What is a prolapse?
Genital prolapse is the protrusion of the pelvic organs into the vagina or even outside the vagina. There are a number of different types of prolapse:
- Uterine prolapse involves the descent of the uterus and cervix down the vaginal canal. In the most severe situation, the entire uterus and cervix protrude through the vaginal entrance.
- Cystocele is where the tissues supporting the wall between the bladder and vagina weaken, allowing a portion of the bladder to descend and protrude into the vagina.
- Rectocele is where the tissues supporting the wall between the vagina and rectum weaken allowing the rectum to descend and protrude into the vagina.
- Vaginal vault prolapse occurs when the top of the vagina descends, usually following a hysterectomy.
What causes a prolapse?
Prolapse occurs due to a weakness or damage that has occurred to the structures which hold the pelvic organs in place. There are a number of contributing factors, including:
- Pregnancy and childbirth can cause prolapse through hormonal changes, damage to tissues or nerves. Damage to the pelvic floor occurs particularly in long labours, instrumental deliveries (the use of forceps or vacuum extraction) and in the delivery of large babies.
- Menopause and ageing increase the risk of prolapse..The female hormone oestrogen plays an important role in maintaining the strength of the pelvic floor. At menopause, a woman’s oestrogen levels decrease and, as a result, the pelvic floor becomes weaker. The lack of oestrogen at this time often exacerbates existing damage that may have occurred as a result of childbirth or other factors. The pelvic support structures also relax due to the natural ageing process.
- Increased pressure in the abdomen, as a result of chronic coughing, lifting of heavy objects and obesity, place pressure on the pelvic floor. If these pressures continue over a long period of time they can weaken the pelvic floor.
- Genetic and hereditary factors also play a role.
What are the symptoms?
The symptoms of prolapse vary according to the organs involved and the severity of the prolapse. A woman with minor prolapse may not have any significant symptoms at all. Common symptoms include
- a dragging sensation or feeling that something is falling down. These feelings are especially noticeable when sneezing, coughing, with physical exertion, after long periods of standing or at the end of the day
- presence of something in the vagina or vaginal entrance. If the cervix and/or uterus protrudes through the vaginal entrance they may become ulcerated and infected or cause difficulty walking
- aching discomfort in the pelvic region or lower back
- urinary problems. The change in position of the bladder that can occur with prolapse may lead to stress incontinence (leaking of urine when coughing, sneezing, laughing), frequent urination, incomplete emptying of the bladder and urinary infections
- bowel problems. A rectocele, for example, can result in constipation or difficulty in emptying the bowel
- sexual problems. Prolapsed pelvic organs can make penetration difficult and the loss of pelvic tone can result in decreased sensation.
How is a prolapse diagnosed?
A prolapse is usually diagnosed by a physical examination, including the front and back walls of the vagina. A rectal examination may also be performed. The woman may be asked to cough or push down during the examination to help look for prolapse and potentially identify incontinence.
What are the treatment options?
There are a range of treatment options available for prolapse. The most appropriate treatment will depend upon the type of prolapse present, severity of the symptoms, the age of the woman, her state of health and whether she wishes to have further children. If a woman is not experiencing any symptoms then treatment is not necessary. For women who are bothered by symptoms, treatment can generally be divided into two types—non-surgical and surgical.
- reducing pressure placed on the pelvic floor. For a mild prolapse, simple measures such as losing weight (if overweight), avoiding lifting heavy objects and treating conditions like chronic coughing and constipation may alleviate some symptoms and help to prevent the prolapse from worsening
- pelvic floor exercises. These exercises are designed to strengthen the pelvic floor muscles. They may improve symptoms in women with mild prolapse but are of limited benefit for women with significant prolapse. Pelvic floor exercises are most useful in the prevention of prolapse
- pessaries. This is a silicone device which is inserted into the upper part of the vagina to provide support to the pelvic structures. Pessaries come in number of shapes and sizes. The pessary stays in for three to nine months, after which it will require changing. When inserted properly, a woman should not be able to feel a pessary. Pessaries provide a temporary solution to prolapse symptoms for pregnant women, women who have recently given birth or for women who are awaiting surgery. Pessaries can also be used permanently by women who do not wish to have surgery or for whom surgery may be particularly risky. If a pessary is too small it may fall out and if too tight-fitting it can cause irritation, ulceration, bleeding and pain. If a woman experiences any of these problems she should return to the doctor who fitted the pessary. Pessaries may be used in conjunction with a topical, low-dose oestrogen cream to improve skin tone and elasticity and, therefore, to reduce skin erosion.
- Hormone replacement therapy has not been shown to help significantly with symptoms of prolapse. Topical low-dose oestrogen cream may be of some benefit when the tissues are very thin and dry.
If non-surgical treatment options do not provide sufficient relief from symptoms, an operation may be required. The aim of surgery is to repair and reconstruct the supporting structures so that the pelvic organs return to their normal positions. Restoring and maintaining bladder, bowel and sexual function are also key factors. There are various surgical procedures and approaches to treat prolapse. The most appropriate procedure will depend on which organ or organs have descended, the woman’s age and whether she wishes to retain her uterus.
- Vaginal repair involves a repair to the tissues supporting the vaginal wall. There are different types of vaginal repair depending on where the weakness is located. Commonly, the existing supporting tissues around the vagina are reinforced with stitches. Alternatively, a synthetic sheet of permanent mesh can be used to further support the natural tissues in areas that are weak. Vaginal repairs are generally performed through the vagina but some surgeons repair prolapse via keyhole surgery.
- hysterectomy and vaginal repair. This procedure involves the repair of the vaginal wall supports (as discussed above) and the removal of the uterus (hysterectomy). The procedure may be performed through the vagina or abdominally. Removing the uterus does not fix prolapse—the structures supporting the vagina need to be reinforced. A hysterectomy is an appropriate option in the setting of other menstrual problems.
- vaginal vault repair. There are several procedures performed to treat vaginal vault prolapse. A sacrospinous ligament fixation involves securing this ligament to the top of the vagina to provide it with additional support. It is performed through the vagina. Another procedure, sacrocolpopexy, involves attaching a piece of synthetic mesh to the top of the vagina and anchoring it to the sacrum, pulling the vagina upwards into its normal position. This procedure is performed through the abdomen.
What are the risks of undergoing these procedures?
Although the risks associated with surgical procedures for prolapse are low, you should be aware that every surgical procedure has some risk.
There are some specific risks to be aware of in relation to these operations:
- Severe bleeding may occur from large blood vessels about the uterus or top of vagina. This is not common. Emergency surgery may be required to repair the damaged blood vessels. A blood transfusion may be required to replace blood loss. A vaginal pack may be used to control the bleeding.
- Infection in the operation site or pelvis or urinary tract may occur. Treatment may include wound dressings and antibiotics.
- Nearby organs such as the ureter(s) (tube leading from kidney to bladder), bladder or bowel may be injured. This would be expected to happen to about 1 in 140 women. Further surgery will be needed to repair the injuries. For bladder injuries, a catheter may be put into the bladder to drain the urine away until the bladder is healed. For ureter injury, a plastic tube (stent) is placed in the ureter for some weeks. If the bowel is injured, part of the bowel may be removed, with a possibility of a temporary or permanent colostomy (bag on the abdomen to collect faeces).
- Rarely, a connection (fistula) may develop between the bladder and the vagina. This causes uncontrollable leakage of urine into the vagina. This would require further corrective surgery.
- In rare cases, the vaginal walls may stick together and require surgery to separate them.
- The bowels may not work after the operation. This is usually temporary. Treatment may be a drip to give fluids into the vein and no food or fluids by mouth.
- Following an open operation there may be internal bleeding into the wound from surrounding blood vessels:
- the layers of the wound may not heal well and the wound open up
- the scar can be thickened red and may be painful
- numbness may develop under or around the wound.
- Pain is common following an operation. Short term pain in the tissue between your vagina and anus (perineum) is common. Following a sacrospinous coplpopexy you may experience pain in your buttock for some days to weeks. Sex may be painful following prolapse surgery and this can sometimes be permanent.
- A prolapse operation my fail. Operations for prolapse are not perfect and prolapse can recur or a different prolapse can arise over time. Numerous factors influence the rate of recurrence which your doctor will talk to you about.
- You may experience incontinence. While you may not have been incontinent before the operation, you may leak some urine when you cough, sneeze or strain after the operation. Often a large prolapse is physically stopping the leak of urine and symptoms of incontinence only becoming apparent when the bulge is fixed. Further surgery may be required later to attend to this problem.
- You may experience difficulty emptying your bladder. About five to ten in every 100 women have trouble emptying their bladder properly following surgery. For a short time it may be necessary to re-insert the catheter. Sometimes we may need to teach you how to insert a catheter yourself to completely empty the bladder. This generally resolves within a few weeks.
- You may feel a frequent need to pass urine. A small number of women will find that they now have to rush to the toilet quickly whenever they have an urge to pass urine. This does usually settle but it may require some ongoing therapy.
- If mesh is used there is a risk of infection (which may require removal of the mesh)
- If mesh is used you may experience mesh erosion. This is where part of the mesh wears through a gap that develops in the vaginal skin so that it pokes out. This can cause discharge or bleeding or pain to you (and your partner) during sex. This will usually require surgery to trim the loose portion and to close the gap in the skin.
There are some general risks inherent to all operations
- Small areas of the lungs may collapse, increasing the risk of chest infection. This may need antibiotics and physiotherapy.
- Clots in the legs with pain and swelling. In rare cases, part of this clot may break off and go to the lungs which can be fatal.
- You may suffer a heart attack of a stroke because of strain on the heart. In extremely rare cases death is a possibility in anyone undergoing an operation.
Some women however are at an increased risk of complications
- Women who are very overweight have an increased risk of wound infection, chest infection, heart and lung complications and blood clots.
- Smokers have an increased risk of wound and chest infections, heart and lung complications and blood clots.
What should I do before the procedure?
- Any tests or referrals arranged at outpatient stage should have been completed.
- You should continue your regular medications, unless advised otherwise.
- Stop smoking.
- Should you develop an illness prior to your surgery, please contact the Gynaecology Case Manager immediately.
What should I do on the day of the procedure?
Unless otherwise specified, you should stop eating and drinking at the following times on the day of the surgery:
- at midnight for a morning procedure
- at 6am for an afternoon procedure.
You should continue all your usual medications, unless otherwise specified. You should shower and remove any body jewellery.
You should bring:
- sanitary pads
- all usual medications
- all X-rays.
What should I expect after the procedure?
When you wake from the anaesthetic, you will be in the recovery room. A drip will be removed from your arm when you are able to take food and fluids by mouth and you are no longer feeling sick. It is common to feel sick for a day or two after surgery. The catheter in your bladder will normally be removed the following day when you are able to move around comfortably. If your prolapse was repaired vaginally, you will usually have a pack (like a large bandage) in the vagina. This can cause pressure on the bowel resulting in pain and/or discomfort until it is removed (often the next day). If your repair was performed abdominally or laparoscopically, you may have clips or stitches covered by a dressing. Your doctor will advise you when these are all to be removed. You should expect a stay of two to five days in hospital. You will be given specific discharge medication if required, but you may use paracetamol or paracetamol-codeine as required (one to two tablets every four hours up to a maximum of eight tablets per day).
After discharge from hospital, you should:
- eat and drink normally
- remain mobile
- use sanitary pads (not tampons) if required
- shower normally (in preference to bathing)
- avoid constipation.
You should NOT:
- have intercourse for six weeks
- undertake any heavy lifting or straining for 6 weeks
- drive until you can comfortably operate foot pedals or change gears (at least four weeks).
You may require up to six weeks off work depending on the procedure performed. You should have returned to normal activity by three months, but full recovery may take longer. When used, sutures are normally dissolvable and do not require removal.
What if I have any problems?
You should seek medical attention if you experience:
- fever or feeling unwell
- offensive vaginal discharge or heavy bleeding
- wound becomes hot, painful or discharges offensively
- severe nausea or vomiting
- inability to empty your bladder or bowels
- severe pain.
Please contact our Gynaecology Case Manager or attend Mater Emergency Department if you require urgent attention.
© 2010 Mater Misericordiae Ltd. ACN 096 708 922
Mater acknowledges consumer consultation in the development of this patient information.
Last modified 12/11/2015.