Pelvic floor surgery involves repair of structures within the vagina that causes fullness and a bulge within the vagina. There is usually a loss of support to these structures.
Pelvic Organ Prolapse (POP)
POP is simply, one or more of the pelvic organs (uterus, bladder or bowel) and in some cases, the vault (or top portion of the vagina from a prior hysterectomy) “dropping down” from their normal position and occupying the vaginal space. If the prolapse is severe, it may bulge out of the vagina.
Which organs are involved in the Prolapse?
- In the front of the vagina (the anterior compartment) – this involves the bladder bulging into the vagina. It is called a cystocele. It may also involve a weak muscle called a paravaginal prolapse.
- The back portion of the vagina (posterior compartment) – here, the rectum bulges into the vagina and is called a rectocele.
- The uterus and cervix may start to prolapse downwards and occupy the space of the vagina. This is called a uterine prolapse.
- In women who have undergone a prior hysterectomy, the top portion of the vagina, called the vault may prolapse
- Occasionally a space or pouch between the back wall of the vagina and the rectum that contains loops of small bowel may prolapse. This is called an enterocoele.
Why do I have a prolapse? What has caused it?
Risk factors that contribute to a prolapse are:
- Having had children. Vaginal deliveries increase this risk
- Increased abdominal pressure – factors like chronic constipation, chronic coughing from respiratory conditions (including smoker’s cough), obesity and prolonged heavy lifting
- Menopause – due to a lack of oestrogen
- Older age group
What are the symptoms?
It is common for women to have a prolapse and not be aware of it. It may be brought to your attention at the time of a cervical smear test or an unrelated pelvic examination.
Common symptoms include:
- Bulge in the vagina – this is either felt as a lump or can sometimes be seen protruding out of the vagina
- A sense of pelvic heaviness or dragging lower abdominal pain which can increase as the day progresses
- Lower back pain
- Digitation – needing to push the bulge back to aid in emptying your bladder or a bowel movement
- Urinary incontinence (involuntary loss of urine)
- Constipation or difficulties in emptying the bowels
- Difficulties with sexual intercourse
What happens at my first visit?
After taking your clinical history, you will be examined. In addition to a general examination, a specific examination is done:
- The abdominal examination – looking for any obvious masses or swellings that may be contributing to pressure on the pelvic organs
- Vaginal examination looking for a bulge or a protrusion out of the vagina. This may include a speculum examination to assess the various parts of the vagina and look at the type of prolapse present. You may be asked to strain downwards and cough to evaluate the bulge and to look for accidental leakage of urine. If you leak urine, please do not worry – it is an important assessment. Sometimes the examination is done with you lying sideways. This makes it easier to assess urinary leakage and anterior compartment bulges.
- You may need a rectal examination as well.
How is Prolapse Managed?
Surgical treatment is only necessary if you have symptoms like pain, pressure, bowel or urinary symptoms and if non surgical options have been unhelpful.
However, there are a few things you can start doing to obtain symptom relief prior to surgery, or to prevent the prolapse from getting worse over a short time. These are:
- Weight loss – if you are overweight, it may make your prolapse worse. Losing weight also helps optimise your health prior to surgery if this is needed.
- Pelvic floor exercises or Kegel’s exercise
- Limit intake of caffeine, tea or excessive alcohol if you have any associated urinary incontinence. .
- Pessaries – this is the first non-surgical option that we try. This is a device made of flexible silicone that is inserted into the vagina. It helps by supporting the pelvic structures. There are various sizes and your doctor will assess which size is suitable for you. Pessaries are changed every 3-6 months, usually by your Gynaecologist, and some GPs are happy to do them.
Surgical options for POP
The aim of surgery is to reconstruct the pelvic floor and restore the pelvic organs to their original position. This is usually via a vaginal approach. Some cases are complex and may need an abdominal procedure or a keyhole operation.
A hysterectomy may be necessary if the uterus is prolapsing. In addition, the other types of surgery offered are:
- Anterior repair - a surgery that aims to correct the bladder bulging into the vagina. This may involve mesh or a graft.
- Posterior repair - a surgery that aims to correct the rectal bulge into the vagina. It may involve reconstructing the floor of the vagina close to the opening (the perineal body) - this is called a perineorraphy.
- Sacrospinous ligament fixation - the top of the prolapsed vagina is stitched to a fixed point within the pelvis. It may be on one side (the right side usually) or both sides.
- A laparoscopic paravaginal repair, sometimes, concurrently with a bladder neck elevation procedure called a Burch's colposuspension.
- The use of vaginal mesh of grafts is no longer offerred. Read more about it from the Tranvaginal (urogynaecological) surgical mesh hub.
At times, a uterosacral ligament suspension may be done following a laparoscopic hysterectomy and combined with a vaginal prolapse repair. A uterosacral ligament suspension attaches the top section of the vault (previously where the cervix was prior to the hysterectomy) to the uterosacral ligament. The uterosacral ligament is attached to the seat bone (the sacrum) and is a fixed structure that helps restore the supports of the vagina to prevent it from collapsing at a later time (a 'vault' prolapse). This step involves identifying the ureters (the tubular structure carrying urine from the kidneys to the bladder) and taking sutures through the uterosacral ligament and fixing it to the top of the tissues covering the vault whilst avoiding the ureters. A cystoscopy is always done to ensure the ureters have not been accidentally constricted during the surgery.
Patient information leaflets on the procedures and interventions for pelvic organ prolapse can be viewed and downloaded from the International Urogynaecological Association (IUGA) website.