Vaginal Prolapse | Glengarry Private Hospital, Perth
A prolapse occurs because of weakness & damage to supporting tissue in the pelvis. The most important contributing factors to prolapse are genetic, increasing age and damage due to the effects of childbirth. The most recent research shows that age of first baby and whether forceps are used to deliver are the most important childbirth-related risk factors for significant damage to the pelvic floor. Other contributory factors are your age, the size of your babies, whether you’re menopausal, chronic coughing, chronic straining when constipated or heavy lifting.
The classic pattern is for damage to occur to the pelvic floor during pregnancy & childbirth in women, especially in those who are vulnerable to that damage. This damage is then compensated for to some extent by other muscles when younger, so it’s often not that evident. However, when the menopause occurs, muscle & tissue strength weakens and the effects of the damage from years ago can then become obvious.
There are several types of prolapse, that may occur in isolation or together.
- Bladder prolapse or cystocele. Weakness at the front of the vagina. The bladder presses downwards creating a bulge at the front.
- Rectal prolapse or rectocele. Weakness at the back of the vagina. The rectum presses at the back of the vagina creating bulging
- Enterocele. This is where bulging occurs at the top of the vagina, caused by the small bowel. Usually seen with a rectocele.
- Uterine prolapse. This is where the whole womb comes down from the top of the vagina
Prolapses generally aren’t dangerous, they are just uncomfortable and annoying. Aching pain and bulging are the commonest symptoms. Interference with intercourse, urinary and bowel symptoms can occur. There are several options for treatment.
This is a reasonable choice. Many women manage with prolapses. In fact many women aren’t even aware they have a prolapse & have no issues. Some prolapses never worsen. Some however do, and that’s often when referral is made for assessment & management.
Physiotherapy with guided pelvic floor muscle training can be very helpful in prolapse, especially with mild-moderate types. Benefits are usually only maintained if the exercises are continued. Research shows that most women do not continue these exercises long term.
A PVC ring device is placed in the vagina which holds the tissues in. These have to be changed every 6 months or so and can cause erosions to the vaginal skin. They are suitable for women who do not want surgery, whether through choice or because they have medical issues that increase surgical risk. They interfere with intercourse & can be worse than the prolapse. There are other types of pessaries too – shaped like cubes or the “Gelhorn” or shelf type.
Surgical repairs of prolapse
- Cystoceles are repaired using an anterior vaginal repair using stitches to refashion the body’s own tissue back & re-tighten the vagina.
- Rectoceles are repaired in the same way by tightening, but this time at the back of the vagina
- Enteroceles are repaired by suturing at the same time as a rectocele
- Womb prolapses are usually repaired by means of a vaginal or laparoscopic hysterectomy with a sutured vaginal vault suspension
Recovery is hopefully steady over a period of some weeks. You do have to avoid lifting and strain for at least 6 weeks and preferably 12 weeks following surgery for prolapse. Possible complications are infection, bleeding, problems with the anaesthetic, pain, recurrence of the prolapse and problems with the bladder. Infection is the commonest issue & slows recovery. We’ll discuss all these and more in detail should you be considering surgery.
Older women are more likely to opt for non-surgical options. Younger women generally prefer surgical repair.
We have never used mesh for prolapse repair.
The use of mesh is very controversial, and most meshes for vaginal prolapse repair have recently been removed from Australia. There are occasional patients who benefit from prolapse repair with mesh, especially if they’ve had repairs previously which have failed. However, the risks are overall higher than repair with the patient’s own tissue. There are a proportion of women who suffer with chronic pain, erosion & other problems after having a vaginal repair with mesh. Some of these issues take years to develop. The mesh can be difficult to remove, and removal can cause chronic problems.
If you have had problems with mesh that has been placed by another surgeon, you should be reviewed & managed by either that surgeon, a subspecialist urogynaecologist, or the multidisciplinary King Edward specialist mesh clinic and/or chronic pelvic pain clinic.
We do not remove mesh or take over the subsequent management of patients with problems caused by other surgeons’ use of mesh. Mesh management requires specialised training & experience together with multidisciplinary input.
Any surgical or invasive procedure carries risks. Before proceeding, you should do your own research. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner. For instance, your GP’s opinion will be very helpful.
Call us if you would like an appointment to diagnose your symptoms and discuss treatment.