What Is Pelvic Organ Prolapse?
Pelvic organ prolapse (POP) is a common condition that results in protrusion of a pelvic organ (bladder, rectum, uterus, intestine) into the vagina. It can affect up to 40% of women ≥ 60 years of age. The condition is analogous to a hernia (a rupture of tissue that allows an organ to bulge out). It is a problem that most women are reluctant to talk about.
There are TV commercials for tampons, urinary incontinence products, and sexual enhancement products. However, the topic of pelvic organ prolapse remains fairly closeted with many women suffering in silence. You are not alone and you don’t have to live with it. Almost 20 million women in the United States have this condition with over 275,000 surgeries performed annually to repair it.
Pelvic organ prolapse may be accompanied by additional functional issues that may adversely impact a woman’s quality of life. Issues such as constipation, fecal incontinence, urinary incontinence, urine retention, and pain with intercourse may accompany POP.
What Are the Symptoms?
Not all women experience symptoms. The greater the degree of prolapse, the more likely symptoms will be noticed.
Some women are not bothered by prolapse even when it extends to the vaginal opening or beyond. When symptoms do occur, they are described in a variety of ways:
- Feeling of pelvic pressure or awareness that there is a bulge in the vagina.
- Feeling of sitting on a ball.
- Low back pain.
- Bowel problems: problems with evacuating stool.
- Urinary problems: incontinence, Urinary frequency, weak force of stream, intermittent flow, hesitancy to start, incomplete bladder emptying, dribbling.
- Pain/discomfort with intercourse.
- Vaginal bleeding/spotting from the skin over the bulge rubbing on clothing or pads.
What Are the Causes of POP?
1) Prolonged labor during childbirth or vaginal delivery.
2) Aging and menopause.
5) Chronic constipation
6) Chronic cough
7) Repetitive strenuous activities or heavy lifting.
8) Family history/weak connective tissue and ligaments due to genetic factors.
9) Previous pelvic surgery
Types of Pelvic Organ Prolapse
Kegel Exercises: pelvic floor muscle exercises that are used to strengthen the muscles that support the pelvic organs.
Vaginal Pessary: device that is similar to a diaphragm that is inserted to hold the pelvic organs in place.
Repair of pelvic organ prolapse can be performed abdominally (open, laparoscopic, robotic) or transvaginally. The common surgical goal is to reposition the pelvic organs by repairing and reinforcing the “hammock” of connective tissue, ligaments, and muscle support. Reinforcement of the repair may be in the form of sutures, biological grafts, and/or synthetic grafts.
What Approaches Are Used for Surgical Repair?
Reconstructive surgery often involves repair of multiple sites of prolapse (anterior, posterior, apical). The surgical treatment of pelvic organ prolapse can be performed transvaginally, transabdominally (open, laparoscopic, or robotic) or as a combined approach. The surgical approach is primarily dependent on the technical expertise, experience, and comfort level of the surgeon with any particular approach. With respect to laparoscopic/robotic approaches, it would be more accurate to characterize them as minimal incision rather than minimally invasive. All approaches have advantages and disadvantages. Thus, the best approach is really the one that is best in your particular surgeon’s hands.
What Are the Surgical Procedures To Repair Pelvic Organ Prolapse?
I. Reconstructive Surgery: the goal is to correct the prolapse and to restore the anatomy.
- Colporraphy: weakened tissue is stitched together (plicated) through a vaginal approach.
Posterior colporraphy (rectocele repair)
- Uterosacral Ligament Suspension: the top of the vagina (apex) is attached to the uterosacral ligaments with stitches. This may improve bulges in the anterior, posterior, and apical areas. Any surgical approach (open, laparoscopic, robotic, transvaginal) can be used.
- Sacrospinous ligament fixation: the top of the vagina is stitched to the sacrospinous ligament through a vagina approach.
Bilateral sacrospinous fixation of the vaginal apex.
- Graft augmented repair: synthetic or biologic graft is placed transvaginally to reinforce the repair and support the prolapsed organs. The graft can be used anteriorly, posteriorly, and apically.
Anterior (Elevate) Mesh (American Medical Systems)
- Sacrocolpopexy: use of synthetic graft is standard to attach the top and bottom walls of the vagina to the bone above the tail bone (sacral promontory). This is typically performed through an open abdominal, laparoscopic, or robotic approach.
II. Obliterative Surgery
- Colpocleisis: this is a vaginal closure procedure performed in older women who are not candidates for more extensive reconstruction and are willing to accept loss of vaginal intercourse. Compared to reconstructive surgery, this procedure involves less operative time, less perioperative morbidity, and has a low prolapse recurrence rate. A disadvantage is the loss of being able to evaluate the uterus (e.g., endometrial biopsy) through a vaginal approach.
Is Hysterectomy Always Necessary in Repairing Prolapse?
If the uterus is not prolapsed, a hysterectomy is not indicated and may increase the risk of complications. There is no data to support that keeping the uterus will increase the risk of a recurrence.
For mild uterine prolapse, there are uterine-sparing techniques that attach the uterus or lower cervix to a supporting structure. If a hysterectomy is recommended for prolapse repair, studies have not shown any detriment to sexual function.
Is an Anti-Incontinence Procedure Recommended During POP Repair?
Stress urinary incontinence (SUI) often occurs with pelvic organ prolapse. Thus, surgical treatment of SUI is recommended at the same time. SUI may be occult (present but not demonstrable because of the prolapse masking the condition).
Bladder prolapse can result in a kink-like effect on the urethra that is obstructive. In continent patients, repair of the prolapse without a concomitant repair of SUI will result in up to 65% developing SUI postoperatively.
What Is the Mesh Controversy All About?
The goal of surgery is to restore anatomy and function. Prolapse surgery aims to reduce a bulge and repair the tissue defects. But, is traditional suture repair of ruptured tissue enough?
General surgeons learned over 30 years ago, the benefits of reinforcing their repairs with synthetic materials to reduce recurrence rates. Traditional repairs, without reinforcement, are fraught with high pelvic organ prolapse recurrence rates of up to 40% on average.
Low failure rates have been associated with abdominal sacrocolpopexy surgery. The reason it has enjoyed low failure rates (and is considered the gold standard) is because synthetic mesh is used to attach the vaginal apex to the sacral promontory.
The use of synthetic mesh in transvaginal surgeries has been mired in controversy. The high incidence of complications resulted in the FDA issuing a public health notification in 2011. Complications such as erosion, bleeding, pain with sex, infection, voiding dysfunction, and injury to pelvic organs were the most commonly cited. The exact cause of the higher complications is not known. The FDA postulated that some causes might be the increased use of POP meshes in the clinical community, an increase in new POP meshes on the market, an increase in awareness of potential adverse events, or an actual increase in adverse effects from the surgical mesh.
One of the problems in evaluating the data is that all surgical meshes are not made the same. Some grafts were more prone to infection and erosion due to mesh coating, braided filaments, tight woven construction, or thickness and size of the graft. One mesh voluntarily pulled off the market due to complications was the Gynecare Prolift made by Johnson & Johnson (Ethicon).
Additionally, also contributing to the complication rates is the fact that many less experienced generalists in the field of urology and gynecology were starting to do prolapse repairs as the manufacturers made pre-cut mesh kits to simplify the placement. It is important to keep in mind that all the potential complications of prolapse repairs with mesh, compared to prolapse repairs without mesh, are identical with the exception of mesh erosion.
The highest chance of a recurrence after a repair is in the anterior wall of the vagina, which bears the brunt of increased abdominal pressures. The use of mesh to reinforce an anterior (cystocele) or apical repair to prevent recurrence must be weighed against the risk of complications. As with any procedure, the risks and benefits as well as alternatives need to be considered carefully. What is agreed upon by most experts is that the ideal graft (biologic or synthetic) has not yet been identified.
What Are the Risks of Prolapse Repair?
It is important to keep in mind that the benefits far outweigh the risks in patients who are deemed good surgical candidates based on age, general health, and bothersome symptoms. Risks are higher in patients who have had previous failed repairs.
- Adhesion (scar) formation
- Constipation or fecal incontinence (may also improve after POP repair)
- Recurrent or de novo (new prolapse in an untreated compartment) prolapse
- Dyspareunia (painful sex)
- Infection: urinary tract or wound
- Nerve damage
- Ureteral obstruction
- Vaginal tightening/contracture
- Urinary fistula
- Difficulty with urinating or defecating (may also improve with POP repair)
- Wound dehiscence (delayed opening of the incision)
- If mesh is used: mesh erosion, extrusion, migration
What Are the Postoperative Recovery Expectations?
- Hospitalization is typically one or two days.
- Avoid lifting heavy objects more than 10 lbs and avoid strenuous activity for 90 days.
- Avoid straining to empty bowels. Stool softeners are prescribed postoperatively.
- Shower is permissible the following day after surgery but no baths for four weeks.
- Vaginal bleeding is typically similar to a light to medium menstrual flow for the first day or two that tapers off during the week. Peripads will be necessary until the bleeding stops.
- Minor vaginal discharge from dissolving stitches may be present for six to eight weeks.
- Vaginal estrogen can be resumed after one month.
- Vaginal intercourse can be resumed in 10 to 12 weeks. It is not unusual for discomfort to be experienced early on as a result of the surgery. This usually improves with time.
- Postoperative pain is mild to moderate for most patients. Pain medication is prescribed but not always needed. Tylenol, Advil or Aleve are adequate for many.
- Walking up stairs is allowed after surgery. Distance walking can be gradually expanded with physician guidance.
- Most patients are able to drive within one or two weeks of surgery as long as they are not in discomfort or taking narcotics.