Although many women choose to manage their prolapse without surgery, surgery for prolapse is very common.
Doctors may suggest surgery if other treatments have failed, and many times, surgery is chosen when a vaginal pessary is either not desired or cannot be retained comfortably. There are several different surgical techniques which are effective. In addition to the experience and training of the surgeon, specific choices offered depend on your:
- Anatomy
- Overall health, including prior surgeries and current medical conditions
- Desire to retain sexual function
Whether or not to have surgery for prolapse is an individual decision. The success or failure of someone else's operation should never be the deciding factor for you. Every woman's situation is different. There is no single operation that is right for every patient. You and your surgeon must decide on the best option together.
Surgery is a major decision you must make with your physician. You may find the tools below helpful in preparing for surgery. One presents questions to ask your doctor during your pre-op visit, providing an overview of what you can expect when preparing for surgery, and general recommendations for how you can prepare for surgery. The other offers information about mesh.
Types of POP Surgery
Pelvic surgeries can help restore the normal pelvic floor anatomy or repair damaged muscles or tissue. Many procedures to correct pelvic organ prolapse can be performed through small incisions in the vagina or abdomen (laparoscopic or robotic-assisted techniques), which may reduce scarring and complications and may shorten recovery time.
Apical Suspensions
Apical suspension surgery restores the support of the top of the vagina, which is also called the vaginal apex or vault, and helps to maintain sexual function. There are two common surgical approaches to apical suspension.
Sacrocolpopexy
The sacrocolpopexy (also called sacral colpopexy) can be performed through an abdominal incision (about 6 inches long), laparoscopically with or without robotic assistance (through 4-5 half-inch incisions). In this procedure, straps of permanent medical mesh graft material are used to reinforce the front and back walls of the vagina. These straps are then attached to a strong ligament overlying the sacrum. The end result is that the vagina is suspended over the pelvic muscles to the backbone. The mesh graft straps replace the original natural support provided by the uterosacral ligaments.
Uterosacral or Sacrospinous Ligament Fixation
In these surgeries, the top of the vagina is suspended to a woman’s own ligaments using sutures. These procedures do not use mesh graft material.
Anterior Vaginal Prolapse Repair
A cystocele or bulge of the front wall of the vagina usually results in loss of support to the bladder that rests upon this part of the vagina. The goal of a cystocele repair (also called anterior repair or anterior colporrhaphy) is to elevate the anterior vaginal wall back into the body and support the bladder. Sometimes an apical suspension procedure can correct anterior vaginal vault prolapse instead of or in addition to an anterior colporrhaphy.
In an anterior colporrhaphy, an incision is made in the top wall of the vagina. The vaginal skin is separated from the bladder wall behind it. The weak or frayed edges of the deep vaginal wall are found and the strong tissue next to edges are sutured to each other, lifting the bladder and recreating the strong “wall” underneath it. The vaginal incision is then closed with dissolving stitches.
Unfortunately, the anterior vaginal wall is the most common site of recurrent prolapse. Studies are ongoing on safe and effective ways to reduce this risk.
Posterior Vaginal Prolapse Repair
A rectocele or bulge of the back wall of the vagina is most often repaired by a vaginal procedure called posterior colporrhaphy. If the muscles at the opening of the vagina have been stretched or separated during childbirth, the repair may include a perineorrhaphy (repairing the perineum). Sometimes an apical suspension procedure can correct posterior vaginal vault prolapse instead of or in addition to a posterior colporrhaphy.
Posterior Colporrhaphy
During the colporrhaphy procedure, an incision is made in the back wall of the vagina. The vaginal skin is separated from the rectal wall underneath. The weak or frayed edges of the deep vaginal wall tissue are identified. The strong tissue next to edges are sutured to each other recreating the strong “wall” between the rectum and the vagina. The vaginal incision is then closed with dissolving stitches.
Perineorrhaphy
Surgical reconstruction of the muscles of the perineum, the area between the vagina and the rectum. This procedure involves reattaching a number of small muscles that normally connect in this area.
Obliterative Procedures
For those women who do not desire to maintain sexual function (vaginal penetration), an obliterative procedure may be the quickest and safest method to correct prolapse. Obliterative operations correct prolapse by narrowing and shortening the vagina. These procedures support the pelvic organs with the patient’s own pelvic muscles in such a way as to make the vagina too small to accommodate penetration.
The skin overlying the vaginal bulge is removed, and the front and back walls of the vagina are sewn to each other. A woman who has undergone this surgery will look the same on the outside of her genital area and she will be able to have bowel movements and urinate normally. Her ability to have an orgasm with clitoral stimulation is similar to before her surgery.
There are two main types of obliterative surgery:
Both are very effective and durable in correcting prolapse. Prior surgeries often influence which procedure is offered to women. The benefit of obliterative surgery is that it is very durable, does not involve the risks of graft materials, tends to be less invasive and therefore is associated with a quicker recovery.