Pelvic Organ Prolapse (POP)
Your pelvic organs include your bladder, uterus (womb) and rectum (back passage).These organs are held in place by tissues called “fascia” and “ligaments”. These tissues help to join your pelvic organs to the bony side walls of the pelvis and hold them inside your pelvis. Your pelvic floor muscles also hold up your pelvic organs from below. If the fascia and ligaments are torn or stretched for any reason, for example, obstetric trauma, or weakened pelvic floor muscles, then your pelvic organs (your bladder, uterus, or rectum) might not be held in their right place and they may bulge down into the vagina (birth canal). This is called prolapse.
The main cause is damage to or weakening of the nerves, ligaments and muscles which support the pelvic organs as a result any of the following:
- Pregnancy and childbirth (considered to be major factors leading to weakening of the vagina and its supports)
- Aging and menopause
- Previous pelvic surgery
- Conditions that cause excessive pressure on the pelvic floor like obesity, chronic cough, chronic constipation, heavy lifting and straining
- Some women may have an inherited risk for prolapse, while some diseases affect the strength of connective tissue e.g. Marfan syndrome and Ehlers-Danlos syndrome.
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 is the most common type of prolapse and involves the bladder and / or urethra bulging into the vagina. This condition is clinically referred to as cystocele or cysto-urethrocele.
Prolapse of the Posterior compartment occurs when the lower part of the large bowel (rectum) bulges into the back wall of the vagina referred to as rectocele) and / or part of the small intestine bulges into the upper part of the back wall of the vagina. This condition is clinically referred to as enterocele.
Prolapse of the apical compartment or uterine prolapse occurs when the uterus (womb) drops or herniates into the vagina. This is the second most common form of prolapse.
Up to 40% of women have a minor degree of prolapse with minimal or no symptoms. A complete medical history will be taken along with a vaginal examination in order to determine the severity and grade of the prolapse.
Most women do not have any symptoms and are diagnosed by their GP when having their pap smears done. Some of the common symptoms reported by women are:
- A sensation of something coming down
- Feeling of a bulge in the vagina
- Pressure in the vagina
- Back pain
- Interference with bladder/bowel functions – need to push the prolapse to help urination or bowel movement
Prolapse is often diagnosed when a woman is having a pelvic examination by GP or specialist either while doing a routine pap smear or examination for a specific complaint.
Treatment options for pelvic organ prolapse can be categorized into surgical and non-surgical options.
Pessaries require fitting by a qualified medical professional and some trial and error is involved to determine the right pessary for you. It is possible to remain sexually active with some types of pessaries.
- Do nothing: Prolapse is very rarely a life-threatening condition and women sometimes choose not to be treated if no symptoms or discomfort is experienced. If you have been diagnosed with prolapse, avoid heavy lifting and chronic straining (e.g. constipation and gaining excess weight).
- Pelvic floor exercises (Kegel exercises): By exercising your pelvic floor muscles, you can help improve or prevent the worsening of the early stages of prolapse. Pelvic floor exercises require time, motivation and proper technique. Our clinic will be able to provide you with information and assistance by Dr. Kannan to help you pursue this option.
- Pessary: Pessaries are vaginal devices that provide mechanical support to the prolapsed organs thus relieving symptoms. They come in various shapes and sizes and are most suitable to those wishing to delay or avoid surgery. E.g. If you haven’t completed your family or you have medical problems that will make surgery a risk.
For women with a high degree of severity of prolapse, surgical repair may be needed. You specialist doctor will recommend the most appropriate form of surgery based on a number of factors that include age, previous history, severity of prolapse and your general health.
There are two main options, Reconstructive surgery and vaginal closure surgery.
1. Reconstructive Surgical Repair
Pelvic reconstructive surgery is used to restore your pelvic organs to their natural positions while retaining sexual function. This can be accomplished in a number of ways including
Our Dr. Kannan can recommend and perform any of the methods above.
- Vaginal approach
- Abdominal approach (through an abdominal incision)
- Laparoscopic (keyhole)
2. Vaginal Closure surgery (Colpocliesis)
This surgery may be recommended to those with a severe prolapse who are not sexually active and have no intention of becoming sexually active in future or to those who are medically unfit for reconstructive surgery. During this procedure, the doctor will stitch the vaginal walls together thus preventing the prolapse from reoccurring. The main advantages of this type of surgery are that it has a short surgical time and recovery time and 90-95% of surgeries are successful.
There is no single best approach for patients and the approach for your particular surgery depends on a number of factors such as your history and experience with different approaches and your personal preference. You various options will be discussed by our surgeon and a type of surgery best suited to your particular case will be recommended. Each repair is individualised and two women with the same type of prolapse may have different needs.
Vaginal approach is minimally invasive and usually involves making an incision in the vagina and separating the prolapsed organ from the vaginal wall and using stiches to strengthen and repair the vagina. Permanent stitches may be placed into the top of the vagina or in the cervix and attached to strong ligaments in the pelvis to support the uterus or vaginal vault.
This involves making an incision in the abdomen and using sutures and/or graft materials to support the vagina, vaginal vault or uterus.
This procedure is similar to the open abdominal approach but often has quicker recovery times and smaller scars due to the nature of the minimally invasive method, often referred as laparoscopic or key-hole surgery.
Not all repairs require a graft. Usually grafts are used in repeated surgeries where there are significant risk factors for failure and/or advanced stages of prolapse. The graft may be absorbable, made from animal tissue and will disappear with time, or non-absorbable synthetic material which stays permanently in your body. Some grafts are a combination of these materials and the pros and cons of using each type should be discussed with your surgeon.
Approximately 75% of women having vaginal surgery and 90-95% having an abdominal approach will experience a long term cure for their prolapse. Recurrent prolapse may be due to continuation of the risk factors which caused the initial prolapse e.g. constipation and weak tissues.
Definitive prolapse surgery is advised to be withheld until the completion of your family. In the meantime, conservative approaches such as pelvic floor exercises or the use of a vaginal pessary can be used.