Evelyn Lyles, MD
Michelle LeBlanc, MD
James Theofrastous, MD
Nancy Howden, MD
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Evelyn Lyles, MD Michelle LeBlanc, MD James Theofrastous, MD Nancy Howden, MD
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Treatment of Vaginal Prolapse Pelvic organ prolapse requiring surgery may affect at least 1 in 3 women over their lifetime. Loss of support of the uterus, bladder, &/or rectum may result in a many clinical symptoms including incontinence, sexual dysfunction, & disruption of social & exercise activities. The most important contributing factor is childbearing, but the inherent strength of the supporting tissues of the vagina & uterus is also important. Numerous studies have demonstrated that there are genetic factors which increase the risk & accelerate the course of prolapse. It is not uncommon for grandmothers, mothers, sisters, & daughters in a family to suffer from the same prolapse problems. With time these problems almost always slowly get worse. Like most things, prolapse occurs in different levels of severity. In mild forms of prolapse, no treatment is necessary & it is reasonable to see what will happen with time. In most women, their prolapse will slowly worsen with time. Exercise, straining, & sex will not significantly cause the condition to get worse; although the prolapse may make these activities uncomfortable. In severe forms of prolapse, the pelvic organs may be completely outside forming a bulge the size of a grapefruit, & immediate treatment is necessary. It is important to have clear goals for treatment of prolapse. Sometimes it is impossible to know whether a symptom, for example back pain, is due to prolapse or something else, & you may not know the answer until after the treatment. As a rule of thumb, once the tissue starts to come outside of the vaginal opening, it is time to start thinking about treatment. There are no medical or exercise therapies for prolapse, & treatment options consist of using a mechanical device called a pessary or surgery. Pessary- Pessaries have been used by women with prolapse for hundreds of years. In the past they have been associated with infection & discharge (some were made of sponges, vegetables, wood, or stone!). Modern pessaries are made of materials such as silicon which do not react with body fluids or tissues & rarely cause discharge or infection. Pessaries come in several sizes & shapes, & it is necessary to get the right one to fit your anatomy. They are inserted much like a contraceptive diaphragm, &, once in place, you usually don’t feel it. It is normal to feel the edge of the pessary at the vaginal opening when in the bathroom, & sometimes you may need to support it with your fingers if you are straining with a bowel movement (which you shouldn’t do!). This diagram shows a pessary in place.
A pessary can not always be fitted, depending on the type & severity of prolapse, particularly when the opening of the vagina is enlarged. If you are sexually active, you may be instructed by the nurse on how to insert & remove the pessary. You can’t put it in wrong or hurt yourself with it, & most women can learn how to do it. It is just like inserting a diaphragm for birth control. Once your pessary is fitted, you will return in about 2 weeks to see the nurse for a recheck. If it falls out before then you should call to come in for a slightly larger one. After that you will need to come back every 4 to 6 months for a recheck. A pessary will not cure prolapse & must be used forever. It is ideal for elderly women who are unable to go through surgery safely, & for younger women who do not want surgery or who need something temporary until surgery can be performed. In older women the vaginal tissues may be thin & the pessary may rub the tissues & make them raw causing spotting. This usually heals quickly with removal of the pessary & treatment with a low dose of estrogen hormone in the vagina. Surgery for Vaginal Prolapse- When prolapse is causing significant symptoms & a pessary is not an option, it is reasonable to consider surgery. Surgery can range from simple outpatient procedures with minimal recovery, which general gynecologists can perform, to advanced reconstructive pelvic surgery procedures requiring hospitalization & a month or 2 of recovery, which are performed by Urogynecologists, like Drs Theofrastous & Howden. Our philosophy is that surgery is a last resort, but when the decision is made to proceed with surgery it is vital to be evaluated by a skilled & experienced doctor to determine the best procedure. If the correct procedure is not performed, it is likely that you will require another surgery down the road. It is also generally recommended to delay prolapse surgery until childbearing is complete, since delivery a baby would disrupt the surgical repair. For women with severe problems who desire more children surgery may be performed, but delivery by caesarian section is generally recommended. The challenge for the surgeon who treats women who suffer from vaginal prolapse is to perform a durable procedure which will restore normal anatomy & allow normal bladder, bowel, exercise & sexual function. Unfortunately the tissues we are dealing with are damaged & inherently weak, & surgery does not make them stronger. Surgery will fix the tears in the tissues & return the vagina to it’s normal position; but the tissues are still inherently weak & vulnerable. Fortunately, most women who undergo surgical repair are not going to deliver a baby after that & damage the tissues, but wear & tear will still occur with time. Risk factors for recurrent prolapse include obesity, lung disease (including smoking), constipation, & developing prolapse at a young age. Surgery raises the threshold for developing prolapse, but everything has a breaking point. Most women with vaginal prolapse have lost support of more than one area of the vagina. This becomes increasingly true with time. It is vital that all areas of significant prolapse are repaired. Otherwise, it is almost certain that those unrepaired areas of prolapse will worsen & require further surgery. It is often necessary to perform several procedures at the same time to reduce the risk of subsequent prolapse & surgery. Sometimes, despite the best surgical repair of their vaginal prolapse, women will develop prolapse of a different area of the vagina surgery. This is not surprising due the inherent weakness of those tissues, but it is frustrating. The old adage "if it is not broken, don't fix it" applies. The risk of subsequent vaginal prolapse can be minimized by undergoing evaluation & treatment by a surgeon who is an experienced expert in repairing vaginal prolapse. Vaginal Mesh Procedures Pelvic surgeons have long recognized that the weakness in the composition of the supporting tissues of the vagina is the primary cause of prolapse. This weakness results in significant failures after many traditional support procedures. Due to this high rate of recurrence using the body's own tissues, many surgical materials have been employed in an attempt to effect a more durable repair. These meshes are biologically inert, so the body's immune system does not react to them or reject them. Biological materials prepared from human or animal sources have generally proven to be ineffective due to breakdown & absorption. While permanent mesh is used routinely & safely to treat hernias outside of the pelvis, some meshes have had significant problems when they are used in the the vagina. This seems to be due to the fact that the vagina has no fat tissue & is a very thin layer of skin unlike the abdominal wall which has a layer of fat tissue between the skin & the mesh. Furthermore, the blood supply to the vagina is damaged during childbirth & sometimes vaginal surgery, & the skin becomes thinner with aging & reductions in estrogen levels. These factors combine to result in higher rates of vaginal erosion with some artificial meshes. Smoking also increases the risk of poor healing & mesh exposure. When this occurs the vagina will not heal over the material resulting in exposed graft. This can cause chronic vaginal spotting & discomfort during sex. Graft exposure can often be treated with vaginal estrogen, but sometimes requires repeat surgery in the office or the operating room. Infection of the mesh is fortunately very rare. There are no definitive surgical studies which demonstrate the best material to use, or even when mesh is preferable to non-mesh procedures; but many studies have suggested that biological materials tend to be reabsorbed & do not increase the rate of successful surgery. Our opinion is that mesh is not needed for every procedure, & that artificial meshes are more effective than biological meshes. Our approach to new surgical treatments is very cautious. We do not start using new techniques until there is considerable scientific evidence that they are safe & effective. We believe that new procedures should be better than more established procedures & more cost effective. Surgery for Bladder Prolapse- The most common operation performed for prolapse is to repair bladder prolapse, or a cystocele. The medical term is “anterior repair” or “anterior colporrhaphy” . This is often referred to as a “bladder tack,” although that is not a medical term & may include other procedures. The surgery for bladder prolapse consists of fixing the hernia by finding the tear in the tissues & sewing them back together, & sometimes sewing the vaginal tissues back to the side of the pelvis (a “paravaginal repair”). By itself, this procedure usually does not improve bladder control. Surgery for Rectal Prolapse- This is the next most common prolapse surgery & is called a “posterior repair” or “posterior colporrhaphy.” This surgery involves finding the tear beneath the vagina which has caused the hernia, & sewing it back together to the opening of the vagina. If the opening of the vagina is widened the torn tissues & muscles will be sewn back together to create a normal vaginal opening (a “perineorrhaphy” or "perineal repair"). Surgery for Uterine or Vaginal Cuff Prolapse- If the uterus is well supported & not causing problems, it is not necessary to remove it . If the uterus is dropping significantly, & you have completed childbearing, a hysterectomy is usually recommended. For women who desire to maintain their ability to have children, or women who wish to retain their uterus, a procedure can be done to suspend the uterus. One of the main advantages in newer mesh procedures is that hysterectomy may not be required, which is much less surgery to go through. Current surgical thinking is that the mesh is best used to support the uterus in women who have completed menopause. Once a hysterectomy has been performed, the top of the vagina (“cuff”) is then secured in place. Hysterectomy by itself will not cure prolapse. The major decision to be made by you & your surgeon is whether to perform an abdominal or vaginal procedure. Hysterectomy can be performed either way, but the prolapse procedures are very different. Not all surgeons are trained or skilled in both methods, & it is reasonable to stick with what they are experienced with. Dr Theofrastous has performed hundreds of each type of these procedures & will discuss these decisions with you. Abdominal Vaginal Suspension Surgery- The abdominal suspension of the upper vagina is called a sacral colpopexy. The sacral colpopexy was developed over 30 years ago & has a very good safety & effectiveness record. It is performed through a bikini-type sideways abdominal incision just above the pubic bone. A cone of fine mesh material is then attached to the top of the vagina with several permanent stiches, & then it is anchored to the bone in the sacral area. The space between the mesh & the bowel is then closed (a "cul-de-plasty"). The surgery is not around any nerves of the spine, they are on the backside. This procedure provides excellent support for the top of the vagina as well as some support to the upper bladder & back of the vagina. Most women go home the day after surgery. This picture shows the pelvis from the side with the mesh in place:
Vaginal Suspension Surgery- It is difficult for most patients to envision, but most prolapse surgery can be accomplished safely & effectively through the vagina. This is due to instruments which help visualize the pelvis, good surgical assistants & lighting. In general vaginal surgery is the way to go if possible. The recovery & discomfort following surgery are much less than with abdominal surgery, & the surgery has the potential for fewer complications. The drawback of a vaginal approach to suspending the vagina using your own tissues is that numerous medical studies have shown that it is not as good for a long-term success as procedures which use mesh. The vaginal suspension procedure consists of attaching each side of the top of the vagina to a ligament or to the side of the pelvis. If the tissues across the top of the vagina are strong enough, this will provide a durable result. Unfortunately there is no way to tell how strong those tissues are, & chances are that they aren’t very strong or the prolapse would not have occurred in the first place. The reported success rate is usually 70-80% over 5 years or so. Most women go home the day after surgery. Vaginal Support Procedures: Using Mesh to Repair Pelvic Organ Prolapse Interest in using mesh for the repair of vaginal prolapse was spurred by very low erosion rates noted following newer pubovaginal slings which use mesh. This has led to the development of larger meshes using the same materials for the repair of more extensive vaginal prolapse. Recent studies have demonstrated safety & efficacy of some of the new vaginal mesh procedures. These mesh procedures are particularly promising in that hysterectomy is often not necessary. These meshes are placed vaginally with small exit incisions in the upper inner thigh. They form a broad platform from one side of the pelvis to the other. They provide support for the upper vagina or uterus, as well as the bladder & rectum depending on the type, location, & severity of the prolapse. Here is a picture of the vaginal mesh in position looking from below (this patient has had a hysterectomy):
Here is a picture of the vaginal mesh in position looking from above:
What is the Right Procedure for You? The choice of the right procedure depends on your type of prolapse, how severe the prolapse is, your health, & lifestyle. Other factors include age, whether hysterectomy is necessary, sexual activity, prior surgery, & anatomy. Ultimately, it is your decision. Your surgeon will discuss these issues with you & honor your wishes. For information about what to expect in the hospital & following surgery click here.
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