ConditionPelvic Organ Prolapse
What is pelvic organ prolapse?
Pelvic Organ Prolapse is defined as prolapse or protrusion of pelvic organs (bladder, rectum, or uterus) into the vaginal canal due to the weakening of pelvic muscles. Cystocele is the protrusion of the bladder into the vaginal canal. It is not the same as urinary incontinence. Some patients have symptoms of incontinence without bladder prolapse, and some patients have bladder prolapse without incontinence. Apical prolapse is the protrusion of the uterus or the top of the vagina (post-hysterectomy patients) into the vaginal canal. Rectocele is the protrusion of the rectum into the vaginal canal.
What causes pelvic organ prolapse?
Approximately 75 percent of prolapse can be attributed to pregnancy and childbirth. One study found that after the second pregnancy, a woman is eight times more likely to develop prolapse, compared to someone who has never had children. Obesity and advanced age also increase the risk of prolapse.
Does hysterectomy cause prolapse?
Advanced laparoscopic hysterectomy does not increase the risk of prolapse, because all of the supporting ligaments and muscles are preserved. Open abdominal hysterectomy and vaginal hysterectomy may increase the risk of prolapse due to the potential removal of supporting ligaments.
How can I prevent pelvic organ prolapse?
Prolapse prevention strategies have not been extensively studied. Although vaginal childbirth is associated with an increased risk of prolapse, it is unclear whether or not cesarean delivery will prevent the occurrence of prolapse.
What are the symptoms of pelvic organ prolapse?
The symptoms usually include the feeling of “bulge or pressure in the vagina” especially with sitting or standing. Other symptoms include incomplete emptying of bladder, slow stream, or incomplete evacuation of stool during bowel movements. Many patients often complain of significant discomfort during sexual relations. The symptoms of prolapse will vary based on the degree and the type of prolapse; patients may suffer from one or more symptoms with varying severity. Patients with a large bladder prolapse (cystocele) but mild rectum prolapse can have significant problems with voiding but will have no difficulty during bowel movements.
Although many women who have pelvic organ prolapse do not have symptoms, the most common and bothersome symptom is pressing of the uterus or other organs against the vaginal wall. The pressure on your vagina may cause minor discomfort or problems in how your pelvic organs work.
Symptoms of pelvic organ prolapse include:
- A feeling of pelvic pressure
- A feeling as if something is actually falling out of the vagina
- A pulling or stretching in the groin area or a low backache
- Painful intercourse
- Spotting or bleeding from the vagina
- Urinary problems, such as involuntary release of urine (incontinence) or a frequent or urgent need to urinate, especially at night
- Problems with bowel movements, such as constipation or needing to support the back (posterior) of the vaginal wall to have a bowel movement
Symptoms of pelvic organ prolapse are worsened by standing, jumping, and lifting and usually are relieved by lying down.
How is pelvic organ prolapse diagnosed?
Pelvic organ prolapse is diagnosed during a pelvic examination. Medical history is also important to elicit prolapse-associated symptoms, since treatment is generally indicated only for symptomatic prolapse. Pelvic organ prolapse is classified using the location (bladder, rectum, or uterus) and the degree/grade of prolapse. The degree or grade of prolapse is assessed by the physician and is defined as the extent of prolapse of each structure (bladder, rectum, or uterus) noted on examination while the patient is straining. The system has five degrees/grades and is graded from 0 (no prolapse) to 4 (maximum prolapse).
When is treatment indicated?
Treatment is indicated for women with symptoms of prolapse or associated conditions such as urinary, bowel, or sexual dysfunction. Obstructed urination and/or defecation are indications for treatment regardless of the degree of prolapse.
What are the treatment options?
The choice of treatment depends upon the patient’s preferences. Expectant management or no treatment is an option for women who can tolerate their symptoms and prefer to avoid treatment. A conservative management option is vaginal pessary, which is a silicone device inserted vaginally to support the pelvic organs. The pessary must be removed and cleaned on a regular basis. Elderly patients may have difficulty inserting/removing the pessary themselves and would require frequent office visits. Approximately 40 percent of women discontinue the use of a pessary within one or two years of use. Another conservative option is pelvic floor muscle exercises; however, this has been helpful in only a small number of women according to several studies. Surgical management should be offered to women with symptomatic prolapse and who have failed or declined conservative management options. Surgical prognosis depends upon the severity of symptoms, extent of prolapse, and the patient’s expectations. Surgery is usually delayed until childbearing is complete.
What are the surgical treatments for pelvic organ prolapse?
The choice of the procedure depends on the degree/grade and location of prolapse.
Pelvic Organ Prolapse Surgery
Cystocele or anterior repair refers to the repair of the bladder prolapse. This repair can be performed through a vaginal approach and involves the reconstruction of the vaginal wall and tissue between the bladder and the vagina. This can be done with and without the use of synthetic mesh. Rectocele or posterior repair refers to the repair of rectum prolapse. This repair can be performed through a vaginal approach and involves the reconstruction of the vaginal wall and tissue between the rectum and the vagina. This can be done with and without the use of synthetic mesh. Apical repair refers to the repair of uterine prolapse or prolapse of the top (apex) of the vagina. The most commonly performed techniques for apical prolapse require a hysterectomy, because the apex is elevated and the vaginal cuff is fixed to a supporting ligament. The two most common techniques are sacrospinous ligament suspension (SSLS) and sacrocolpopexy (abdominal or laparoscopic). Sacrospinous ligament suspension (SSLS) is performed through a vaginal approach. During this procedure, the uterus is removed and the vaginal apex is fixed to the sacrospinous ligament with a non-absorbable suture. After two years of having this procedure completed, the recurrence rate of prolapse is approximately 15 percent. This approach has a short recovery time and can be performed at the time of rectocele and cystocele repair. Laparoscopic sacral colpopexy is fixation of the vaginal apex or the cervix to the anterior longitudinal ligament of the sacrum using a synthetic mesh graft. Laparoscopic approach is superior to the open abdominal approach because of the shorter recovery and less post-operative pain. Sacral colpopexy procedures (abdominal and laparoscopic) require the use of synthetic mesh and are considered more effective in the treatment of apical prolapse than SSLS. After two years of having this procedure completed, the recurrence rate of prolapse is approximately five percent. The reported rate of mesh-related complications is approximately three percent. As SSLS, sacral colpopexy requires the removal of the uterus.
Why is synthetic mesh sometimes used during bladder and rectum prolapse repair?
Cystocele and rectocele repairs are performed through a vaginal approach. During the repair, a large segment of mesh is placed between the bladder and vagina for cystocele repair and between the rectum and the vagina for rectocele repair. Transvaginal mesh placement has primarily been associated with improved short-term outcomes for repair of bladder prolapse, as compared with procedures without the use of mesh. Synthetic mesh was thought to provide better support and have a lower recurrence rates of prolapse, as compared to procedures performed without the use of mesh.
What are the risks associated with using synthetic mesh during cystocele and rectocele repair?
Concerns have been raised regarding the safety of transvaginal placement of reconstructive synthetic materials. The most common complication of transvaginal mesh placement is mesh erosion, which is usually treated successfully with mesh excision. The rate of mesh erosion has been shown to be as high as 30 percent. Most patients with mesh erosion do not have symptoms. The most important issue of concern regarding transvaginal mesh is the development of severe pelvic pain and pain with intercourse in a subset of patients. In contrast to mesh erosion, multiple surgical procedures are often required and pain may persist even with removal of mesh. Due to the potential negative long-term effects, our surgeons do not use synthetic mesh during cystocele and rectocele repair.
What is the FDA warning regarding the use of transvaginal mesh?
The FDA has issued several documents on the use of reconstructive materials for female pelvic floor surgery. The conclusions to date have been that transvaginal placement of these materials are of uncertain efficacy and are associated with safety risks. In contrast, use of synthetic mesh for sacral colpopexy (for apical prolapse repair) or for full-length retropubic or transobturator midurethral slings (for incontinence treatment) was considered safe and effective.
I have urinary incontinence. Can this be fixed during prolapse repair?
Anti-incontinence surgery is often performed during the prolapse repair. Women with symptoms of both prolapse and stress incontinence are treated with a combined prolapse repair and continence procedure (urethral sling). For more information on the urethral sling procedure, please see Treatment of Urinary Incontinence.
Is a urethral sling necessary during prolapse repair if I do not have symptoms of incontinence?
For women with advanced prolapse, there is a high likelihood that they will develop stress incontinence (SUI) post-operatively. These women will benefit from a concomitant continence procedure (urethral sling) at the time of prolapse repair. Pre-operative urodynamic testing can be performed to determine whether a urethral sling will be necessary. However, even with normal testing (no incontinence), approximately 40 percent of patients will have symptoms of urinary incontinence after prolapse repair surgery. Patients who chose not to undergo a sling procedure may have it performed at a later time if incontinence symptoms develop after the prolapse repair surgery.
WHY CIGC FOR MY PELVIC ORGAN PROLAPSE SURGERY?
At CIGC, our pelvic organ prolapse surgeons are focused on your health and comfort. Some patients find that their symptoms are manageable and prefer not to treat them. Others decide that surgical management is the best option for them. Our job is to inform you of the best surgical option for your situation and to perform as minimally invasive a procedure as possible.
Why not my OB/GYN?
CIGC surgical specialists have undergone extensive training, are board-certified and fellowship-trained in the advanced techniques and procedures to surgically treat pelvic prolapse.
The majority of the care provided by your OB/GYN is Obstetrics, and their main focus is not on surgery. We partner with OB/GYNs to ensure patients have the highest level of care. Pelvic organ prolapse requires experienced, practiced minimally invasive GYN surgeons.
Choosing a minimally invasive GYN surgeon means your pelvic organ prolapse surgery will have fewer incisions, and you will have a shorter recovery period than with more invasive procedures. Many OB/GYN surgeons perform open procedures or robotic procedures to cure pelvic organ prolapse. Open procedures are painful, require a hospital stay, and leave much more visible scarring. Robotic procedures involve long surgeries, more incisions, and higher expenses. CIGC does not use either of these methods for these reasons.
It can be confusing for patients looking to make the best decision for themselves, so it is important to conduct extensive research when “shopping around” for a surgeon. It is important to find a surgeon who will listen to you, and who is highly skilled in gynecological surgery.
Hear it from our customers. Our patients share their success stories so you can hear it from them, not us, as to why our pelvic organ prolapse surgeons are superior.
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