Pelvic Organ Prolapse
Pelvic organ prolapse refers to prolapse or descent of the uterus and/or vaginal walls into the vaginal canal. In more severe cases, these organs can protrude beyond the vaginal opening and are visible or palpable outside of the body. Many women with pelvic organ prolapse experience problems with normal bladder and bowel function. The relationship between symptoms and the findings on physical examination can be very complicated, making accurate diagnosis and treatment plans very important. Pelvic organ prolapse represents a weakening or tearing of the structures that support the pelvic floor. Surgical repair is the mainstay of therapy for this disorder.
A multitude of surgical repair options exist, including traditional approaches and a large variety of emerging technology and techniques. Drs Toglia and Fagan have extensive experience in a variety of surgical approaches, including vaginal, abdominal, and laparoscopic approaches. By working together, they are able to offer each patient a specific approach (or combination of approaches) based upon the individual woman’s needs.
Most surgical techniques for prolapse aim to lift the prolapsed organs back into place and to restore normal anatomic support. Hysterectomy (removal of the uterus) may or may not be necessary in the treatment of pelvic organ prolapse. The choice of surgical procedure depends on many different factors including the type of prolapse you have, your health, age, desire for uterine preservation and whether or not you are sexually active.
Common surgical approaches include Vaginal (e.g. incisions are made through the vagina), Abdominal (an incision is made through the wall of the abdomen) or laparoscopic (several small incisions made in the abdominal wall).
Before agreeing to go under a specific surgical procedure, a woman should seek answers to the following:
- What is the exact type and stage of my prolapse? (Most Urogynecologists use the POPQ staging system which is internationally recognized)
- Will the surgery relieve all or only some of my symptoms?
- Which surgical approach is recommended and why?
- What are the surgeons credentials for reconstructive pelvic surgery. Many but not all are becoming board certified in the sub specialty of Female Pelvic Medicine and Reconstructive Surgery
- Who will perform the surgery and how much experience does the surgeon have doing this procedure?
- How successful is the procedure and what are the potential complications?
- How might the treatment affect my sex life?
- Do I need an additional procedure to correct or prevent stress urinary incontinence (leakage of urine with coughing or physical exertion)
- What tests might be helpful in deciding the best type of surgery for my problem?
- What will happen if I choose not to have surgery?
Treating Prolapse of the Bladder & Urethra
Anterior Repair (Colporrhaphy)
Prolapse of the anterior vaginal wall (cystocele) is commonly repaired through a vaginal approach by making an incision through the prolapsed vagina wall and stitching the weakened underlying tissue layer together for better support. The main complications of this surgery are recurrent prolapse (in up to 30% of cases), painful intercourse, and incontinence.
Advanced surgical techniques involve the placement of mesh materials, either synthetic or animal based to provide better support. Although this technique may provide better long-term support, it can be associated with additional complications such as inflammation or erosion of the surrounding tissues or erosion of the mesh. There is also an increased risk of painful sex. Some specific animal based grafts have been associated with a higher failure rate than traditional repairs. The PROLIFT pelvic floor repair system is a new approach that is rapidly gaining popularity amongst advanced pelvic surgeons for the correction of a cystocele, especially after a traditional repair has failed
Treating Prolapse of the Uterus and/or Apex of the Vagina
Removal of the uterus is often considered to be the most effective treatment for uterine prolapse, although it must be combined with specific techniques to re-suspend the top of the vagina. Failure to adequately suspend the apex of the vagina during hysterectomy is frequently associated with recurrence of prolapse. The technique of vaginal hysterectomy requires removal of the uterus and the cervix. Removal of the ovaries is possible, but not always necessary or recommended. Removal of the cervix and uterus eliminates the possibility of a woman developing cervical or uterine cancer, and can relieve other bothersome symptoms including painful or heavy menstrual cycles. Pregnancy, of course, is not possible after the removal of the uterus. Some newer techniques, such as PROLIFT, allow for uterine preservation, as long as the cervix or uterus is not too enlarged or abnormal. It is important to seek out a surgeon with extensive experience in vaginal surgery to increase the likelihood of success.
Many surgeons prefer an abdominal approach to more severe cases of vaginal or uterovaginal prolapse. This procedure involves using synthetic mesh to support the top of the vagina by fixing one end of the mesh to the vagina and the other end to the bony sacrum which is located at the end of the spine. Sacrocolpopexy is considered by many to have the highest rate of success but has a longer recovery period than alternative procedures because of the relatively large abdominal incision. Uncommon complications include extensive bleeding during surgery, mesh erosion or infection., and development of stress urinary incontinence following surgery Recent studies suggest that sacrocolpopexy is best performed in combination with an anti-incontinence procedure (e.g. Burch) to minimize the occurrence of stress urinary incontinence developing following surgery.
Sacrospinous Ligament Fixation (SSLS, SSLF)
This is a vaginal technique designed to suspend the top of the vagina or uterus to one of the pelvic ligaments known as the sacrospinous ligament using sutures instead of mesh. This procedure is done vaginally, and is therefore less invasive than a sacrocolpopexy. Several studies have suggested that success rates can be equal to or slightly lower than sacrocolpopexy. Complications are rare, but include chronic inflammation of the vagina surrounding the sutures (resulting in bleeding), or chronic pain in the buttocks or pelvic area.
Colpocleisis (Colpectomy or LeForte Procedure)
Colpocleisis – closure of the vagina- is a less common procedure that closes off the vagina by stitching the front and back wall together after removing several portions of the vaginal epithelium. It is only offered to women who are absolutely certain that they don’t ever want to have sexual intercourse again. It is a very effective treatment, with a quick recovery, and few complications. It is typically reserved for patients with severe prolapse, are very elderly, or because their poor health precludes a more extensive procedure. However, a woman (and her partner) must understand and accept closure of the vagina will make future sexual intercourse impossible.
Treating Prolapse of the Posterior Vaginal Wall & Rectum
This vaginal approach is analogous to an anterior repair, except that it involves opening to posterior vaginal wall to correct prolapse of the rectum (rectocele) or small bowels (enterocele). Depending upon the exact anatomic defects found at the time of surgery, the repair may involve reducing the prolapse with sutures (colporrhaphy), closing specific site defects, or placement of mesh material. Meticulous surgical technique is important to obtain the best results. The major complication of posterior repair is painful sex (dyspareunia), if the vagina is made too narrow or too tight. Symptoms of constipation may or may not be relieved following this procedure. The use of mesh material may provide long-lasting support, but studies suggest that some mesh material may become inflamed or eroded, and may increase the risk of painful sex.