Advanced Women's Health Institute

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Pelvic Prolapse

What is pelvic prolapse?
When the pelvic tissues are no longer in the same natural position as when you were born doctors refer to these losses of support as pelvic prolapse.

What causes pelvic prolapse?
Prolapse is more common after vaginal delivery than a C/section delivery. The pelvic floor fascia that holds the vagina, cervix and uterus in place is torn as the fetal head passes through the vaginal canal. In some women these tears are extensive and never heal properly.

Other conditions that can cause prolapse, or make it worse include:

  • Chronic cough from asthma or smoking
  • Chronic constipation
  • Crohn’s disease or other bowel issues
  • Obesity
  • Heavy lifting work 

 What are the symptoms?
Urinary incontinence and/or tissue bulging from the vagina are the most common reasons for prolapse visits. Stress incontinence from coughing, laughing, or lifting is caused by the lack of proper anatomic support for the bladder and urethra. Urgency and frequency can also be a problem.
Tissue bulging from the vagina can be uncomfortable. In addition to urinary problems some women can have trouble emptying the rectum. They describe the need to press against the back of the vagina to move the bowel.
Some women feel heaviness or pain as if the uterus is falling out. This tends to worsen with standing for long times or heavy lifting.

How do you diagnose prolapse?
Three parts of pelvic anatomy are assessed in a prolapse exam.

The anterior compartment
The front wall of the vagina supports the bladder and urethra. Anatomic stress urinary incontinence is not infrequent. Other anterior compartment problems are urethrocele and cystocele. A woman may notice through visual mirror exam tissue that was not there before is now present.

The posterior compartment
The vaginal opening and back wall supports the rectal and anal anatomy. The vaginal opening is also referred to as the genital hiatus. Relaxation of the opening can occur following vaginal delivery. When the genital hiatus is larger the vaginal tissues are more noticeable on visual exam. Rectocele(back wall descent) may be seen.

The apical compartment
The top of the vagina, with or without cervix, descends when there is apical prolapse. This is determined by careful examination.

During the exam we ask the woman to Valsalva, push like in labor. The prolapse of each compartment is categorized and the options are discussed. 

One way to understand prolapse is by a Grade 1-4 pelvic prolapse classification.

Grade 1– One or more of the compartments descend part way down the vagina but not to the opening.
In general, grade 1 pelvic prolapse is not a cause for alarm. Most women do not have problems requiring surgery. Stress incontinence is sometimes a problem with grade 1 prolapse. A mid-urethral sling is an outpatient procedure with typically 2-4 days of recovery without prolapse repair.

Grade 2 – One or more of the compartments descend down the vagina to the opening.
More prolapse means the tissues are descending further and some women start to experience issues. A discussion should include which compartments are affected and what can be done. What is the recovery like?
Going online and searching the topics after the appointment is a way to get more information. One medical expert recommends .gov websites for their fair and balanced scientific information.
There is no need to rush into a decision. It is okay to just do a sling for incontinence and nothing else.

Grade 3 - One or more of the compartments protrudes beyond the vaginal opening.
This degree of prolapse can be tolerated if not bothersome. Others may feel uncomfortable from pressure, tissue irritation or bladder and/or bowel issues.
Women are more likely to consider surgery for grade 3 prolapse. Choosing the right procedure for each compartment is important to discuss. Search other sources for information and validation.

Grade 4 - All three compartments protrude beyond the vaginal opening.
When prolapse gets to this point surgery becomes necessary. If not the vaginal tissues tend to get very irritated and can bleed. It can become difficult to walk.

What are the treatment options for prolapse?
Do Nothing Right Now
Just about every woman who has had a baby has some form of prolapse. Most of the time it is low grade. If there is not a problem there is no need to do anything. Take as much time as you need to research your options. Yes, it might get worse. Then would be the time to fix it.

None Surgical Options
Kegel’s exercises can strengthen the pelvic muscles and reduce incontinence problems. A physical therapist can help show you the correct way to strengthen the pelvic floor.
A pessary is a device that pushes the tissues back into place and holds them up. There are several different types. Pessaries are generally reserved for elderly women who are too unhealthy for surgery or until surgery can be performed.
A woman may choose to use a pessary rather than have surgery. Tissue irritation is sometimes a problem. If the vaginal opening is smaller a pessary is more successful. When the opening is relaxed the pessary is less likely to stay in place.

What are the surgical options?
When prolapse worsens a woman may consider surgery. There are many procedures described in the medical literature. This means there is no one best operation. We strive to provide you with an accurate diagnosis first and foremost. Then we discuss procedures for each compartment.
Over the years experts have examined the merits of each of the various prolapse procedures. Some studies have been performed that support one operation is better than another. Expert panels have made recommendations as to which operations may have a better outcome.

Anterior Compartment repairs
Urinary incontinence –The procedure that may be the best is the retropubic sling. A strip of mesh tape is guided through the space on each side of the urethra. A needle-like guide passes the tape behind the pubic bone.
Two small incisions are just above the pubic bone on each side of the midline. Return to work is in the 2-4 day range without or procedures.

Urethrocele – The excess tissue beneath the urethra can protrude and be uncomfortable. Repair is generally vaginal trimming and repair.

Cystocele– There are two kinds of cystocele. One is called a midline cystocele and the other is a paravaginal cystocele.
The paravaginal cystocele is considered more common by some experts than the midline cystocele. Paravaginal means the vaginal tissue has pulled away from the pelvic side wall. Laparoscopic paravaginal repair appears to be the least painful option.
A midline cystocele is repaired vaginally because of which tissues are injured. When the protruding tissue is smooth a midline defect is more likely. When the tissue is rugated a paravaginal defect is more likely the cause. A vaginal repair may be possible if there is no significant apical compartment prolapse.
The right procedure for the right patient is important for success. A vaginal cystocele repair for a paravaginal defect is not likely to work.

Posterior Compartment problems
Rectocele – If the area between the vaginal and anal opening does not heal well after delivery a rectocele is created. The back wall of the vagina and rectal tissues protrude. Difficulty with bowel movements can occur.
Vaginal repair is the most common recommendation. Concerns to be addressed include the use of mesh. In general, the primary repair should be done with native tissues and mesh should be reserved for failures. Biological grafts are an alternative to mesh but the benefit is still controversial.

Apical Compartment prolapse
Uterine prolapse– As the cervix and uterus descend down the vaginal canal a woman may feel uncomfortable as well as feel a firm mass at or beyond the opening. Heavy lifting or standing a long time can make it feel worse.

Enterocele – When the top of the vagina protrudes from the opening after hysterectomy it is called an enterocle. The symptoms of heaviness and pressure are similar with or without the uterus. Instead of the cervix vaginal tissues protrude.

Laparoscopic sacrocolpopexy is considered by many to be the procedure of choice for apical prolapse. Vaginal procedures may be appealing but less effective. Hysterectomy is not required for most women. It is their choice.

Multiple Compartment issues
Often, women have problems with more than one compartment. Our approach is to diagnose, as accurately as possible, which compartment problems are present and how we can help you.
Gynecologic endoscopic surgery and urogynecology sub-specialist in many areas can be located with the assistance of societies such as the American Association of Gynecologic Laparoscopist(AAGL) or the American Urogynecology Society(AUGS).