Pelvic Organ Prolapse
Pelvic organ prolapse is a serious condition; however, your organs will not fall out of your body.
What is pelvic organ prolapse what causes it?
Pelvic organ prolapse when the pelvic organs (bladder, rectum, or uterus) push into the vaginal canal due to the weakening of pelvic muscles. Specific conditions include:
- Cystocele prolapse is the protrusion of the bladder into the vaginal canal. 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 prolapse is the protrusion of the rectum into the vaginal canal.
Approximately 75 percent of prolapse can be attributed to pregnancy and childbirth. According to one study, 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.
What are the symptoms?
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 function.
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
Symptoms of pelvic organ prolapse are worsened by standing, jumping, and lifting and usually are relieved by lying down.
How is pelvic organ prolapse treated?
The choice of treatment depends upon the patient’s preferences. Treatment plans may include the following:
- Expectant management or no treatment is an option for women who can tolerate their symptoms and prefer to avoid treatment.
- Conservative management can involve utilizing a 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. 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 is offered to women with symptomatic prolapse and who have failed or declined conservative management options. Surgery is usually delayed until childbearing is complete.
What advances are there in surgery to treat pelvic organ prolapse, and what are the benefits over other procedures?
The type of surgical procedure conducted depends on the amount (degree) of prolapse and the location. They include:
- Cystocele repair refers to the repair of the bladder prolapse. This can be done through a vaginal surgery and involves the reconstruction of the vaginal wall and tissue between the bladder and the vagina. The procedure can be performed with and without the use of transvaginal synthetic mesh.
- Rectocele repair refers to the repair of rectum prolapse. This repair can be performed through a vaginal surgery 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 transvaginal synthetic mesh.
- Apical repair refers to the repair of uterine prolapse or prolapse of the top (apex) of the vagina. This involves much more complex techniques to repair the prolapse. There are two common techniques, which involve fixating the top of the vagina to two different ligaments in the lower pelvic region.
Why is synthetic mesh sometimes used in pelvic organ prolapse repair and what are the risks?
Bladder prolapse repair and rectum prolapse repair often use a large segment of synthetic mesh to separate the bladder and the vagina or the rectum and the vagina, respectively.
Previously, transvaginal mesh use was associated with improved short-term outcomes for repair of bladder prolapse, as compared with procedures without the use of mesh. However, concerns have been raised regarding the safety of transvaginal synthetic mesh. The most common complication of transvaginal mesh placement is mesh erosion, which is usually treated successfully with mesh removal (excision). The rate of mesh erosion has been shown to be as high as 30 percent.
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 effectiveness and are associated with safety risks.
In contrast, use of synthetic mesh for uterus prolapse repair or for full-length slings (for incontinence treatment) are considered safe and effective.
What should I ask my doctor or OB-GYN if he/she recommends pelvic organ prolapse surgery?
Before undergoing surgery, you will likely have many questions for your physician or surgeon. View our recommended questions to ask – and background information to help you weigh the answers – below or download a printable version.
HOW DO YOU PERFORM PELVIC ORGAN PROLAPSE REPAIR?
The choice of the procedure depends on the degree/grade and location of prolapse.
Cystocele repair refers to the repair of the bladder prolapse. This can be done through a vaginal surgery 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 transvaginal synthetic mesh.
Rectocele repair refers to the repair of rectum prolapse. This repair can be performed through a vaginal surgery 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 transvaginal synthetic mesh.
Apical repair refers to the repair of uterine prolapse or prolapse of the top (apex) of the vagina. This involves much more complex techniques to repair the prolapse. There are two common techniques, which involve fixating the top of the vagina to two different ligaments in the lower pelvic region.
DO YOU RECOMMEND OPEN SURGERY?
Open surgery for pelvic organ prolapse is never required. Minimally invasive techniques, such as DualPortGYN, can be used to repair all types of pelvic organ prolapse with fewer complications, less pain and faster recovery times.
HOW MANY TIMES HAVE YOU PERFORMED THIS PROCEDURE?
When it comes to any form of surgery, training, skill and practice matter, which is why GYN surgeons who specialize in minimally invasive surgery are the most qualified. The reality is that OB-GYNs are highly skilled obstetric practitioners, but very few perform GYN surgeries often enough to be surgical specialists. This is borne out by studies, which find that GYN surgery is commonly a secondary component of what an OB-GYN does.
WHAT HAVE YOUR OTHER PATIENTS EXPERIENCED AFTER THIS PROCEDURE?
Robotic, open and conventional laparoscopic GYN surgeries can lead to longer recovery times, increased blood loss and larger scars than newer procedures. Make sure your surgeon is trained in the latest minimally invasive techniques, such as The Center for Innovative GYN Care’s DualPortGYN, that prevent injury to the pelvic structures and minimize blood loss – resulting in reduced complication rates and improved recovery times.
HAVE YOU HAD FELLOWSHIP TRAINING IN MINIMALLY INVASIVE GYN SURGERY?
While most OB-GYNs are highly trusted generalists, they spent most of their time focusing on obstetrics and basic GYN care and therefore, perform specialized GYN surgeries rarely. Be sure to choose a surgeon who has received comprehensive training and is an expert in prolapse repair.
WILL YOU USE TRANSVAGINAL SYNTHETIC MESH?
The FDA has issued several documents on the use of reconstructive materials for pelvic floor surgery. The conclusions to date have been that transvaginal placement of these materials are of uncertain effectiveness 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.
Make sure to ask your surgeon plans to use transvaginal mesh and in what way. This way you can weigh the benefits against the risks.
WILL YOU USE ROBOTICS TO ASSIST WITH THE SURGERY?
Although the American Medical Association and other leading medical societies have issued statements discouraging robotic techniques due to dramatically higher costs to patients without any medical advantages, robotics continue to be used in GYN surgeries. This is because robotic procedures “enable” an OB-GYN not well trained in laparoscopic GYN surgical techniques to complete GYN surgeries through a “minimally invasive” approach. This is why women need to ask if robotics will be used during a GYN surgery and to seek a specially trained surgeon able to perform the latest minimally invasive surgical techniques, such as DualPortGYN and retroperitoneal dissection that do not use robotics.
WHAT IS MY ANTICIPATED RECOVERY TIME?
New minimally invasive techniques require, on average, only a week to recover. Other procedures such as open abdominal surgery can take up to 8 weeks.
WHAT ARE MY OTHER SURGICAL OPTIONS?
Ask your physician if he or she is aware of new, minimally invasive procedures.