Pelvic Organ Prolapse

When the natural mesh-like tissue and ligaments that hold pelvic structure in place begin to fail, the result is a condition known as Pelvic Organ Prolapse (POP). Pelvic organ prolapse occurs with descent (sagging/drooping) of one or more pelvic structures: the uterus/cervix (metrocele/uterovaginal prolapse), vaginal cuff (vaginal cuff prolapse), anterior vagina/bladder (cystocele), posterior vagina/rectum (rectocele), or peritoneum of the cul-de-sac/small intestine (enterocele) (Compare Figures 1 & 2). To explain this in more detail, a well supported vagina can withstand natural intra-abdominal/pelvic pressure. Such proper vaginal anatomical position and performance depends on adequately functioning endopelvic fascia. Fascia is an intricate natural elastic mesh layer lining the entire pelvic floor. Pelvic organs (bladder, uterine cervix, rectum and vagina) are partially embedded into the endopelvic fascia. Weakening or breaks of the fascia result in different types and degrees/stages of pelvic floor relaxation. The stages/grades of POP are determined on physical exam and depend on whether or not the prolapse is still inside the vagina or protruding outside the vagina. Possible risk factors for pelvic organ prolapse include genetic predisposition, number of full term pregnancies (particularly vaginal birth), menopause, advancing age, prior pelvic surgery, connective tissue disorders, and factors associated with elevated intra-abdominal pressure such as obesity and chronic constipation with excessive straining.

Pelvic organ prolapse (POP) is a common condition, especially in post-menopausal women, and almost 50% of women who have carried at least one pregnancy to full term can be identified as having at least mild POP by physical exam. POP is the most common indication for hysterectomy in women aged 55 years and older in the United States. This process can cause a variety of symptoms, including vaginal bulging/fullness, pelvic pressure, urinary incontinence, difficulty emptying the bladder, chronic constipation, and difficulty evacuating the bowels. These symptoms can significantly compromise daily activities. Fortunately, most women with POP do not have bothersome symptoms and treatment is only recommended if a patient is having symptoms that significantly affect her quality of life. It cannot be assumed that nonspecific symptoms, such as pelvic pressure or back pain, will be alleviated with prolapse treatment.

In symptomatic patients with POP, the options for treatment are as follows: observation, pelvic floor muscle rehabilitation (Kegel exercises), vaginal insertion of a pessary, or surgical restoration. There are many factors that go into deciding which treatment is best for each patient. These deciding factors include the patient’s symptoms, her desire for treatment, the type and degree of the prolapse, her desire for vaginal intercourse, and whether or not she is healthy enough to undergo surgery.

Pessary is a ring, “donut”, cube or otherwise shaped device made of plastic or rubber which is fitted and inserted vaginally in our office. It usually can be successfully fitted in one or two office visits. Success rates range from 50-73%. Pessaries can be fitted in most women with prolapse, regardless of prolapse stage or site of predominant prolapse, and are used by 75% of urogynecologists as first-line therapy for prolapse. It prevents pelvic organ sagging through the vagina and allows spontaneous and natural urination. In one study, 2 months after successful fitting, 92% of patients were satisfied with pessary management, nearly all prolapse symptoms had resolved, and 50% of urinary problems were reduced. The Pessary needs to be removed and cleaned periodically (about every 3 months) either by a gynecological provider or the patient herself. Vaginal intercourse is not possible while the pessary is inside the vagina. But a patient can remove it to have intercourse and then replace it. Pessary is a very good solution for patients who are no longer having vaginal intercourse or cannot have surgery because of other medical conditions.

Another option for patients who are no longer having vaginal intercourse and do not desire to use a pessary, or a pessary has been unsuccessful, is a surgical procedure called Colpectomy/Colpocliesis. This is a vaginal surgery (with or without vaginal hysterectomy) which effectively eliminates the prolapse and results in a shortened and narrowed vagina. It may be done under general anesthesia or regional (spinal or epidural) anesthesia. Usually patients stay overnight in the hospital and it requires between four and six week recovery.

There are multiple available surgical procedures for patients who desire to preserve the vaginal canal and have the option of future vaginal intercourse. The surgical approach depends on the patient’s symptoms, type of prolapse, the patient’s history of previous abdominal/urogynecological surgeries, as well as the surgeon’s level of skill and comfort. Laparoscopic Repair of Pelvic Prolapse (Laparoscopic Sacrocolpopexy) is the most effective, permanent, minimally-invasive surgical solution. It involves suspension of the vagina towards the sacrum using polypropylene mesh. This is an outpatient procedure with only three small incisions, requiring only about a 2 week recovery at home. Abdominal (non-laparoscopic) sacrocolpopexy has been the “gold standard” and the most effective surgical resolution of pelvic prolapse for more than 50 years. It requires a 5-10 inch abdominal incision, 2-3 day hospital stay and 6 week recovery at home. At AMIGS, we perform this procedure laparoscopically. The advantages of a laparoscopic procedure are many. Patients usually go home the same day, the recovery time is faster and less painful, and the cosmetic outcome is better. After May 2010 we will also have the option of performing minimally-invasive Robotic Surgery. Sometimes this procedure is combined with other vaginal procedures such as anterior/cystocele,posterior/rectocele, and/or paravaginal repairs.

When the natural mesh-like tissue and ligaments that hold pelvic structure in place begin to fail, the result is a condition known as Pelvic Organ Prolapse. After childbearing, heavy physical occupation or traditional hysterectomy a large percentage of women suffer from pelvic floor relaxation. This occurs mainly into or through the vaginal space and many women commonly describe this as “drooping”, “hanging out” or “my contents are falling out”. The bladder, uterus, rectum, small and large bowel rest upon the vagina, and one or more of these organs may be involved in the vaginal drooping. This process can cause a variety of symptoms, including vaginal bulging/fullness, pelvic pressure/pain, urinary incontinence, and more, and can significantly compromise the quality of life.

A well supported vagina can withstand natural intra-abdominal/pelvic pressure. Such proper vaginal anatomical position and performance depends on adequately functioning endopelvic fascia. Fascia is an intricate natural elastic mesh layer lining the entire pelvic floor. Pelvic organs (bladder, uterine cervix, rectum and vagina) are partially embedded into the endopelvic fascia. Weakening or breaks of the fascia result in different types and degrees of pelvic floor relaxation. Pelvic organ sagging through the vagina may be defined as cystocele (bladder prolapse), enterocele (bowel prolapse), rectocele (rectal prolapse), metrocele (uterine prolapse) or any combination of two or more of these conditions.

Surgical restoration is the only effective way to address significant and symptomatic pelvic floor relaxation. Laparoscopic Repair of Pelvic Prolapse is the minimally invasive solution.

Learn more about Laparoscopic Repair of Pelvic Prolapse.

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