Overview
Pelvic prolapse or vaginal prolapse is the term used to describe a weakness in one or more sides of the vaginal wall, allowing one or more pelvic organs to fall into the vagina. Vaginal prolapse is a broad term used to describe the following:
- Cystocele or weakness in the front wall of the vagina allowing the bladder to fall into the vagina,
- Rectocele is a weakness in the back wall of the vagina allowing the rectum to fall into the vagina,
- Enterocele is a weakness in the top or roof of the vagina allowing small bowel to fall into the vagina,
- Uterine prolapse is when the uterus and cervix descend from its normal position deep in the pelvis at the top of the vagina, towards the vaginal opening and sometimes through and outside the vaginal opening. Vaginal vault (or vaginal cuff) prolapse is when the top of the vagina, (after hysterectomy) which is usually deep in the pelvis, descends into the bottom of the vagina or completely outside of the opening of the vagina.
Women often have more than one type of prolapse. The prolapse is staged according to how severe it is, meaning how much the prolapse has descended into the vagina and sometimes outside of the vaginal opening.
Symptoms
Women complain of a bulging or pressure inside the vagina. Some women can see or feel a bulge from the vagina. Women with a rectocele might need to push the prolapse back inside the vagina to defecate (or have a bowel movement) properly. They may also have difficulty emptying their rectum completely and might leak stool after having a bowel movement. Conversely, women with a cystocele might need to push the prolapse back inside to empty their bladder completely. Women with an enterocele might complain of low abdominal or back pain.
Diagnosis
Vaginal prolapse is diagnosed during a vaginal exam by a physician, usually a primary care physician or gynecologist. Some physicians who specialize in treating prolapse and urologic conditions, such as a urologist, or urogynecologist, might recommend a urodynamic test (evaluation of bladder function) or defecography (evaluation of lower bowel function) to determine if there are associated bladder or bowel conditions that need to be addressed concurrent to the prolapse, such as urinary incontinence, constipation.
Treatment
Vaginal prolapse may be treated non-surgically or surgically. Nonsurgical treatment involves using a pessary.
Surgical treatment involves repairing the vaginal defect that is causing the pelvic organ to prolapse into the vagina. For example, a cystocele is a weakness in the front wall of the vagina, near the bladder. A cystocele repair is repairing this weakness by sewing the fascia, or tough vaginal tissue, back together where it had broken. This repair is usually done through the vagina, however sometimes the break in fascia is in a place that requires the surgeon to repair the break through an abdominal incision. Surgeons will often, but not always, reinforce the repair with a piece of mesh or allograft material to prevent the prolapse from recurring. A rectocele repair is done in a similar way, except the repair is done on the back wall, or posterior wall, or the vagina.
Women who have a vaginal vault prolapse, or a drop in the top, or roof, of the vagina, require a different type of surgery. They may either have a vaginal or abdominal surgery. During the vaginal surgery, the surgeon reattaches the top of the vagina to supportive ligaments or structures in the pelvis, the uterosacral ligaments, sacrospinous ligaments, or ileococcygeous muscle. The abdominal approach is called an abdominal sacrocolpopexy and is done through a low midline abdominal incision or laparoscopically by using instruments through several small incisions. Regardless, the surgeon attaches a piece mesh from the top of the vaginal to the sacrum, which is the bony spine just above the tailbone. Oftentimes, an enterocele is repaired at the same time as a vault suspension surgery because vault prolapse often occur with an enterocele.
If a woman is no longer sexually active, she will be offered a type of vaginal surgery for prolapse that renders the vagina functionally inadequate for intercourse. This surgery, called a colpocleisis, closes the vagina completely. The introitus, or outside of the vagina, will appear quite normal, but the length will be about 1 inch (an average vagina is about 7 inches).
Women whose uterus is prolapsing will be offered a hysterectomy if they have completed childbearing. A gynecologist almost always performs this procedure. If a woman who has uterine prolapse has not completed childbearing, then a hysteropexy can be considered if a trial of pessary use has failed. Hysteropexy involves leaving the uterus in place and anchoring it to supportive ligaments in the pelvis, sometimes synthetic material is used to reinforce the repair. However, these surgeries can be prone to recurrence and are not recommended unless a woman wants to bear more children.
Preoperative Considerations
Any woman with vaginal prolapse that is bothering them (usually high stage) and who has either tried or considered a pessary, is a candidate for the above described procedures.