Utero-Vaginal Prolapse-Chapter 30:

Q 30. 1 What is a prolapse?

The normal anatomy of the female pelvis is illustrated in Figure 2.1.

The walls of the vagina have elasticity to facilitate intercourse and childbirth. If the support is weakened a prolapse may develop. The prolapse may involve the uterus, which descends into the vagina and may eventually protrude from the vaginal opening. The concept that all prolapses relate to the uterus (Figure 30.1) is incorrect.

Sometimes it is the front or back walls of the vagina which are bulging with associated distortion of the bladder (cystocoele – Figure 30.2) or rectum (rectocoele – Figure 30.3). If you have had a hysterectomy the vault of the vault (top) of the vagina can prolapse. Sometimes the bowel may prolapse under the posterior (back) wall of the vagina (enterocoele – Figure 30.4).

Q 30. 1 What is a prolapse?

Q 30. 2 What are the symptoms associated with prolapse?

Q 30. 3 I have developed a prolapse. Why has this happened?

Q 30. 4 I have a vaginal prolapse. Should it be treated?

Q 30. 5 How can my prolapse be treated?

Q 30. 6 What happens during a pelvic floor repair operation?

Q 30. 7 What can I expect after a repair operation?

Q 30. 8 What are the risks of a repair operation?

Q 30. 9 How successful are repair operations?

Q 30. 10 What should be done if I have a bladder problem or prolapse and plan to have another pregnancy?

Q 30. 11 Are there any alternatives to surgery for pelvic floor prolapse?

Q 30. 12 Where can I obtain more information?

Q 30. 13 Could I have some useful Web sites?

Q 30. 2 What are the symptoms associated with prolapse?

Usually there is a feeling of “something coming down” or vaginal discomfort. Some women are aware of a “dragging ache” in the pelvis. The degree of prolapse does not necessarily match the severity of symptoms that you may experience. Sometimes we find quite marked prolapse but the patient has no symptoms. Other women report quite severe symptoms although there may be only minimal prolapse. Most backaches are due to problems in the back, although, on occasion, repair of a prolapse may provide some relief.

If there is a cystocoele there may be bladder symptoms (Chapter 29).

Q 30. 3 I have developed a prolapse. Why has this happened?

Prolapse is usually seen in women who have had children delivered vaginally. It is unusual to see a prolapse in ladies who have never had children. Vaginal delivery of a large baby is particularly likely to weaken the vaginal supports, and there is greater likelihood of prolapse if you have a large family. After themenopause, the reduced levels of oestrogens may further weaken the vaginal support.

Overweight women are stretching the vaginal support (pelvic floor) as well as their backs and joints. Patients with chronic cough (e.g. smokers), or others with constipation may similarly weaken their pelvic floor.

Q 30. 4 I have a vaginal prolapse. Should it be treated?

If a prolapse is causing problems for you treatment is advisable. In deed, the only reason to treat a prolapse is to alleviate symptoms.

Many women have lax vaginal walls but are not aware of any problems: they may, for instance, be told that they have a prolapse when they are examined at a well woman clinic. If there are no symptoms there is probably no reason to recommend surgery. For reassurance, a further examination at six monthly or yearly intervals may be sensible.

Q 30. 5 How can my prolapse be treated?

The treatment of choice is surgery to repair your pelvic floor. In some circumstances, where other illness preclude this, or if it is your preference, an internal support pessary, usually a ring, may be fitted by your gynaecologist. For hygienic reasons these rings should be replaced at three or four monthly intervals.

Q 30. 6 What happens during a pelvic floor repair operation?

This depends on what parts have prolapsed and the degree of uterine descent (Figure 30.1; Figure 30.2; Figure 30.3 and Figure 30. 4). If there is a cystocoele (Figure 30.2) or rectocoele (Figure 30.3) the vaginal skin is dissected off the underlying bladder or rectum, and the excess skin is removed. Two layers of stitches are introduced to restore the vagina into its correct position.

Should there be a major degree of uterine prolapse, it may be necessary to remove the uterus vaginally – vaginal hysterectomy (hysterectomy). If there is a lesser degree of uterine prolapse just the neck of the womb (cervix) may be taken away and the ligaments previously attached to the neck of the womb are then stitched into the lower part of the uterus to keep it in place. This is called a Manchester repair or Fothergill procedure.

Q 30. 7 What can I expect after a repair operation?

You will probably need to be in hospital for a week. On return from the operating theatre you will have a fine tube (drip) in one of your arm veins with fluid running through. Most surgeons will have introduced a bandage in the vagina (pack) and a catheter into the bladder. Usually the drip and pack come out the day after surgery and the catheter is removed three to five nights after the operation. As soon as your bladder is functioning without difficulty and you are feeling ready you will be able to go home.

It is important to avoid stretching the repair particularly in the first weeks after surgery. The stitches dissolve during the first three weeks and the body will gradually lay down strong scar tissue over a few months. It is usual to have a consultation with your gynaecologist about six weeks after the operation. After that assessment, you should be able to resume most activities, including sexual intercourse. It is advisable to avoid heavy lifting for a few more weeks and even then care should be taken.

Q 30. 8 What are the risks of a repair operation?

The general risks of surgery are discussed in Q4.21. The risks of hysterectomy (hysterectomy) are discussed in Q24.21. During pelvic floor surgery your gynaecologist will be tailoring the vagina so that the symptoms related to the laxity will be resolved whilst not making the vagina too tight. On occasion the vagina may still feel too loose or too tight.

Q 30. 9 How successful are repair operations?

The majority of operations are successful. Failure is more likely to occur if you are overweight, if you are a smoker or if constipation is a chronic problem. These problems should be corrected, if possible, before surgery. In postmenopausal women who have not had HRT the tissues may be weak. There is often merit in treating the vagina with local oestrogen (Q28.2) before surgery. Again, care to allow the repair to heal in the weeks after surgery must be emphasised.

When there is vaginal prolapse causing discomfort, surgery is likely to provide symptomatic relief. If there is prolapse and stress incontinence, surgery may resolve both problems. When urgency is the major bladder problem, it may not respond to surgery if the cause is detrusor instability. If there is a doubt as to whether surgery is likely to provide benefit for the incontinence, urodynamic studies may be considered before operating (Q29.22).

Occasionally a second operation may be required if the prolapse recurs. Success rates from a second operation are lower.

References:

Posterior colporrhaphy: Its effects on bowel and sexual function (1997-1637)

Q 30. 1 What is a prolapse?

Q 30. 2 What are the symptoms associated with prolapse?

Q 30. 3 I have developed a prolapse. Why has this happened?

Q 30. 4 I have a vaginal prolapse. Should it be treated?

Q 30. 5 How can my prolapse be treated?

Q 30. 6 What happens during a pelvic floor repair operation?

Q 30. 7 What can I expect after a repair operation?

Q 30. 8 What are the risks of a repair operation?

Q 30. 9 How successful are repair operations?

Q 30. 10 What should be done if I have a bladder problem or prolapse and plan to have another pregnancy?

Q 30. 11 Are there any alternatives to surgery for pelvic floor prolapse?

Q 30. 12 Where can I obtain more information?

Q 30. 13 Could I have some useful Web sites?

Q 30. 10 What should be done if I have a bladder problem or prolapse and plan to have another pregnancy?

Clearly there is no reason to refrain from pelvic floor exercises. The question of surgery is more difficult to answer. The benefits of surgery for prolapse or stress incontinence may well be lost after another vaginal delivery. If the pregnancy is to be fairly soon, a support vaginal ring pessary may relieve some prolapse symptoms. If surgery has been performed, the obstetrician may offer Caesarean section delivery next time, particularly if stress incontinence has been successfully treated.

Q 30. 11 Are there any alternatives to surgery for pelvic floor prolapse?

A ring pessary can be introduced into the vagina to support some prolapse and reduce symptoms. If the vaginal outlet is enlarged, the ring may slip out. Shelf pessaries have been useful for many patients with prolapse when the ring is not suitable.

Q 30. 12 Where can I obtain more information?

Q 30. 13 Could I have some useful Web sites?

Evaluation of the quality of Web sites is discussed in Q4.27. You may find that several general women’s health sites may help you (Q4.28). The following are more specialised Web sites on topics found in this chapter: https://2womenshealth.com/