Pelvic organ prolapse with or without urinary incontinence is very common. In fact, even though it may not be talked about much, minor degrees of prolapse affect up to 50 percent of all women who have had a vaginal delivery, while 20 percent have symptoms that require them to seek care. One in 9 women will have surgery for prolapse or incontinence in her lifetime.
Normally, a woman's pelvic organs are supported by the muscles of the pelvis. Her uterus, vagina, bladder, and rectum are held over the muscles that provide support to keep the organs in place. If the muscles or supportive connective tissue is weak, damaged, or stretched, eventually any or all of the organs can begin to slip downward into the vagina. Occasionally, if left untreated, the organs can actually protrude outside of the vagina or body.
The early symptoms of this can be a feeling of pressure at the end of the day, feeling like one is sitting on something all the time, feeling something protruding when wiping after voiding, an altered urinary stream or difficulty initiating voiding. Sometimes a woman will experience altered sensation with intercourse or feel like her partner is hitting something. Women with prolapse may also experience bladder or bowel symptoms such as difficulty controlling urges or incontinence with coughing, sneezing, exercising, and other activities.
Causes of prolapse or pelvic floor disorders
Although the exact cause of prolapse is not known, vaginal child birth is the most important risk factor. Certainly the birth weight and number of children a woman has can increase her risk, but even a single small child can lead to prolapse or urinary incontinence. We don't completely understand it yet, but we believe it is related to muscle and nerve damage that can occur with vaginal delivery. Not every woman who delivers her child vaginally will get prolapse and not every woman with prolapse has delivered a child vaginally. Even a cesarean section does not completely eliminate the risk for prolapse or incontinence. So there must be other factors. We think the next most important factor is related to genetics. Pelvic floor disorders are more common among siblings with prolapse or incontinence. Other factors that can increase a woman's risk are anything that put chronic straining or stress on the pelvic organs (chronic cough, obesity, constipation or repetitive heavy lifting).
First, if a patient is not bothered by prolapse, she may not need any treatment at all. In general, treating prolapse is about quality of life. Patients should be reassured that this is common and except in rare situations, can usually be observed without treatment. However, patients should also be reassured that if they are bothered by prolapse or incontinence, there are many treatments available that can help them get back to normal life. There is no reason to live with prolapse or incontinence if it bothers you or affects your quality of life.
Kegel exercises or physical therapy can help strengthen the pelvic muscles. This is helpful with urinary incontinence and may delay the development of prolapse. However, it is unlikely that exercises alone will repair significant vaginal prolapse.
Pessaries are removable rubber or silicone devices that can be placed in the vagina to hold the organs in place. Once appropriately fitted, a pessary can be removed and cleaned on a regular basis by the patient for as long as she would like. Pessaries often work well, but the prolapse will likely return if pessary use is stopped. Therefore, we recommend pessaries for young woman who may want to have more children, women who have a medical condition that makes surgery inadvisable, or for women who would like to post-pone surgery for some period of time - perhaps to take care of an ill family member or when it may be more convenient for her schedule.
There are several ways to surgically treat prolapse. In general, the options that will be offered to a woman will depend on the training and experience of the surgeon. There is no one right answer for all patients. We suggest a consultation with a fellowship-trained urogynecologist to determine which option is best for each patient. Below is a brief explanation of the different types of surgical repairs that may be considered.
Traditional vaginal repairs have been used for several decades. These repairs are used for bladder prolapse, cystocele, rectocele, enterocele, uterine prolapse, and vaginal prolapse. These repairs are very common and are performed by many gynecologists. They are called anterior or posterior repair, colporrhaphy, uterosacral or sacrospinous vault suspensions. They are the simplest to perform and have the advantage of being performed through an entirely vaginal approach. That means that they don't generally require a long hospital stay and are relatively well tolerated. Patients usually stay 1-3 days in the hospital after surgery. The surgeon treats the prolapse using the patient's own tissue to repair the connective tissue attachments. Although this may be a good option for some patients, it is the approach that has the highest risk for recurrent prolapse. According to the literature, 20-40% of patients may experience return of their prolapse in the future. It should be noted that although this is a seemingly high recurrence rate, many of those patients will NOT have symptoms or need repeat surgery.
Another option for prolapse repair is called abdominal sacral colpopexy. This procedure has been performed for more than 20 years. It is a very good operation for uterine or vaginal prolapse. In fact, many would consider it to be the "gold standard." The success rate is well above 90% for at least 20 years. This success rate is, at least in part, because the repairs are performed using a permanent surgical mesh implant.
For many urogynecologists, this is the procedure used when vaginal surgery fails or recurs. It is more difficult and is generally only performed by specialists. The vagina is re-suspended to strong ligaments in the pelvis by the mesh. Since the repair is not relying on the patient's own tissues, the repair has a much better chance of lasting 20-30 years or more. Other defects can be treated at the same time with procedures that repair specific defects: paravaginal defect repair and/or enterocele repair.
The disadvantage is that with most surgeons, it is usually performed through a large abdominal incision. This is much more invasive than vaginal repairs. Patients often spend 2-4 days in the hospital.
Relatively recently, surgeons skilled in advanced laparoscopy have perfected laparoscopic sacral colpopexy. With this approach, patients can receive the "gold standard" procedure with the best success rates - but in a minimally invasive procedure. A small camera is inserted through the umbilicus (belly-button). Additional thin instruments are inserted through a few small incisions less than ½ inch long. The remainder of the surgery should be completed exactly like the well-studied abdominal approach. There can be no short cuts. Therefore laparoscopic sacral colpopexy is difficult and requires several specific skills to complete. With additional training, surgeons can perform the entire case by laparoscopy. In some cases, surgeons may use robotic assistance to overcome some of the more difficult aspects of this complex laparoscopic case. Many patients are able to go home the same day of surgery or after observation overnight. Some patients may be a candidate for the newest type of laparoscopy called Laparo-Endoscopic Single Site surgery (LESS) using only a single tiny incision in the umbilicus to complete the entire prolapse repair.
Vaginal Mesh Repairs
When comparing traditional vaginal repairs with sacral colpopexy, many surgeons feel that the better success rates of sacral colpopexy are due to the use of a permanent mesh material rather than relying on the patient's own weakened tissue. In an effort to improve the results of traditional vaginal repairs and avoid the more invasive open abdominal approach, surgeons began to explore placing mesh vaginally to repair prolapse. Surgeons in Europe were the first to develop some of these techniques and it has been performed in the United States since 2001. (Dr. Stepp trained with one of the original developers in France.) During the procedure, a mesh implant is placed through vaginal incisions using specifically designed instruments. The early results of published reports suggest vaginal mesh procedures have the potential to improve the anatomic success rates for prolapse repair. Other advantages for these procedures are that they result in minimal pain, overnight hospital stay only, and they can be performed quickly. Longer surgeries place patients at higher risk of complications - particularly patients over 70 years old. Potential disadvantages include lack of long-term research, possible pain with sexual activity, or problems related to mesh healing. We generally do not perform this procedure on patients who are or plan to be sexually active.
Pelvic Reconstructive Surgery
Our urogynecologists specialize in rebuilding and restoring the vagina and pelvic anatomy to its normal state. Whether patients have experienced trauma during childbirth and/or episiotomy, or as a result of complications from prior surgery, we can help restore the normal appearance of supportive and functional structures of the pelvis and vagina. Our approach is to address the entire pelvis from the deeper supportive ligaments to the outer structures also responsible for good support and function.