Pelvic organ prolapse refers to a herniation of pelvic organs such as uterus, the womb,
bladder and the rectum such as the bowel through the vaginal walls. It is a common condition
which affects many women. One in five women will develop symptoms from the weakening of
the pelvic floor and one in ten of those will require surgery.
Pelvic floor organs are supported normally by muscles and ligaments referred to as pelvic
floor. When they are weakened or stretched, women will experience symptoms of prolapse.
Prolapse may be mild and will involve a bulge through the vagina or sometimes the
organs can completely protrude outside.
Pelvic organ prolapse happens when there is a weakening
of the pelvic floor muscles due to a number of potential problems. Most commonly, it’s
associated with labor and birth. Women who have had more babies or they had difficult
deliveries are more likely to develop prolapse in their future life. Or if they experienced
instruments, there is such as forceps and ventouse that also increases the chance of developing
prolapse. Prolapse also happens in women who are older,
so aging does make a difference. Being older, tissue tends to get weakened, that lack of
oestrogen, and that it contributes to the prolapse factor.
Some of the lifestyles such as heavy lifting, having been overweight, or having a chronic
cough can also increase the risk of prolapse. Some women have conditions which have increased
their genetic predisposition to prolapse and that will also be a cause.
Mild prolapse will
not require any treatment and women may not even be aware of it. Some women who have symptoms
will need some treatment and management and will depend on the severity of their problem.
There are simple measures women can improve the prolapse such as lifestyle changes, losing
weight, avoiding heavy lifting, avoiding constipation will clearly improve the symptoms. Pelvic
floor exercises will have great benefit to improve the pelvic floor muscles and some
women will need a combination of the treatment before they embark on any surgery.
Traditionally,
the prolapse was treated by vaginal surgery utilising surgical techniques using sutures.
Vaginal hysterectomy and anterior and posterior repair were the main treatment options. They
have a success rate of treating prolapse at 80 to 90% but long-term, they realised that
the prolapse recurrence is a problem. To reduce the risk of recurrence and to retain the anatomical
function of the vagina, a number of new procedures were introduced which were mainly utilising
a mesh repair. Meshes have been traditionally used in abdominal
surgery for hernia repair for a long time. Introduction in the vagina is recent. It allows
us to interlay the mesh material between the vaginal wall to strengthen the pelvic floor,
thus retain the anatomical situation in the vagina.
However, meshes in the vagina have been associated with more complications which became apparent
very recently. Although many women will benefit from it, there are complications such as mesh
erosion rates and infections and pain which have been quite a problem for a number of
women. Meshes therefore have been withdrawn from the treatment and are not recommended
unless they are for specific women with high risk of recurrence or they are done by specialists
who are trained to do that. Our education for the women when they are
choosing the prolapse repair is important part of the counselling that they need to
understand potential risks and benefits of having a mesh repair.
The apical prolapse which is the vault prolapsing again and recurrences have also been a problem.
To improve the prolapse repair and reduce the risk of a recurrence, there are a number
of other procedures used such as keyhole surgery and laparoscopic approach which can successfully
treat and prevent pelvic vault prolapse. These techniques are clearly advances in the
pelvic floor surgery which introduce laparoscopic approach to the pelvic floor. Often, these
are done again in specialist centres by trained individuals and many women may need to be
referred to a specialist who has got that expertise.