Prolapse

UTERO-VAGINAL PROLAPSE

A prolapse is a medical condition where an organ or tissue falls down or slips from its normal position. A pelvic organ prolapse is a condition that occurs when the structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself falls out from their normal position.

Utero-vaginal prolapse is a downward movement of the uterus and/or vagina.

Causes of Utero-vaginal prolapse

The main cause of the prolapse is the weakness in the supporting tissues of the uterus and vagina. The common factors such as frequent lifting of heavy objects, chronic cough, severe constipation, menopause, childbirth, and pregnancy may increase your risk of developing utero-vaginal prolapse.

Symptoms Utero-vaginal prolapse

A woman with a mild prolapse may not experience any symptoms. However, women with more severe forms of prolapse may experience:

Sensation of pulling in the lower abdomen or pelvis
An uncomfortable feeling of fullness in the vagina
Low back pain
Urinary problems, such as urine leakage or urine retention
Difficulty in urinating and emptying bowel
Vaginal bleeding or discharge

Diagnosis of Utero-vaginal prolapse

Dr Alexander will diagnose the condition by taking a detailed history and performing a physical examination. During the examination, you may be asked to cough or bear down. [doctor] may also perform computerised testing of the bladder to test for urinary leakage.

Treatments for Utero-vaginal prolapse

If the symptoms are mild, non-surgical treatment options such as medications, pelvic floor exercises, vaginal pessary (a device that is inserted into the vagina to support the pelvic floor), estrogen containing vaginal cream, and lifestyle changes may be helpful.

Surgery can be considered in patients with severe symptoms of utero-vaginal prolapse. There are different types of procedures to address the prolapse, such as hysterectomy (removal of the uterus), hitching up the bladder or vagina, or repair and 'tightening' of the vagina.

The surgery may be done through an incision in either the abdomen or the vagina, depending upon the condition. The aim of the surgery is to restore normal anatomy and function of the pelvic organs.

Complications with Utero-vaginal prolapse

If left untreated, severe cases of utero-vaginal prolapse can cause ulceration and infection of the cervix and vaginal walls, urinary tract infections, lower tract bleeding, thickening of the skin of the cervix, urinary obstruction, and worsening of the prolapse.

Prevention of Utero-vaginal prolapse

Although utero-vaginal prolapse is not always preventable, there are certain measures that can be taken to help reduce the risk of developing utero-vaginal prolapse or prevent it from getting worse. These include:

Perform Kegel exercises to strengthen your pelvic floor muscles especially during pregnancy and after childbirth
Do not bear down when giving birth until your cervix is completely dilated
Take hormone replacement therapy after menopause
Avoid constipation and straining with bowel movements, after delivery
Avoid heavy lifting, prolonged standing, and chronic cough
Perform pelvic floor exercises on a regular basis

PELVIC ORGAN PROLAPSE

This condition most commonly occurs in women when the pelvic floor organ shifts from the normal position and bulges out against the walls of the vagina.

When this condition occurs, you may feel a bulge coming out of the vaginal opening. The condition occurs due to weak or stretched pelvic muscles resulting from childbirth or surgery.

Types of Pelvic Prolapse

There are different types of pelvic organ prolapse, such as

rectocele,
cystocele,
enterocele, and
uterine prolapse.

Dr Alexander will diagnose the condition by performing a physical examination, including pelvic examination, with reference to medical and family history, and may perform other tests such as cystoscopy, ultrasound scan, and magnetic resonance imaging (MRI).

Treatments for Pelvic Prolapse

Treatment options include

physical therapy,
biofeedback, and
medicines which will weaken the vaginal muscles and ease the pelvic muscles.
Pessary, a removable device fitted in the vagina to reduce pain and pressure of pelvic organ prolapse.

If the non-surgical treatment does not reduce the symptoms of pelvic organ prolapse, then surgery treatment is considered. There are several types of surgeries to correct different types of pelvic floor prolapse which include:

Repair of the vaginal wall
Repair of prolapsed pelvic organ
Closure of the vaginal opening
Removal of uterus

Voiding dysfunction

This condition refers to inability to completely empty the bladder. It most commonly affects children. In normal cases, when an individual wants to have a bowel movement, the pelvic muscles relax and the abdominal muscles contract allowing to empty the bowel.

But in the voiding dysfunction, the pelvic muscles contract instead of relaxing, resulting in incomplete emptying of urine.

Voiding Dysfunction Treatment

Voiding dysfunction treatment options include

managing constipation,
treating urinary tract infections,
physical exercises, and
medicines to decrease the bladder hyperactivity.

Diet changes are suggested. Surgery is rarely considered and involves correction of anatomical abnormality that is causing the voiding dysfunction

Vaginal Prolapse/Pelvic Floor Disorders

Vaginal prolapse is a condition where the pelvic organs such as bladder, rectum, uterus, urethra, and small bowel protrude into the vaginal wall. Several types of vaginal prolapse conditions have been identified and they include:

Cystocele – Bladder protrudes into the vagina
Rectocele – Rectum protrudes into the vagina
Vaginal vault prolapse – Top portion of vagina herniates into vaginal canal
Uterine prolapse – Uterus prolapse into the vagina
Enterocele – Small bowel herniates into vagina

Causes of Vaginal Prolapse

The main cause of vaginal prolapse is the weak muscles, tissues, and ligaments that support the vagina, surrounding tissues and organs.

The factors that can cause vaginal prolapse include

frequent lifting of heavy objects,
chronic cough,
severe constipation,
menopause,
childbirth,
previous surgeries in the pelvic area,
advanced age,
hysterectomy and
obesity.

Symptoms of Vaginal Prolapse

Women with prolapse may have different symptoms based on the type of prolapse. The signs and symptoms include

difficulty in urinating and emptying the bowels,
enlarged and wide vaginal opening,
vaginal lump, and
the protrusion of tissues at the front and back wall of the vagina.

Impact of Pelvic Floor Disorders

When the pelvic floor muscles and connective tissue that support the pelvic organs are weakened, the pelvic support is lost resulting in protrusion of the

bladder,
urethra,
cervix and
rectum.

This is called pelvic organ prolapse.

Women with pelvic organ prolapse will experience excessive pressure in the lower abdomen associated with a bulging or aching sensation, difficulty in urination, and urinary tract infections

PELVIC FLOOR REPAIRS

The pelvic floor is a set of muscles that form a hammock or sling around the opening of the pelvis. The pelvic organs, including the womb (uterus), rectum and bladder, are held in position by the pelvic floor muscles and the surrounding tissues.

Conservative Treatments for Pelvic Floor Disorders

If the symptoms are mild, non surgical treatment options such as

medications,
pelvic floor exercises,
vaginal pessaries (a device that is inserted in the vagina to support the pelvic floor), and
lifestyle changes may be helpful.

Surgical Treatments for Pelvic Floor Disorders

Surgery can be considered in patients with severe symptoms of pelvic organ prolapse.

There are different types of procedures to address a specific prolapse. The aim of pelvic floor reconstruction is to restore normal anatomy and function of the pelvic organs.

Surgery can be done through an open incision in the abdomen or the vagina or through tiny incision over the abdomen with the use of laparoscopic instruments.

Robotic assisted surgery may also be an option. The most essential part of the surgery is to restore support to the vaginal apex.

The most common procedures to restore vaginal apex support are:

Abdominal Sacral Colpopexy (ASC): During this procedure, straps of graft material are placed over the front and back walls of the vagina and secured to the ligament over the sacrum. As a result, the vagina is suspended over the pelvic muscles, to the sacrum. This graft material replaces the uterosacral ligaments, which is a natural support of the uterus.

Uterosacral and Sacrospinous Ligament Fixation – This is performed through a vaginal approach. The vaginal apex is suspended to a patient’s uterosacral or the sacrospinous ligaments. Traditionally, graft material was not used. However, recently, graft materials are being employed to enhance the durability of the prolapse repair in patients with weak vaginal wall.

Mesh Repairs for Vaginal Prolapse Mesh Repair is sometimes used by some gynaecologists to support the walls of the vagina. The mesh is stitched to the side wall and will also support the top of the vagina or the uterus.

VAGINAL PROLAPSE SURGERY

Uro-gynecology is the subspecialty of medicine for diagnosing and treating pelvic floor disorders in women such as urinary incontinence and prolapse of pelvic organs such as bladder, uterus, rectum, vagina and small bowel.

Cystocele – Bladder protrudes into the vagina
Rectocele – Rectum protrudes into the vagina
Vaginal vault prolapse – Top portion of vagina herniates into vaginal canal
Uterine prolapse – Uterus prolapse into the vagina
Enterocele – Small bowel herniates into vagina

Complications of Vaginal Prolapse Surgery

Every surgical procedure may be associated with certain risks and complications. The possible complications after the surgeries for vaginal prolapse include pain, infection, bleeding, recurrence of symptoms, injury to ureters, and perforation of rectum and bladder.

The complications are usually mild and can be treated accordingly.

The advantages of choosing minimally invasive surgery is that the defects can be clearly identified, incisions are small, postoperative pain and discomfort are reduced, shorter duration in hospital, and quicker recovery.

VAGINAL PROLAPSE REPAIR

Urogynaecology is the subspecialty of medicine for diagnosing and treating pelvic floor disorders in women such as urinary incontinence and prolapse of pelvic organs such as bladder, uterus, rectum, vagina and small bowel.

Cystocele – Bladder protrudes into the vagina
Rectocele – Rectum protrudes into the vagina
Vaginal vault prolapse – Top portion of the vagina herniates into vaginal canal
Uterine prolapse – Uterus prolapse into the vagina
Enterocele – Small bowel herniates into the vagina

The main cause of vaginal prolapse is the weak muscles, tissues, and ligaments that support the vagina, surrounding tissues and organs. The factors that can cause vaginal prolapse include frequent lifting of heavy objects, chronic cough, severe constipation, menopause, childbirth, previous surgeries in the pelvic area, advanced age, hysterectomy and obesity.

Women with prolapse may have different symptoms based on the type of prolapse. The signs and symptoms include difficulty in urinating and emptying bowel, enlarged and wide vaginal opening, vaginal lump, and the protrusion of tissues at the front and back wall of the vagina.

Surgery is done to restore the vagina and the pelvic organs back to their respective positions and provide symptomatic relief. It helps to strengthen the muscles around the vagina and prevent further damage of pelvic floor muscles. Vaginal prolapse surgery may be done through laparoscopy or open surgery. Various surgical procedures are performed to correct the prolapse of different pelvic floor organs.

Colporrhaphy

Colporrhaphy is the surgical procedure to correct cystocele and rectocele. In this procedure, Dr Alexander makes an incision in the vaginal wall. The bladder and rectum are pushed back to their normal positions, the excess tissue is removed and the incisions are closed. If you are suffering from urinary incontinence (involuntary leakage of urine) then Dr Alexander may use a splint to support the urethra and this procedure is called as bladder neck suspension.

Uterine suspension

This procedure is done to correct uterine prolapse using laparoscopic technique, where the uterus is pushed to its normal position. Incisions are made on the vaginal wall and the vagina is attached to a strong ligament at the back of the pelvis or at the base of the spine to support the vagina. Uterine prolapse can also be treated by a procedure called as hysterectomy, where the uterus is removed. After hysterectomy, you will not be able to have children.

Surgery for enterocele

Enterocele may develop in women who have had a rectocele and/or hysterectomy. In women who have had hysterectomy, the supporting structures or the ligaments of the anterior and posterior vaginal walls may not be fused together into the uterus. This creates an area that lacks support, which further causes the muscles and the ligaments to bulge out into the vagina.

In the enterocele repair, the ligaments and muscles are reattached to the top of the vagina with the help of sutures. Suturing the vaginal walls will only repair the defect and will not provide support to the apex of the vagina and to the supporting structures. Often, following the enterocele repair, other procedures may be performed to correct the abnormalities that are found together with enterocele. Other surgeries done with enterocele are for cystocele, rectocele and vaginal vault prolapse.

Sacrohysteropexy

It is another method to correct uterine prolapse. This procedure can be done through open surgery or laparoscopy. A synthetic mesh is used where one end of the mesh is attached to the cervix and top of the vagina and the other end is attached to the sacrum, at the base of the spine. The mesh provides support to the weakened vaginal wall.

Meshes are available in various sizes and shapes. It reduces the risk of recurrence of prolapse and enables the growth of new tissue through which this tissue incorporates the mesh into the surrounding area.

Vaginal vault suspension – It is similar to uterine suspension procedure. The top of the vagina is attached to a strong ligament at the back of the pelvis or at the base of the spine to support the vagina.

Other surgical procedures to correct vaginal vault prolapse include:

Sacral colpopexy – In this procedure, one end of the mesh is attached to the top of the vagina and the other end is attached to the upper part of the sacrum situated at the base of the spine. This mesh helps to repair the damage in the tissue.
Plication – In this procedure, the weakened tissue is re-attached to the other tissues.

The advantages of choosing minimally invasive surgery are, the defects can be clearly identified, incisions are small, postoperative pain and discomfort is reduced, shorter duration in hospital, and less time for recovery.

VAGINAL NATIVE TISSUE PELVIC FLOOR SURGERY

The pelvic floor is made up of pelvic muscles, ligaments, connective tissues, nerves and arteries. It contains organs such as the rectum, uterus, vagina, and bladder.

Causes of Pelvic Floor Problems

Several factors such as vaginal birth, trauma during childbirth, repeated lifting of heavy objects and chronic disease or surgery may weaken or stretch the pelvic floor.

When the pelvic floor can no longer hold the pelvic organs in place, the pelvic organs come down and bulge into the vagina. This condition is referred to as pelvic organ prolapse.

Pregnancy and childbirth are the most important risk factors for prolapse. Pelvic organ prolapse is asymptomatic in most patients. However, in a small percentage of patients it causes symptoms that vary from vaginal discomfort to difficulties in sexual, urinary and defecatory activities.

Native Tissue Surgery

Pelvic organ prolapse was traditionally treated surgically using native vaginal tissue (NT). It involved the use of the patient’s own tissue and sutures to restore the vagina to a natural position by reattaching it to the various supportive structures.

Reports in the literature of high recurrence rates associated with vaginal native tissue repair led to the development of alternative techniques, such as synthetic mesh.

However, the newer current data obtained from large population studies with long term follow up periods show that the recurrence rate with NT is much lower than was earlier predicted.

Native tissue repairs have similar outcomes to synthetic mesh without the risks inherent in mesh use.

Native Tissue Surgery Complications

The most common complication associated with mesh repair is erosion or protrusion of the mesh from the soft tissues in the vaginal wall leading to discomfort in intercourse and blood spotting and may require additional surgery. Thus, newer isn’t always better. Native vaginal tissue repair is still the standard of care for the typical patient with pelvic organ prolapse.

Surgery for pelvic organ prolapse is optional. Decision about the surgery should be made only after proper discussion of the risks and benefits of the possible procedure with your Urogynecologist.