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The pelvic organs comprise of the bladder, bowel, vagina, uterus and ovaries.
When the supporting structures for these organs become weakened then we have a 'prolapse', where these organs protrude or drop into the vagina. The problem generally occurs if there is weakness of the muscles and/or a stretching of the ligaments in the pelvis. There is the feeling of 'something falling out of the vagina'.
Causes of Prolapse
- Childbirth and Pregnancy.
This is one of the main predisposing factors for prolapse. Prolapse may present itself during or after a pregnancy but, on the other hand, may take years to manifest itself.
- Menopause and Advancing Age.
With a lack of Oestrogen, there may be further weakening of the muscles and tissues supporting the pelvis.
Any condition that causes an increase in pelvic pressure may predispose and encourage the development of prolapse. These conditions include weight gain and obesity, smoking, chronic cough and chronic constipation.
An inherited factor may cause pelvic floor weakness but is uncommon.
Types of Prolapse
There are three different types of prolapse: uterine prolapse, prolapse of the bladder and prolapse of the rectum.
We will discuss these three types and explain respective treatment. Uterine prolapse
This is where the uterus drops down in the vagina and may, in fact, protrude outside the vagina. There are various grades:
- Grade 1 - where the uterus has reached the low half of the vagina.
- Grade 2 - where the uterus has reached the opening of the vagina.
- Grade 3 - where the uterus (cervix) is protruding outside the vagina.
- Grade 4 - where the whole uterus and vagina are completely outside the vaginal opening.
- Treatment of uterine prolapse
A ring pessary can be used. This is a ring that is inserted into the vagina and may support the uterus. No operation needed.
This can be treated conservatively by saving or conserving the uterus. The procedure is known as a hysteropexy and uses stitches and/or a mesh to support the uterus to some of the ligaments known as utero-sacral ligaments.
If a woman has completed her family or has other uterine problems such as heavy bleeding or fibroids, then a hysterectomy may be considered. This will almost always be done vaginally. Prolapse of the bladder (front wall of the vagina) - cystocoele
This is the most common form of prolapse. The front wall of the bladder is weakened so that the bladder protrudes in the vagina and may be seen creating a swelling or bulge at the opening of the vagina. Sometimes this is called a cystocoele.
Small cystocoeles are common and often don’t cause any problems. However, larger cystocoeles may be associated with urinary difficulties such as incontinence, straining to pass urine or incomplete emptying. - Treatment of bladder prolapse
These exercises are particularly useful in strengthening the pelvic floor muscles. They need to be done correctly and frequently.
A ring pessary can be used. This is a ring that is inserted into the vagina and may support the bladder or front wall of the vagina.
Many operations exist for the treatment of this bulge in the vagina. The technique that has been used for many years is a standard 'anterior repair', which supports the bladder by stitching support tissue to the side wall of the pelvis. This generally has about a 50% to 60% success rate and there is a high rate of recurrence.
- Vaginal repair using mesh.
This technique has become very popular as the mesh is rather strong and avoids the possibility of recurrence. It is a synthetic mesh that is attached to the side wall of the pelvis in a 'hammock' or 'sling' fashion. The recurrence rate is very low.
Laparoscopic correction of the prolapse is being used by some surgeons. Good access to the supporting structures can be obtained through the operating laparoscope and good visualization is achieved. Because of the site specific repair, good results can be obtained. Prolapse of the rectum (back wall of the vagina) - rectocoele
This is where the bowel bulges into the back part of the vagina and may also be present as a bulge at the entrance of the vagina. This is often called a rectocoele or posterior wall prolapse. One may not only have a bulge but may also have difficulty in evacuating the bowels, especially when constipated. One may have to push on the bulge to gain a bowel movement. - Treatment of rectal prolapse
These exercises are particularly useful in strengthening the pelvic floor muscles. They need to be done correctly and frequently.
Again, a variety of techniques have been used over the years in order to treat and prevent a recurrence of this condition. The standard procedure has always been a 'posterior repair', where the tissue between the vagina and rectum are supported to the side wall of the pelvis. Again, there is a reasonable rate or recurrence.
Currently, more and more Specialist Gynaecologists are using a mesh repair to support the back wall of the vagina. This is stitched to the side wall and will also support the top of the vagina. The recovery after surgery is very rapid and the recurrence rate is very small.
- Laparoscopic pelvic floor.
Laparoscopic pelvic floor repair has been used for the last 10 years and has a good success rate. The operation may be prolonged and rather difficult but can have good results in the right hands.
Some complications
Obviously, there are the general risks of surgery but, more specific to pelvic organ prolapse, is the fact that there is a failure rate depending on the actual procedure. A standard repair of the bladder may have an up to 40% or 50% recurrence rate. However, the rate of failure or recurrence is very small with mesh repair.
Stress incontinence may develop, even though it was not present prior to the operation. It is generally easily corrected.
- Difficulty in passing stools/urine.
There may be incomplete emptying of stools.
Mesh erosion can occur at some sites and, uncommonly, the mesh may need to be removed.
Damage to rectum or bladder can uncommonly occur. |