Pelvic Organ Prolapse
Q: What is prolapse?
A: Prolapse is a hernia of the vagina that a woman may feel as a bulge or pressure. This is referred to in many different ways. Sometimes it is called a “dropped bladder”, “dropped uterus,” “dropped vagina,” or “dropped rectum.” Your doctor may have also called this a cystocele, rectocele, or enterocele.
Prolapse is caused by a weakening of the vaginal tissues. Prolapse is associated with pregnancy and childbirth; however prolapse can happen in women who have never had children. Prolapse is also associated with repetitive heavy lifting, chronic constipation, chronic cough, and poor tissue.
Prolapse symptoms may be worse at different times in the day. Some women notice that they feel more pressure after walking or standing for long periods of time.
Q: My doctor told me I have a “dropped bladder.” What is this?
A: Sometimes the vaginal tissue under the bladder becomes weak and causes a hernia. This is called prolapse. You may feel a bulge outside the vagina or pressure. Your doctor may also have called this condition a “cystocele.”
Q: Is prolapse something serious?
A:Prolapse may be uncomfortable, especially if you can feel the bulge after walking or standing for long periods of time. The good news is that prolapse is generally not life-threatening and many treatment options are available. For most women, the treatment they choose depends on how much they are bothered by their symptoms. Many conservative treatment options are available including dietary changes, pelvic floor muscle exercises, and physical therapy. One treatment for prolapse is a device inserted into the vagina called a pessary. Finally, some women are bothered by the prolapse enough to decide to have surgery.
Q: Can prolapse get worse?
A: For some women, their prolapse gets worse over time. For others, their prolapse will stay the same with conservative treatment options. Prolapse generally does not improve without surgery.
Q: What will happen if I just ignore this problem? Will it get worse?
A: Most likely. Prolapse, left untreated, almost always gets worse over time but this is usually a gradual change. “New” prolapse (noticed by a patient or doctor in the early postpartum period) will often get better within the first year after the delivery. This is one exception to the rule.
Treatment of prolapse should be based on your symptoms. In rare cases, severe prolapse can cause urinary retention (inability to empty the bladder) that progresses to kidney damage or infection. When this occurs, prolapse treatment is considered mandatory. In most other cases, patients should be the ones to decide when to have their prolapse treated - based on the symptoms they are having.
Q: Do I have to have a hysterectomy as a part of my surgery?
A: No. Any or all of the operations for prolapse and incontinence can be performed with or without a hysterectomy. However, hysterectomy is often performed along with these operations for a variety of reasons. In some cases, removing the uterus first makes the rest of the surgery easier to perform. In other cases, there is another reason besides prolapse or incontinence (such as cancer or excessive bleeding) to remove the uterus. Whether or not to remove the uterus should be discussed between the patient and her surgeon, and the decision should be individualized from patient to patient.
Recently, there has been renewed interest in the possibility of repairing the prolapse without taking the uterus out (uterine preservation). Reasons to consider uterine preservation include the following:
- Potentially decreasing the operative time and risk of surgery, because the hysterectomy part is not required
- Reducing vaginal incisions, which might in turn reduce some kinds of complications like erosions, and leave more of the support structures intact
- Individual patient preference
- The desire to become pregnant. Most surgeons, however, discourage prolapse surgery until childbearing is complete.
There are, however, reasons to be cautious about leaving the uterus in place, which include the following:
- Presence (or development) of abnormalities, such as fibroids or cancer
- Continued need for Pap smears, especially if there have been abnormal Pap smears in the past
As always, these issues require a careful conversation that addresses the experience and recommendations of the surgeon, along with the values and preferences of the patient.
Q: I have prolapse, but I don't leak urine. Do I still need bladder testing?
A: Most likely. If you are going to have surgery to correct the prolapse, bladder testing (called urodynamics) usually is done first. That's because the prolapsed portion of your vagina may be pushing on your urethra and preventing urine leakage. If that is the case, having the prolapse corrected can give you a new problem - urinary incontinence. The best way to tell whether a continence procedure is needed at the time of prolapse surgery is to perform urodynamics while holding the prolapse up in its normal position.
Q: If my surgery is successful, how long will it last?
A: The goal of continence or pelvic reconstructive surgery is to re-create normal anatomy permanently. However, none of these procedures are successful 100% of the time. According to the medical literature, failures occur in approximately 5 - 15% of women who have prolapse surgery. In these cases, it is usually a partial failure requiring no treatment, pessary use, or surgery that is much less extensive than the original surgery. Patients who follow the recommended restrictions after surgery give themselves the best chance for permanent success.
Q: How successful is surgery for pelvic organ prolapse?
A: Many factors affect the outcome of reconstructive surgery. Some of the factors that originally contributed to your pelvic floor problems, such as decreased muscle and nerve function and weak connective tissue, might still exist after the reconstructive procedure has been performed.
Pelvic organ prolapse, like a hernia, is the abnormal protrusion of an organ through a weak pelvic floor. Hernias in the pelvic floor are technically more difficult to repair than other hernias because pressure in the pelvic floor from daily activities puts a lot of stress on the surgical repair. As a consequence, some women have a persistence or recurrence of their prolapse after surgery.
It is important to have realistic expectations: some patients cannot be cured. Surgery may result in fewer symptoms, but all of your symptoms may not be relieved. Sometimes surgery for pelvic organ prolapse fails to relieve any symptoms. Discuss the success rates of your particular procedure, or combination of procedures, with your surgeon.
Q: If I decide to have surgery, what can I expect during the recovery period?
A: Depending on the extent of your surgery, the hospital stay usually lasts one to four days. Many women have difficulty urinating immediately after the surgery and have to go home with a catheter in place to drain the bladder. These catheters are usually only necessary for 3 - 7 days. Most patients require at least some prescription strength pain medicine for about one to two weeks after surgery. After any surgery to correct urinary incontinence or prolapse, we ask that patients “take it easy” usually for 12 weeks to allow proper healing. This means no lifting more than 5 pounds (the weight of a gallon of milk), no intercourse, nothing in the vagina and no exercise other than walking unless otherwise instructed.
The amount of time necessary for you to "bounce back" from surgery has a lot to do with the route of surgery. In other words, if an abdominal incision is necessary to perform your operation, you will probably have more pain after surgery than if your procedure is performed through a laparoscope or through the vagina. However, some patients are not good candidates for the vaginal or laparoscopic approaches. Your doctor should be able to explain his/her choice regarding the type of surgery you need.
Even if your surgery is performed via a less invasive route, prolapse operations tend to be "major surgery". In other words, all of these operations are a big deal and shouldn't be taken lightly. If you are bothered enough by your symptoms to want a surgery to fix them, then you should give yourself the best chance of success by following the doctor’s instructions after the surgery, even if you feel okay.
Q: What are the risks with using graft material?
A: Graft material, most often used for prolapse repair, is a medical grade polymer or plastic called polypropylene. This graft material is also used for abdominal and groin hernia repairs. Approximately 90% of patients do very well with this material. However, 5-10% of patients may experience an exposure of the material into the vagina, causing vaginal discharge or spotting, and these patients may require removal of the exposed mesh material. This can either be done in the office or as an out-patient procedure.
Other less common complications associated with the mesh grafts include infection which is treated with antibiotics and surgery to remove the graft. Women who smoke tobacco products carry a greater risk for mesh exposure. Currently, women with severe or recurrent prolapse who prioritized retaining sexual function gain the greatest benefit from mesh reinforcement procedures. Every woman has a different risk/benefit profile regarding graft repairs.
Q: What is a pessary?
A: A pessary is a plastic device that can be used to help support prolapse. It is used for women who do not want surgery. Pessaries come in different shapes and sizes and can be fitted to help women with different degrees and types of prolapse. Pessaries are safe to use and are latex free. Once you decide that you would like to try a pessary, you will be fitted for the correct size and shape to help support the prolapse without causing any discomfort or pain. The pessary that fits best will be able to support the prolapse, feel comfortable and allow you to urinate and have bowel movements without difficulty. Pessaries should be removed and cleaned on a regular basis. Most pessaries are easy to remove, clean and replace daily or weekly. Some pessaries are difficult to remove and require you to be seen in the doctor’s office for removal, cleaning and replacement. A pessary can be used for any woman who is bothered by her prolapse but does not want to have surgery or for women with other medical conditions that makes surgery more risky. Pessaries can be used for as long as the woman desires.
Original publication date: May, 2008