Pelvic Organ Prolapse

If you have pelvic prolapse, you may experience pressure or heaviness in the pelvis, or actually notice tissue that is hanging or dropping out of the vagina. This feeling is usually worse at the end of the day or after you have been active and on your feet a lot. You may also feel as if you are ‘sitting on a ball,’ need to place your fingers into the vagina to push the stool or urine out when defecating or urinating, or discomfort with sexual intercourse. You may also have a range of urinary problems such as difficulty starting to urinate, a weak urine stream, frequent urination, feeling like you are not emptying your bladder well, or even loss of bladder control.

It is important to note that the symptoms and size of the prolapse do not correlate; in other words, one person can have a ‘small’ prolapse, but be very bothered by it, whereas another person can have a ‘large’ prolapse and not be bothered by it at all.

It should also be mentioned that some women who have vaginal deliveries may experience some loss of support but this is common and usually does not result in bothersome symptoms.

How common is pelvic organ prolapse?

While we do not know exactly how many women suffer from pelvic organ prolapse, mostly because many women do not seek treatment, we do know that it is a very common problem. Nearly half of all women between the ages of 50 and 79 have some form of prolapse. Approximately 200,000 procedures for correction of pelvic organ prolapse are performed each year in the United States.

What causes pelvic organ prolapse?

There are several risk factors that have been found to predispose, cause, promote or worsen pelvic organ prolapse. Injury to the pelvic floor predisposes to prolapse, particularly vaginal childbirth. Having had a vaginal delivery is the strongest risk factor, and the risk increases with increased numbers of vaginal deliveries. Other ways that the pelvic floor might be injured include pelvic surgery, pelvic radiation, back and pelvic fractures from falls or motor vehicle accidents. Additional conditions that may contribute to a woman developing pelvic organ prolapse include chronic constipation, chronic cough, obesity, repetitive heavy lifting, advancing age, as well as genetics. Studies have shown that Caucasian women are more likely to have prolapse than African Americans.

Where can prolapse occur?

A prolapse may arise in the front wall of the vagina (anterior compartment), back wall of the vagina ( posterior compartment), the uterus or top of the vagina (apical compartment). Many women have a prolapse in more than one compartment at the same time.

Prolapse of the Anterior Compartment: Cystocele and Cystourethrocele
This is the most common type of prolapse, and involves the bladder and/or urethra bulging into the front wall of the vagina.

Prolapse of the Posterior Compartment: Rectocele and Enterocele
This is when the lower part of the large bowel (rectum) bulges into the back wall of the vagina, and is called a rectocele. Sometimes the small intestine can also bulge into the upper part of the back wall of the vagina – that is referred to as an enterocele.

Prolapse of the Apical Compartment: Uterine Prolapse, Vaginal Vault Prolapse and Enterocele
A uterine prolapse is when the uterus, or womb, drops into the vagina. This is the second most common kind of prolapse. In someone who has had a hysterectomy, the top of the vagina may fall down towards the vaginal opening – that is referred to as a vaginal vault prolapse. As mentioned above, small intestine can bulge into the vagina; if it is bulging into the top of the vagina, that is called an enterocele.

How can I prevent pelvic organ prolapse?

There is no single way to prevent POP since these problems have several different causes (see risk factors above). However, you can become aware of the risk factors for POP and try to avoid habits and activities that may predispose her to POP. We recommend that you:

• Maintain a normal weight or lose weight if overweight.
• Avoid constipation and chronic straining during bowel movements. For many, this is can be achieved with a diet with plenty of fiber and fluids, as well as regular exercise.
• Seek medical attention to evaluate and treat a chronic, persistent cough.
• Avoid heavy lifting and learn how to lift safely by using leg and arm muscles as much as possible.
• Do not smoke.
• Avoid repetitive strenuous activities.
• Learn and perform pelvic floor muscle exercises (Kegel) regularly to improve the strength of the pelvic floor. Once prolapse has developed, pelvic floor exercises will not correct the prolapse, but they may limit the development of worsening prolapse and may diminish some of the symptoms.

How do I know if I need treatment?

Pelvic organ prolapse is generally not life threatening, however it can have a negative impact on a woman’s life. You do not have to wait until your symptoms are ‘really bad.’ Vaginal and uterine prolapse, while common, are not a normal result of childbirth and aging. You do not have to ‘learn to live with it.’

If you are experiencing symptoms of pelvic organ prolapse, even mild ones, we urge you to speak to your health care provider and consider being examined by a specialist. Seeking medical help does not mean that you have to have surgery. The goals of treatment should include improvement of your quality of life. So if the prolapse is not causing discomfort or interfering with your daily life, it may not require treatment. One exception to this rule is if your prolapse is severe. It is possible for the pelvic organs to drop down low enough to pull on the ureters and block the flow of urine, although this is not common. This can cause recurrent urinary tract infections or even kidney damage. Since the symptoms associated with prolapse often progress very gradually, the adaptive changes in physical or social activities may go unnoticed until they are extreme.

There are three ways to manage pelvic organ prolapse:

1. Do Nothing

Prolapse is rarely life-threatening and generally does not have to be treated if it is not causing bothersome symptoms. The goals of treatment should include improvement of your quality of life. So if the prolapse is not causing discomfort or interfering with the things that you enjoy doing, it may not require treatment. If you have been diagnosed with prolapse and choose to not treat it, it is a good idea to continue to see your provider on a regular basis to monitor for prolapse progression and symptoms over time.

2. Wear a Pessary

What is a pessary?

A pessary is a removable device that fits into the vagina, much like a diaphragm used for contraception. It is used to lift and support the vaginal walls and hold the bladder, uterus and rectum in place to relieve the symptoms of POP. Its use may even slow the progression of POP. Most pessaries are made of silicone. They come in several sizes and shapes. For example, some have a knob which compresses the urethra and can help prevent leakage.

Who should wear a pessary?

Pessaries are a low risk treatment option for POP and UI. A pessary is a good alternative to surgery for you if you:
» have symptoms and want to avoid surgery.
» are in poor health and the risks of surgery are great.
» need relief from symptoms while awaiting surgery.
» need temporary relief of POP or incontinence symptoms from time to time.

Approximately half of women who are successfully fit with a pessary will continue to use it on a long-term basis.

How is it used?

If you and your urogynecologist decide that a pessary is the right choice for your condition, your provider will work closely with you to find one that fits. Your provider will teach you how to insert, remove, and clean it. Some women prefer to remove the pessary nightly, while others prefer to leave it in for several weeks at a time. Alternatively, if you cannot or do not want to remove and insert the pessary yourself, than we will see you at regular intervals, usually every 3 months, to remove, clean and reinsert the pessary.

What are the risks of wearing a pessary? A pessary is not appropriate for you if you cannot come for regular follow-up visits to the doctor’s office. Pessaries do require ongoing care to avoid problems with vaginal discharge, infection, ulceration or bleeding. A neglected pessary can result in erosions through the vaginal wall into the bladder or rectum. They should be avoided in women with dementia or those who have persistent vaginal erosions. Your provider may suggest using some form of vaginal estrogen to help prevent or treat erosions and ulcerations from wearing a pessary. Estrogen will help make the lining of the vagina thicker and healthier and more resistant to developing erosions and ulcerations. Estrogen can be delivered to the vaginal tissues via a cream, tablets or a ring.

3. Surgery to Correct the Prolapse

There is no single best surgery for all patients. Your surgeon will discuss with you the various options and will recommend the type of surgery best suited to your condition and needs. The type of surgery that is recommended depends on the kind of pelvic organ prolapse you have, the severity of the prolapse, your general health, your surgical history, your preference and your goals of treatment. Your urogynecologist will work with you to design a plan that is right for you. Each repair is individualized, so it is possible that two different women with the same kind of prolapse may have different needs and thus opt for different surgical procedures. Generally, the surgery can be performed in a minimally-invasive manner that will require an overnight stay in the hospital.

Surgical approaches

Prolapse repair can be performed through different surgical approaches:

• Vaginal: performed through incisions in the vagina
• Abdominal: performed through an abdominal incision
• Laparoscopic and robotic: performed through several small incisions in the abdomen

Grafts

Your surgeon may also suggest that a graft material be placed during surgery. Grafts used in pelvic reconstructive surgery can be absorbable or non-absorbable. Absorbable grafts, also called ‘biologic’ grafts, are made from animal tissue and will gradually disappear over time. Non-absorbable grafts are made of synthetic material which stays in your body permanently. Your surgeon will discuss the advantages and disadvantages of using grafts in the repair of your prolapse.

Robotic surgery

Our surgeons were among the first to routinely offer robotic surgery to their patients with prolapse. Our state-of-the-art robotic system called the Da Vinci® surgical system, allows your surgeon to perform a minimally invasive technique using small incisions with extreme accuracy. This approach provides more dexterity, precision and control than standard laparoscopic surgery. When compared to an open approach, robotic surgery typically results in less pain after surgery, less blood loss and need for transfusions, less risk of infection and scarring, a shorter hospital stay and recovery time, and a quicker return to normal activities.