Prolapse

What is a Utero-Vaginal Prolapse?

A prolapse is a medical condition where an organ or tissue moves or is displaced from its normal position. A pelvic organ prolapse is a condition that occurs when the structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself fall out from their normal position.

Utero-vaginal prolapse is a downward movement of the uterus and/or vagina.

Types of Vaginal Prolapse & Pelvic Floor Disorders

Vaginal prolapse is when pelvic organs such as the bladder, rectum, uterus, urethra, and small bowel protrude into the vaginal wall. Several types of vaginal prolapse conditions have been identified, and they include:

• Cystocele – Bladder protrudes into the vagina
• Rectocele – The rectum protrudes into the vagina
• Vaginal vault prolapse – Top portion of the vagina herniates into the vaginal canal
• Uterine prolapse – Uterus prolapse into the vagina
• Enterocele – Small bowel herniates into the vagina

Causes of Vaginal Prolapse

The main cause of vaginal prolapse is the weak muscles, tissues, and ligaments that support the vagina, surrounding tissues and organs.

The factors that can cause vaginal prolapse include

• frequent lifting of heavy objects,
• chronic cough,
• severe constipation,
• menopause,
• childbirth,
• previous surgeries in the pelvic area,
• advanced age,
• hysterectomy and
• obesity.

Symptoms of Vaginal Prolapse

Women with prolapse may have different symptoms based on the type of prolapse. The signs and symptoms include

• difficulty in urinating and emptying the bowels,
• enlarged and wide vaginal opening,
• vaginal lump, and
• the protrusion of tissues at the front and back wall of the vagina.

Impact of Pelvic Floor Disorders

When the pelvic floor muscles and connective tissue that support the pelvic organs are weakened, the pelvic support is lost, resulting in protrusion of the

• bladder,
• urethra,
• cervix and
• rectum.

Conservative Treatments For Pelvic Floor Disorders

If the symptoms are mild, non-surgical treatment options such as

• medications,
• pelvic floor exercises,
• vaginal pessaries (a device that is inserted in the vagina to support the pelvic floor), and
• lifestyle changes may be helpful.

Surgical Treatments For Pelvic Floor Disorders

Surgery can be considered in patients with severe symptoms of pelvic organ prolapse.

There are different types of procedures to address a specific prolapse. Pelvic floor reconstruction aims to restore the normal anatomy and function of the pelvic organs.

Surgery can be done through an open incision in the vagina; the surgery's essential part is restoring support to the vaginal apex.

Vaginal Prolapse Surgery

Native Tissue Surgery

Pelvic organ prolapse was traditionally treated surgically using native vaginal tissue (NT). It involved using the patient’s tissue and sutures to restore the vagina to a natural position by re-attaching it to the various support structures.

Reports in the literature of high recurrence rates associated with vaginal native tissue repair led to the development of alternative techniques, such as synthetic mesh.

However, the newer data obtained from large population studies with long-term follow-up periods show that the recurrence rate with NT is much lower than was earlier predicted.

Native tissue repairs have similar outcomes to synthetic mesh without the risks inherent in mesh use. Due to side effects from using mesh, it is now banned in Australia for vaginal repairs.

Colporrhaphy

Colporrhaphy is the surgical procedure to correct cystocele and rectocele. In this procedure, your doctor makes an incision in the vaginal wall. The bladder and rectum are pushed back to their normal positions, the excess tissue is removed, and the incisions are closed. If you are suffering from urinary incontinence (involuntary leakage of urine), your doctor may use a splint to support the urethra, and this procedure is called bladder neck suspension.

Uterine prolapse

Uterine prolapse can be treated by a procedure called hysterectomy, where the uterus is removed. After the hysterectomy, the Vault is attached to the uterosacral ligament to prevent future Apex/vault prolapse.

Vaginal vault suspension –The top of the vagina is attached to a strong ligament at the back of the pelvis or at the base of the spine to support the vagina.

The ligaments and muscles are reattached to the top of the vagina with the help of sutures. Suturing the vaginal walls will only repair the defect and will not provide support to the apex of the vagina and to the supporting structures.

The most common procedures to restore vaginal apex support are:

1. Abdominal Sacral Colpopexy (ASC): During this procedure, straps of graft material are placed over the front and back walls of the vagina and secured to the ligament over the sacrum. As a result, the vagina is suspended over the pelvic muscles to the sacrum. This graft material replaces the uterosacral ligaments, which naturally support the uterus.
2. Uterosacral and Sacrospinous Ligament Fixation – This is performed through a vaginal approach. The vaginal apex is suspended to a patient’s uterosacral or the sacrospinous ligaments. Traditionally, graft material was not used. However, recently, graft materials have been employed to enhance the durability of prolapse repair in patients with weak vaginal walls.

Enterocele is another vaginal compartment prolapse. It is a weakness in the top of the posterior vaginal wall between it and the rectum.

Complications Of Vaginal Prolapse Surgery

Every surgical procedure may be associated with certain risks and complications.

The possible complications after the surgeries for vaginal prolapse include pain, infection, bleeding, recurrence of symptoms, vagina becoming too narrow for sexual activity, injury to ureters, and perforation of rectum and bladder.

The complications are usually mild but may need further surgery and can be treated accordingly.