagina or lower back
2. Lumps inside or outside the vagina
3. Urinary symptoms, such as slow urine flow, incomplete urination, frequent or urgent urination, stress urinary incontinence
4. Intestinal symptoms, such as difficulty in bowel movement or a feeling of not being able to pass the bowel properly, or the need to press on the vaginal wall during defecation
5. Discomfort during sexual intercourse
What causes pelvic organ prolapse?
The main cause is destruction of the nerves, muscles, ligaments and support of the pelvic organs and may lead to the following.
1. Pregnancy and childbirth are considered to be the main factors that cause vaginal and weaken its support. Prolapse occurs in 1/3 of women after childbirth. Prolapse may occur shortly after pregnancy or after years of accumulation. However, it is important to emphasize that only one out of nine women (11%) need to undergo surgery for prolapse.
2. Age and menopause may further contribute to the laxity of the pelvic floor structures.
3. Other factors that contribute to excessive pressure on the pelvic floor, such as obesity, chronic cough, chronic constipation, heavy lifting and stress.
- Some women may be at risk for genetic predisposition, while others may have connective tissue defects such as Marfan’s syndrome and Ehler-Danlos syndrome.
Where does prolapse occur?
Prolapse can occur on the anterior vaginal wall, posterior vaginal wall, uterus or vaginal apex.
The top of the vagina. Many women have multiple prolapses at the same time.
Prolapse of the anterior wall
This is the most common type of prolapse and the bladder and urethra may bulge into the vagina. Your doctor may diagnose it as a bulging bladder or urethral bladder bulge.
Posterior wall prolapse
Posterior wall prolapse is diagnosed when the rectal recess protrudes into the posterior vaginal wall (your doctor will call this a rectal bulge) and/or part of the small bowel recess protrudes into the upper part of the posterior vaginal wall (your doctor will call this a small bowel bulge).
Top prolapse
Uterine prolapse – When the uterus descends from its normal position along the vagina, this is the second most common type of prolapse.
Vaginal vault prolapse – when the top of the vagina bulges downward (like the head of a sock turning inward) and falls out beyond the vaginal opening due to a hysterectomy.
How is prolapse of the pelvic organs treated?
The treatment is divided into surgical and non-surgical.
Non-surgical treatment
No treatment required: If there are no symptoms, the prolapse is not life threatening and you can choose not to treat it. If you are diagnosed with prolapse, you should avoid heavy lifting, prolonged exertion such as constipation, and avoiding excess weight, conditions that can cause prolapse to worsen.
Uterine supports.
Uterine rests are devices used inside the vagina and come in various shapes and sizes. They provide enough support for the prolapsed organ to relieve symptoms. They are best used in infertile patients who are delayed or reluctant to undergo surgery, or in patients who are at risk for surgery due to medical comorbidities.
The appropriate uterine trays are provided by the doctor, and different shapes and sizes are usually tried to find the best one for you. Some types of braces do not interfere with sexual life.
Pelvic floor exercises (Kegel exercises).
Training your lax pelvic floor muscles can improve or prevent the worsening of early prolapse. Just like regular exercises, pelvic floor training requires time, motivation and proper technique.
Please check the relevant online links for more information on this type of training.
Surgical Treatment
Female patients with significant symptoms of prolapse will require surgical repair. Your surgeon will recommend the most appropriate surgical procedure, taking into account factors such as age, surgical history, severity of prolapse, and general condition. There are two general options: reconstructive surgery and vaginal closure surgery.
Reconstructive repair
Reconstructive pelvic floor surgery is performed to restore the pelvic organs to their original position and to preserve sexual function. There are different surgical routes.
1. from the vaginal route
2. From the abdominal approach (through an incision in the abdomen)
3. laparoscopic approach (“keyhole” surgery)
Robotic laparoscopic route
1. Vaginal route
This is an incision through the vaginal route, where sutures or mesh are used to separate the prolapsed organ from the vaginal wall in order to strengthen and repair the vagina. Permanent sutures are placed on the top of the vagina or cervix, while adhering to the strong pelvic ligaments that support the uterus or vaginal vault (they are called sacrospinous or uterosacral ligament suspensions, respectively)
2. From the abdominal route
This is where sutures or mesh are used to support the vagina, vaginal vault, or uterus. An anterior sacral suspension involves suturing the prolapsed vaginal vault to the sacrum for support.
3. Laparoscopic route and robotic laparoscopic route
Similar to the open route, but with faster recovery and less scarring.
Currently, robotic laparoscopy is only available in a few institutions
Is a mesh necessary for the procedure?
Not all repairs require the use of mesh. Traditionally, mesh has only been used for patients with recurrence or for patients at risk of surgical failure. There are absorbable meshes, which are made from animal tissue (biological patches) that are absorbed by the body and will slowly disappear, and non-absorbable patches, which will remain permanently in the body after surgery. Some patches are made up of both absorbable and non-absorbable materials. You must discuss the advantages and disadvantages of each material with your surgeon.
Vaginal closure surgery
Your surgeon will recommend this procedure if you have severe prolapse, have no sexual requirements, or if reconstructive surgery is not possible due to medical comorbidities. During this procedure, your physician will your vaginal walls are sutured together to prevent the reoccurrence of prolapse. The advantages of this surgical method are the short time as well as the quick recovery and the success rate of 90-95%.
The success rate of the surgery?
Nearly 75% of women who undergo vaginal surgery and 90-95% of patients who undergo transabdominal surgery will have their prolapse symptoms eradicated after surgery. Recurrence of prolapse is associated with the persistence of ongoing factors such as constipation and unimproved tissue laxity.
What if I still finish my childbirth?
It is generally recommended that patients do not undergo repair of the prolapse until they have completed childbirth. However, conservative treatments such as pelvic floor exercises and uterine supports are available.
What type of surgery is right for me?
The truth is that no one method is perfect for all patients. The choice of a procedure is determined by many factors, including your personal medical history, your physician’s training, your experience with different approaches, and your personal preferences. Your physician will discuss the different approaches with you in order to recommend a procedure that is best for you. Each treatment is individualized, and even if two women have the same prolapse, each has different needs.