Pelvic Organ Prolapse (Vaginal Prolapse)

KEY POINTS

  • Vaginal prolapse is a weakness of the vaginal wall
  • Prolapse is very common, particularly after childbirth
  • The womb, bladder or bowel can push into the vagina
  • Women with prolapse may feel a bulge or heaviness in the vagina
  • Treatment includes pelvic floor strengthening, using a pessary for support or surgery

MORE INFORMATION

What is a vaginal prolapse?

A woman’s pelvic organs include her bladder, uterus (womb) and rectum (bowel). The pelvic floor has muscles and tissue that hold these organs in place.
If the support structures of the pelvic floor are weakened, any of the pelvic organs (bladder, womb or bowel) or the vaginal wall itself, can drop down from their usual position and bulge into the vagina. This is known as a vaginal prolapse.

What are the signs of vaginal prolapse?

Prolapse is a very common condition. Although many women may have a prolapse when examined by their doctor, if the prolapse is minor there may not be any symptoms.

When the prolapse has moved further into the vagina, a woman may notice symptoms including:

  • A heavy or dragging feeling in the vagina
  • A sensation of a bulge or “egg” in the vagina
  • Feeling a lump in the vagina
  • Bladder symptoms such as difficulty passing urine, needing to urinate very often, or problems with urinary control (incontinence)
  • Bowel symptoms such as difficulty in emptying completely, or needing to push within the vagina to help empty the bowel
  • Discomfort during sexual intercourse

What causes vaginal prolapse?

Pregnancy and childbirth is a major cause of prolapse, due to damage to the pelvic floor supports. Over 1 in 3 women who have been pregnant will have some level of prolapse. However only about 1 in 9 women will need surgery for prolapse over their lifetime.

The pelvic floor can also be weakened by age and after menopause, so prolapse related to pregnancy may only become noticeable years and even decades later.

Other risk factors include any conditions that increase pressure on the pelvic floor:

  • Being overweight
  • Often being constipated and needing to strain to use your bowels
  • Regularly lifting heavy things
  • Coughing frequently

Which pelvic organs can be affected by prolapse?

A prolapse can affect any of the pelvic organs, and any part of the vagina. Many women can have prolapse affecting more than one part of the vagina at the same time.

Prolapse of the bladder is the most common and affects the front wall of the vagina. The uterus can bulge down from the top of the vagina, and in women who have had a hysterectomy the vaginal wall in this area can still bulge down. If the rectum loses its support, the back wall of the vagina is affected.

How is prolapse diagnosed?

Your GP or Woman’s Urologist will ask you questions about your symptoms and health. You may then have an examination of the pelvic area and vagina. You may be asked to push down or cough during the examination to work out which area of the vagina is affected, how far the prolapse is coming down, and if there is any bladder leakage. A prolapse is often diagnosed for the first time during the examination for a routine PAP test.

How is prolapse treated?

Prolapse can be managed conservatively or with surgery. Your Woman’s Urologist will spend time going through the different options with you, and will recommend the best way to manage your prolapse.

Conservative (non-surgical) treatment options:

  • Do nothing
    • Who? If your prolapse doesn’t bother you, and it is not causing any harm, it is safe to do nothing.
    • Success: To help stop your prolapse from getting worse, avoid heavy lifting, straining (e.g. constipation) and putting on weight.
  • Pessary
    • How? Pessaries are devices that can be placed inside the vagina to support your prolapse. They need to fitted correctly, and can sometimes require some trial and error to find your perfect fit.
    • Success: Pessaries can help relieve your symptoms, and are a good option if you want to delay or avoid surgery (e.g. you are planning more children, or you have a medical problem that may make surgery risky)
  • Pelvic floor exercises
    • How? Pelvic floor exercises (Kegel exercises) help strengthen your pelvic floor muscles. Time, motivation and good technique is required, and great results can be achieved under the supervision of a specialised pelvic floor physiotherapist.
    • Success: May help improve or prevent early prolapse.

Surgical treatment options:

The best surgery for you will depend on several things like your age, general health, previous surgeries, and the type and stage of your prolapse. Every woman is different, and every repair will be slightly different. There are two types of prolapse surgery: reconstructive surgery or vaginal closure surgery.

Reconstructive Surgical Repair

  • Vaginal approach
    • How? A small incision is made in the vagina, the vaginal wall is separated from the prolapsed organ (bladder or rectum), and stitches are used to repair the weakened vaginal wall to give the organ better support. Sutures may be placed through the top of the vagina and attached to the strong ligaments in the pelvis to hold up the uterus or vaginal vault.
    • Success: 75-80%
  • Abdominal approach (through an abdominal incision)
    • How? An incision is made in the lower abdomen, and the uterus or vagina is brought higher up into the pelvis and attached to the sacrum, sometimes using a special mesh. This procedure is called a sacrocolpopexy.
    • Success: 90-95%
  • Keyhole surgery (laparoscopic or robotic)
    • How? Similar to the abdominal approach, the uterus/vagina is held up out of the pelvis by sutures or mesh attached to the sacrum. This can all be done through very small keyhole incisions, meaning the recovery is faster and the scars are smaller.
    • Success: 90-95%

Vaginal Closure Surgery (Colpocleisis)

  • Who? Women with severe prolapse, who are not sexually active (and do not plan on becoming sexually active in the future), and are unfit for reconstructive surgery
  • How? The vaginal walls are stitched together, closing the vagina, and preventing prolapse from recurring. This is a short operation, and has a quick recovery.
  • Success: 90-95%

Do I have to use mesh?

  • No! Most prolapse repairs DO NOT require mesh.
  • Some women may need mesh to add strength to their prolapse repair.
    • Women who have had a previous prolapse repair and it has come back (recurrence)
    • Women who have a high risk of recurrence
    • Women who wish to have a very low risk of recurrence with their first surgery
  • This mesh can be placed through an abdominal incision, or with laparoscopy/robotic.
  • Mesh will not be placed through the vagina.
  • Mesh alternative
    • It is possible to take make a graft using a woman’s own tissue (fascia) from the strong tissue around the muscle in her leg or abdomen. This fascia graft can be used to strength the prolapse repair (instead of mesh)
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