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PELVIC ORGAN PROLAPSE

Definition
Pelvic organ prolapse is a very common condition, particularly among older women. It's estimated that half of women who have children will experience some form of prolapse in later life, but because many women don't seek help from their doctor the actual number of women affected by prolapse is unknown. Prolapse may also be called uterine prolapse, genital prolapse, uterovaginal prolapse, pelvic relaxation, pelvic floor dysfunction, urogenital prolapse or vaginal wall prolapse.

Pelvic organ prolapse occurs when the pelvic floor muscles become weak or damaged and can no longer support the pelvic organs. The womb (uterus) is the only organ that actually falls into the vagina. When the bladder and bowel slip out of place, they push up against the walls of the vagina. While prolapse is not considered a life threatening condition it may cause a great deal of discomfort and distress.

There are a number of different types of prolapse that can occur in a woman's pelvic area and these are divided into three categories according to the part of the vagina they affect: front wall, back wall, or top of the vagina. It is not uncommon to have more than one type of prolapse

A. PROLAPSE OF THE ANTERIOR (FRONT) VAGINAL WALL
CYSTOCELE (bladder prolapse)
When the bladder prolapses, it falls towards the vagina and creates a large bulge in the front vaginal wall. It's common for both the bladder and the urethra (see below) to prolapse together. This is called a cystourethrocele and is the most common type of prolapse in women.



In mild cases of cystocele, you may not notice any signs or symptoms. When signs and symptoms occur, they may include:
  • A feeling of fullness or pressure in your pelvis and vagina — especially when standing for long periods of time
  • Increased discomfort when you strain, cough, bear down or lift
  • A bulge of tissue that, in severe cases, protrudes through your vaginal opening and may feel like sitting on an egg — often going away when you lie down
  • A feeling that you haven't completely emptied your bladder after urinating
  • Repeated bladder infections
  • Pain or urinary leakage during sexual intercourse

URETHROCELE (prolapse of the urethra)
When the urethra (the tube that carries urine from the bladder) slips out of place, it also pushes against the front of the vaginal wall, but lower down, near the opening of the vagina. This usually happens together with a cystocele

B. PROLAPSE OF THE POSTERIOR (BACK) VAGINAL WALL
Uterine prolapse
Uterine prolapse is when the womb drops down into the vagina. It is the second most common type of prolapse and is classified into three grades depending on how far the womb has fallen.

Grade 1: the uterus has dropped slightly. At this stage many women may not be aware they have a prolapse. It may not cause any symptoms and is usually diagnosed as a result of an examination for a separate health issue.

Grade 2: the uterus has dropped further into the vagina and the cervix (neck or tip of the womb) can be seen outside the vaginal opening.

Grade 3: most of the uterus has fallen through the vaginal opening. This is the most severe form of uterine prolapse and is also called procidentia.



Vaginal vault prolapse
The vaginal vault is the top of the vagina. It can only fall in on itself after a woman's womb has been removed (hysterectomy). Vault prolapse occurs in about 15% of women who have had a hysterectomy for uterine prolapse, and in about 1% of women who have had a hysterectomy for other reasons.

RISK FACTORS
Normally, the pelvic organs are held in place by the pelvic floor muscles and supporting ligaments, but when the pelvic floor becomes stretched or weakened, they may become too slack to hold the organs in place. A number of different factors contribute to the weakening of pelvic muscles over time, but the most significant factors are thought to be:
  • Pregnancy and childbirth
  • Aging and the menopause
  • Obesity, large fibroids or tumors
  • Chronic coughing or strain
  • Heavy lifting
  • Genetic conditions (Marfan or Ehlers-Danlos syndrome)
  • Previous pelvic surgery
  • Spinal cord conditions and injury
  • Ethnicity (white and Hispanic women have the highest rate of pelvic organ prolapse, followed by Asian and black women)

SYMPTOMS
  • Feeling a lump or heavy sensation in the vagina
  • Lower back pain that eases when you lie down
  • Pelvic pain or pressure
  • Pain or lack of sensation during sex

Women with mild prolapse may have no symptoms or discomfort at all and may not be aware they have a prolapse. When symptoms do occur, however, they tend to be related to the organ that has prolapsed.

A bladder or urethra prolapse may cause incontinence (leaking urine), frequent or urgent need to urinate or difficulty urinating.

A prolapse of the small or large bowel (rectum) may cause constipation or difficulty defecating. Some women may need to insert a finger in their vagina and push the bowel back into place in order to empty their bowels.

Women with uterine prolapse may feel a dragging or heaviness in their pelvic area, often described as feeling 'like my insides are falling out'. With severe prolapse, when the uterus is bulging out of the vagina, the skin may become irritated, raw and infected.

DIAGNOSIS
If you have any of the symptoms of prolapse, particularly if you can see or feel something near or at the opening of your vagina, make an appointment to see your doctor. Many women with prolapse avoid going to the doctor because they are embarrassed or afraid of what the doctor might find, but prolapse is very common and is nothing to be ashamed of.

TREATMENT
Laparoscopic Sacrohysteropexy
Laparoscopic sacrohysteropexy involves the use of a permanent polypropylene mesh, which is attached to the cervix and the sacral promontory (the first and second vertebra of the sacrum). The mesh is buried below the peritoneum to prevent adhesions. In this fashion, the uterus and cervix are suspended from the tailbone, restoring a normal anatomy, enhancing sexual function, and preserving childbearing capability.

If you've already had a hysterectomy and have a vaginal vault prolapse, theis same procedure is called a laparoscopic sacral colpopexy,and is one of the most successful operations for suspending the vagina.



Vaginal mesh
Surgery for pelvic organ prolapse may not always be successful and the prolapse can return, meaning another operation may be needed.

For this reason, synthetic (non-absorbable) and biological (absorbable) meshes have been introduced as supporting materials in the surgical treatment of pelvic organ prolapse.

These permanent implants support the vaginal wall and/or internal organs. About 1,500 such operations are carried out in the UK each year.

The majority of women with prolapse who are treated with mesh respond well to this treatment. However, the MHRA has received a number of reports of complications associated with vaginal meshes. The most frequently reported problems have included persistent pain, sexual problems, mesh exposure through vaginal tissues and occasionally injury to nearby organs such as the bladder or bowel.



Recovering from surgery
Many prolapse operations are done as day surgeries with no overnight stay, although more major operations may require a stay in hospital for one or two days.

If you need to stay in hospital, you may have a drip in your arm to provide fluids and a thin plastic tube called a catheter to drain urine from your bladder. Some gauze will be placed inside your vagina to act as a bandage for the first 24 hours. This may be slightly uncomfortable. Your stitches will usually dissolve on their own after a few weeks.

For the first few days or weeks after your operation you may have some vaginal bleeding similar to a period. You may also have some vaginal discharge. This may last three or four weeks. During this time you should use sanitary towels rather than tampons.

PREVENTION
To reduce your risk of developing a cystocele, try these self-care measures:
  • Perform Kegel exercises on a regular basis. These exercises can strengthen your pelvic floor muscles, and this is especially important after you have a baby.
  • Treat and prevent constipation. High-fiber foods can help.
  • Avoid heavy lifting, and lift correctly. When lifting, use your legs instead of your waist or back.
  • Control coughing. Get treatment for a chronic cough or bronchitis, and don't smoke.
  • Avoid weight gain. Talk to your doctor to determine your ideal weight and get advice on weight-loss strategies, if you need them.

Pelvic organ prolapse
Varicocelectomy
Treatment options for upper ureteral calculi (size > 10 mm)
Benign Prostatic Enlargement (Hyperplasia)
Bladder slings (TOT)
Prostate Cancer
Vasectomy
Semen Analysis
Prostate Biopsy
Erectile Dysfunction (ED)
Prostate Infection
Urinary Calculi
Varicocele
Over Active Bladder
Kidney Cancer
Bladder Cancer
Premature Ejaculation
Haematuria