Urogynaecology Pelvic Organ Prolapse

What is Pelvic Organ Prolapse

This is a hernia of the pelvic floor. The organs within a woman’s pelvis (uterus, bladder and rectum) are normally held in place by ligaments and supportive tissues (fascia) known as the pelvic floor. If these support structures are weakened, the pelvic organs can bulge (prolapse) from their natural position into the vagina. When this happens it is known as pelvic organ prolapse. Sometimes a prolapse may be large enough to protrude outside the vagina.

Why does pelvic organ prolapse happen?

  • Being pregnant and giving birth are the most common causes or weakening of the pelvic floor, particularly if your baby was large, if you had an assisted birth (forceps/ventouse) or your labour was prolonged. The more births a woman has, the more likely she is to develop a prolapse in later life; however you can still get a prolapse even if you have never given birth. Performing pelvic floor exercises is very important after childbirth but may help prevent prolapse from occurring.
  • Prolapse is more common as you get older, particularly after the menopause.
  • Being overweight can weaken the pelvic floor and increases the pressure on your pelvic floor.
  • Constipation, persistent coughing or prolonged heavy lifting can cause a strain to the pelvic floor and cause pelvic organ prolapse.
  • Following a hysterectomy and in particular one performed vaginally, the top of the vagina (called the vault) is supported by ligaments. If these supports weaken, a vault prolapse may occur
  • It is possible to have a natural tendency to develop a prolapse if you have some rare disorders affecting collagen.

The most common types or prolapse are:

  • Anterior wall prolapse (cystocele)- when the bladder bulges into the front wall of the vagina.
  • Posterior wall prolapse (rectocele/enterocele)- when the rectum or other parts of the bowel bulge into the back wall of the vagina.
  • Uterine Prolapse- when the uterus hangs down into the vagina. Eventually the uterus may protrude outside the body. This is called a procidentia or third-degree prolapse.
  • Vault prolapse- after a hysterectomy has been performed, the top (or vault) of the vagina may bulge down. This is called a vault prolapse. This happens to one in ten women who have had a hysterectomy to treat their original prolapse

There are different degrees of prolapse depending on how far the organ(s) have bulged. It is important to distinguish between the various types and degrees or pelvic organ prolapse as their symptoms and treatment may differ.

Prolapse Diagram

What are the symptoms of Pelvic Organ Prolapse?

Your symptoms will depend of the type and severity of your prolapse.

You may not have any symptoms at all and may only find out that you have a prolapse after a vaginal examination by a healthcare professional, for example when you have a smear test. A small amount of prolapse can often be normal.

The most common symptom is the sensation of a lump “coming down”. You may also have had backache, heaviness or a dragging discomfort inside your vagina. These symptoms are often worse if you have been standing (or sitting) for a long time or at the end of the day. These symptoms often improve when lying down.

You may be able to feel or see a lump or bulge. You should see your doctor if this is the case because the prolapse may become sore, ulcerated or infected.

If your bladder has prolapsed into the vagina, you may:

  • Have difficulty in passing urine or a sensation that your bladder is not emptying properly
  • Have frequent urinary tract infections (cystitis)
  • If your bowel is affected, you may experience low back pain, constipation or incomplete bowel emptying. You may need to push back the prolapse to allow stools to pass.
  • Sex may be uncomfortable and you may also experience a lack of sensation during intercourse

What are my options for treatment?

Your options for treatment will depend on the type of prolapse you have, how severe it is and your individual circumstances. Treatment options include the following.

Pelvic floor exercises

These are taught by appropriately trained healthcare professionals (usually physiotherapists) and are an excellent way to improve bladder and bowel function and prevent minimise prolapse problems.

Local recommended physiotherapists are:

Bernie Leamy http://www.physio4women.ie/index.php/contact/

Linda Williams at www.kilkennyphysioclinic.com

Laura Carroll at www.livewellwaterford.ie 

Pessary

  • A pessary can be good way of supporting a prolapse. You may choose this option if you do not wish to have surgery, are thinking about having children in the future or have a medical condition that makes surgery more risky. Pessaries are more likely to help a uterine prolapse or an anterior wall prolapse, and are less likely to help a posterior wall prolapse. The pessary is a plastic or silicone device that fits into the vagina to help support the pelvic organs and hold up the uterus. There are various types and sizes. The most commonly used type is the ring pessary.
  • Fitting the correct size of pessary is important and may take more than one attempt as it is a case of trial and error.
  • Pessaries should be changed or removed, cleaned and reinserted regularly. This can be done by you the patient as is common practice within mainland Europe, although it is often done in the UK and Ireland by a doctor or nurse. Estrogen cream is sometimes used when changing the pessary, particularly if you have any soreness.
  • Pessaries do not usually cause any problems but on occasion cause inflammation. If you have unexpected bleeding, you should see your doctor.
  • It is possible to have sex with some types of pessary although you and your partner may occasionally be aware of it.

Surgery

  • The aim of surgery is to relieve your symptoms while making sure your bladder and bowels work normally after the operation. If you are sexually active, every effort will be made to ensure that sex is comfortable afterwards.
  • Whether you choose to have surgery will depend on how severe your symptoms are and how your prolapse affects your daily life. You may want to consider surgery if other options have not adequately helped.
  • There are risks with any operation. These risks are higher if you are overweight or have medical problems. Dr McMurray will discuss this with you so that you can decide whether you wish to go ahead with the operation.
  • If you plan to have children you may choose to delay surgery until your family is complete.

What are the different types of surgery for pelvic organ prolapse?

There are many different operations that can be performed to treat prolapse. Dr McMurray will advise you of your options so that you can choose what is best for you. This will depend on your type of prolapse and your symptoms, as well as your age, general health, wish to have sexual intercourse and whether or not your have completed your family.

Possible operations include:

  • A pelvic floor repair if you have prolapse of the anterior or posterior walls of the vagina (cystocele or rectocele); this is where the walls of your vagina are tightened up to support the pelvic organs. This is usually done through your vagina so you do not need a cut in your abdomen. In recent years a number of new operations have been developed where mesh (supporting material) is sewn into the vaginal walls. This is a very safe procedure that has been done for many many years however there can be a very high rate of recurrence.
  • A Sacrospinous Fixation operation aims to lift up and attach your uterus or vagina to a ligament within your pelvis.
  • A Sacrocolpopexy is an operation that aims to lift up and attach your uterus or vagina to a bone (the sacrum) towards the bottom of your spine. Dr McMurray does not perform sacrocolpexys and would refer you on to a consultant in Cork to have this done using robotic keyhole surgery.
  • A vaginal hysterectomy (removal of the uterus) is sometimes performed for uterine prolapse. Dr McMurray might recommend that this be performed at the same time as a pelvic floor repair.
  • Closing off your vagina (colpocleisis) may be considered but only if you are in very poor medical health or if you have had several operations previously that have been unsuccessful. Vaginal intercourse is no longer possible after this operation.
  • A new type of surgery called Site Specific Repair has been developed because of the high recurrence rates associated with the traditional forms of pelvic floor surgery and the litigation which resulted from complications which occurred with the pelvic floor mesh repair kits. The philosophy behind the surgery is quite different to that of the pelvic floor repair. The aim is to correct the defect by repairing the natural/injured tissues and correcting the anatomical defect.  Surgery is performed to correct one defect at at time (as there are often a couple present) starting with the worst one. Traditionally multiple defects are corrected at once so that multiple procedures are performed at the same time. If there are multiple defects then further surgery is planned 6 months to 1 year after the first procedure. The early results from this type of surgery are encouraging (although by no means perfect) but it does seem to be very safe and liked by patients. Dr McMurray has begun to perform this type of surgery over the past year and has been encouraged by the results. It his aim to replace the older more traditional procedures with site specific repairs.

How successful is surgery for pelvic organ prolapse?

No operation can be guaranteed to cure your prolapse, but most offer a good chance of improving your symptoms. The benefits of some last longer than others.

About 40 out of 100 women having traditional surgery for prolapse will develop another prolapse in the future. There is a higher chance of the prolapse returning if you are overweight, constipated, have a chronic cough or undertake heavy physical activity. Prolapse may occur in another part of the vagina and may need repair at a later date.

Is there anything else I need to know?

The length of time you need to spend in hospital after the operation will vary depending on the type of operation and how quickly you recover, but will usually be no more than a few days. Generally speaking, you should avoid heavy lifting after surgery and avoid sexual intercourse for 8-12 weeks.