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 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.
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:
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.
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.
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.
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.
Stress urinary incontinence (SUI) often occurs with pelvic organ prolapse.
Thus, surgical treatment of stress urinary incontinence 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.
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 Pelvic organ prolapse meshes in the clinical community, an increase in new Pelvic organ prolapse 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.
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.
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