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Pelvic organ prolapse

The pelvic organs (bladder, womb, vagina and rectum) are supported by the pelvic floor muscles and ligaments. If these muscles and ligaments become weakened the pelvic organs may bulge downwards into the vagina causing a prolapse.

There are several different types of prolapse, depending on which pelvic organ is affected and where the bulge is. Some patients have more than one type of prolapse.
Normal anatomy

Causes

What causes prolapse?
Anything which puts excessive strain on the pelvic floor can cause weakening and overstretching of the muscles leading to a prolapse. Pregnancy is the most common factor. Other causes include ageing, being overweight, constipation, heavy lifting and chest conditions with chronic coughing.

There are a number of different types of prolapse:

Bladder prolapse
This is known as a cystocoele. A bladder prolapse causes a bulge in the front wall of the vagina. This may cause discomfort and it is not uncommon for patients to experience urinary symptoms such as incontinence or an overactive bladder. Some patients have difficulty emptying their bladder due to the prolapse.

Prolapse of the small bowel
This is known as an enterocele. In this type of prolapse, part of the bowel pushes down causing a bulge near the top of the vagina. This often occurs alongside other types of prolapse.

Prolapse of the womb
A womb or uterine prolapse happens when the womb drops down into the vagina. It is common to get a prolapse of the bladder or bowel at the same time.

Prolapse of the rectum
This is known as a rectocele. The rectum (back passage) bulges into the back wall of the vagina. Some patients may notice they have difficulty opening their bowels.

How do I know if I have a prolapse?
Common symptoms of prolapse are:

  • A bulge in the vagina, or a feeling of “something coming down”
  • Lower back ache, especially after prolonged standing or walking
  • Vaginal pain or discomfort during sexual intercourse
  • Problems with the bowel or bladder

Some patients have little or no symptoms from their prolapse. Pelvic floor exercises can help prevent the situation getting worse. Ask your specialist for more details.

How does the specialist know if I have a prolapse?
The doctor will talk to you about your symptoms and ask about problems with the bladder and bowel. It is necessary to do an internal vaginal examination (similar to having a cervical smear taken). An instrument called a speculum is used to help determine what type of prolapse you have and the doctor will ask you to bear down or cough to look for weakness in the vaginal wall.
This is usually all that is required to diagnose the problem. Sometimes further tests are necessary, such as urodynamics.

Treatments

Non-surgical treatments
Sometimes an operation is required to treat prolapse but there are often simple measures that can be considered first. These may also be useful for patients who don’t have too much trouble from their prolapse but want to prevent things from getting worse.

  • Pelvic floor exercises to strengthen the pelvic floor muscles
  • Dietary advice to improve constipation
  • Oestrogen treatment to improve vaginal discomfort
  • Vaginal pessaries

Vaginal pessaries
A pessary is a device that is inserted into the vagina by the specialist to support the prolapse. Sometimes you will need to try a few different shapes and sizes to find the one that suits you best. The pessary will stay in all the time but it is not uncomfortable once it is in place. The specialist will do a check-up every 3 to 6 months to change the pessary and make sure you are happy with it.

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Some women experience side-effects from pessaries. These include interference with sexual intercourse, vaginal discharge and soreness.

Pelvic floor repair
An operation may be needed if the prolapse does not improve with simple treatments and is causing bothersome symptoms. Surgical procedures for prolapse aim to support the walls of the vagina and hold the prolapse back in its correct place.
Anterior repair (colporrhaphy)
This is an operation to treat a prolapse of the bladder (anterior repair). The bladder is pushed back into the correct position and held in place with stitches under the skin.
Posterior repair (colporrhaphy)
This is similar to an anterior repair but the operation is done for a bulge in the back wall of the vagina. The rectum is pushed back into the correct position and held in place with stitches under the skin.

Vaginal hysterectomy
A vaginal hysterectomy is the removal of the uterus or womb. It is the commonest surgical procedure for uterine prolapse. The womb is removed through the vagina and the top of the vagina (vault) is closed with stitches. This does not require any cuts or stitches on the tummy. 

Alternatives to vaginal hysterectomy
For women who do not want their womb to be removed, there are operations that help strengthen the tissues that support the womb and hold it in place. These may involve the use of a mesh (see below).

Sacrospinous fixation
Sacrospinous fixation is an operation to treat a prolapse of the womb or the top of the vagina. Strong stitches are placed between the ligaments at the back of the pelvis and the top of the vagina. This provides strong support for the top of the vagina.

Mesh repair
For women whose prolapse has come back after a previous prolapse operation, it may be necessary to insert a mesh to give extra strength to the tissues. A mesh is a fine net made from a type of soft plastic material. Once inserted, it stays under the skin providing support. Using mesh can reduce the risk of the prolapse coming back. Some women experience side-effects from the mesh including discomfort during sex, or an “erosion”, where the mesh is felt through the vaginal skin.

Colpocleisis
A colpoclesis operation involves closing off the vagina by stitching the front and back of the vagina together. Colpocleisis is only appropriate for women with a severe degree of prolapse who do not want to be sexually active. It is ideal for those who want to avoid a bigger operation as the recovery time is usually quick and you can go home sooner.


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