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Correcting Prolapse: An Overview

May 25, 2016 | Dr. Ray Bologna

There are several options for correcting prolapse, both abdominal (laparoscopic) and vaginal, depending on the type of prolapse and the individual. Both abdominal and vaginal approaches have had excellent outcomes, and in many cases, are used in combination to ensure the best results.

The abdominal approach or laparoscopic has long been considered the gold standard. Because it can be done with a minimally invasive approach, patients often go home the same day. Abdominal and vaginal approaches both have excellent outcomes. Surgical correction of prolapse deals directly with what can fall down and what can be done to re-support it. It’s not uncommon for prolapse to occur in more than one area, so when prolapse requires surgical correction, it’s important to identify all areas of weakness in the pelvic floor and fix them all for meaningful results. The top of the vagina or apex can be supported a number of ways. When mesh is used, it is attached to the cervix or the outside of the vagina. Therefore, not placing it through a vaginal incision and reducing the risk of a mesh exposure to a minimum.

Below you’ll find a brief overview of the different types of prolapse and corrective procedures.

Bladder Prolapse, Cystocele: Loss of support on the anterior side (top wall) of the vagina

If the bulge is coming from the top of the vagina it allows the bladder to push down on the vaginal wall. Patients often experience the sensation of a bulge and can have difficulty urinating. Correcting this problem involves a vaginal incision and bringing a patient’s own support tissue back together again.

Enterocele: Loss of support at the apex or top of the vagina

An enterocele is a loss of support at the apex (or top) of the vagina. With enterocele, a hernia appears, allowing the bowel to push into the vagina. Enterocele is often accompanied by vaginal prolapse, but abdominal or vaginal approaches can correct both issues at the same time.

Uterine or Vaginal Prolapse: Loss of support for the uterus

Uterine and vaginal prolapses result from a stretching or a weakening of the ligaments that hold the uterus in place. Vaginal prolapse often occurs after a hysterectomy (removal of the uterus), but the same prolapse surgeries can be done with the uterus in place or removed.

Surgical correction of uterine and vaginal prolapse is done at the top of the vagina and supported by an abdominal or vaginal approach:

  • Abdominal procedures can be done with the uterus in place (abdominal sacral hysteropexy) or without the uterus in place (abdominal sacral colpopexy). Through a small incision in the abdomen or laparoscopically, a soft synthetic or biologic mesh is placed at the top of the vagina and connected to the area at the base of the spine above the tailbone, the sacral promontory.
  • Vaginal procedures (sacrospinous ligament fixation, uterosacral ligament fixation, iliococygeal ligament suspension) are done by attaching the top of the vagina or cervix to ligaments deep in the pelvis to provide support.

Rectocele: Posterior vaginal wall prolapse

When the support tissues on the bottom (or posterior) side of the vagina have loosened, it allows the rectum to bulge into the vagina. Women with this problem often feel the need to “splint” – that is, having to put a finger in the vagina to push the rectum back into place in order to have a bowel movement. They may also rock forward or push in the perineum for relief.

This type of prolapse is only managed with a vaginal surgery that repairs the support tissue and re-supports the perineal body.

Urinary Incontinence    

The status of your bladder control is always a key question with prolapse. Prior to surgery it is important to evaluate how your bladder will function after the vaginal walls are supported. Some patients already have stress incontinence and that can be corrected at the time of prolapse correction. For other patients, correcting the prolapse may bring out the stress incontinence. A bladder study – also called Urodynamics – is performed before prolapse correction to help identify if a patient needs more support to the tube through which she urinates at the time of prolapse correction.

What to expect after surgery

Here are a few of the most common complaints after pelvic floor surgery.

  • Constipation is a constant battle because of the location of the surgery, decrease in physical activity and the use of pain medication. Patients should increase fluids and use a stool softener daily. Occasionally, medications are prescribed to help with the constipation and it never hurts to get on a high-fiber diet.
  • Urinary urgency is common with any pelvic floor surgery for a period of time, but will resolve on its own as you heal.
  • Spotting is common for two to four weeks after surgery and nothing to be concerned about it.
  • Pain with sex is typical after vaginal surgery and should resolve. Doctors often recommend waiting 6-12 weeks post surgery to resume intercourse. Vaginal estrogens are often prescribed and started 1-2 weeks prior surgery to improve healing and decrease discomfort with intercourse.

Patients shouldn’t experience any discomfort after three months. If it persists, don’t be shy – talk to your doctor because it can be a symptom of mesh exposure or an infection.

Dealing with prolapse is a pain – literally and figuratively – but the good news is that it can be managed. You deserve the freedom to move on with your life, incontinence-free and with a healthy pelvic floor.

If you suffer from prolapse, you’re not alone. Click here to read more about prolapse in women of all ages.

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