Prolapse is a common condition, which affects one in two women over the age of 50 years and has an overall prevalence of 30-50%. Pelvic organ prolapse is the descent of one or more of the pelvic organs including urinary bladder, uterus, rectum or the top of the vagina from their normal position, through the genital hiatus. Nearly 11-12% of women will need surgery for prolapse repair in their lifetime.

 

What causes pelvic organ prolapse?

Prolapse occurs because of the weakness in the pelvic floor. Advancing age and childbirth are the most common causes of pelvic floor weakness. With age and menopause, there is a loss of connective tissue and the pelvic floor weakens. Childbirth especially prolonged difficult labour and giving birth to big babies can also damage the pelvic floor. Sustained pressure on the pelvic floor caused by excess weight (obesity), chronic cough, chronic straining due to constipation or regular heavy lifting also damages the pelvic floor. Some connective tissue disorders like hypermobility syndrome, Marfan syndrome, and Ehlers-Danlos syndrome also lead to weakness of the pelvic floor.

 

What are the Symptoms caused by pelvic organ prolapse?

Pelvic organ prolapse can be totally asymptomatic or produce symptoms related to the urethra, bladder, rectum and vagina. It can also produce psychological and emotional distress.

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Symptoms caused by prolapse include dragging sensation/pressure in the vagina, vaginal bulge or lump, vaginal discomfort, urinary symptoms like frequency of passing urine, difficulty emptying the bladder or urinary incontinence. It can cause difficulty with opening bowel and a feeling of pressure and constipation. It may also cause pain during intercourse.

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What are the different types of Prolapse?

The prolapse can be bladder prolapse into the vagina (Cystocele), Rectal or small bowel prolapse into the vagina (Rectocele or Enterocele) or uterine prolapse. In women with hysterectomy, the top of the vagina can drop (vault prolapse).

 

What can be done for Prevention of Pelvic Organ Prolapse?

Factors which can reduce the occurrence of prolapse include performing regular pelvic floor exercises, maintaining a healthy weight, avoiding straining at stools by including adequate fibre in your diet and using the right lifting techniques to avoid putting a strain on your pelvic muscles while lifting heavy things. Quitting smoking also helps by reducing the chronic cough, which weakens the muscles.

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What are the Treatments for Pelvic Organ Prolapse?

Prolapse can be treated conservatively or surgically. Pelvic floor muscle training (PFMT) aims at strengthening the muscular support of the pelvis and is considered to be an effective treatment for mild grades of prolapse. They are also called Kegel’s exercises and are best taught individually to make sure each patient understands which muscles to contract and how to exercise them.

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Pessaries

Pessaries are devices made of rubber (latex) or silicone, which are inserted into the vagina and left in place to support the vaginal walls and pelvic organs.

They are most suitable for women who have minor stages of prolapse, have not completed their family and for those who do not wish to have surgical repair due to personal choice or presence of medical co-morbidities.

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Surgical Treatment

Surgical repair of the prolapse depends on the type of prolapse and involves reconstruction of the pelvic anatomy by re-positioning prolapsed organs (Bladder or bowel) to its anatomic location using sutures.  The vaginal wall is also cut back to the required size so that it no longer bulges. If the uterus is prolapsing, a vaginal hysterectomy is usually recommended. Surgery for prolapse is usually carried out through the vagina but in some cases, your surgeon might discuss an abdominal approach with you. Surgeons who are skilled in pelvic reconstruction techniques will usually produce better results.

 

Complications of Prolapse Surgery

Complications of surgical repair include bleeding, infection, anaesthetic complications, urinary infections, change in bladder behaviour and sometimes urinary tract damage. Vaginal narrowing or shortening can also occur with surgery, which can lead to pain with intercourse.

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Can the prolapse recur after Surgery?

Prolapse can still recur after surgery. Some of the factors, which can reduce the recurrence, include avoiding precipitating factors like constipation, lifting heavy weights etc. Also, your surgeon might take additional steps during repair to prevent its recurrence to some extent. Pelvic floor muscle exercises before the operation and continued regularly after the surgery also reduces the recurrence rate. Topical estrogen treatments also improve the strength of the muscles and ligaments in peri and post-menopausal women.