What is a Prolapse?

A prolapse is a medical condition where an organ or tissue falls down or slips from its normal position. This occurs when the pelvic floor muscles and connective tissue that support the pelvic organs are weakened.

A pelvic organ prolapse is a condition that occurs when the structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself falls out from their normal position.

Utero-Vaginal Prolapse

Utero-vaginal prolapse is a downward movement of the uterus and vagina.

Types of Pelvic Prolapse

There are different types of pelvic organ prolapse, such as

• Rectocele - rectum protrudes into vagina
• Cystocele - bladder protrudes into vagina
• Enterocele - small bowel protrudes into vagina
• Uterine prolapse - uterus and cervix protrude into vagina
• Vaginal Vault prolapse - vaginal apex herniates into vagina

Your surgeon will diagnose the condition by performing a physical examination, including pelvic examination, with reference to medical and family history, and may perform other tests such as cystoscopy, ultrasound scan.

Treatments for Pelvic Prolapse

Treatment options include

• Pelvic floor exercises
• Lifestyle changes - to avoid heavy lifting, constipation
• Local oestrogen treatment
• Pessary, a removable device fitted in the vagina to reduce pain and pressure of pelvic organ prolapse.

If the non-surgical treatment does not reduce the symptoms of pelvic organ prolapse, then surgery is considered. There are several types of surgeries to correct different types of pelvic floor prolapse.

The surgery can be performed laparoscopically or through the vagina, depending on the nature of the prolapse.

Surgical Treatments for Pelvic Floor Disorders

There are different types of procedures to address a specific prolapse. The aim of pelvic floor reconstruction is to restore normal anatomy and function of the pelvic organs. The most essential part of the surgery is to restore support to the vaginal apex.

Your surgeon will discuss with you the laparoscopic surgical options such as

• Laparoscopic Pelvic Repair and
• Vaginal Pelvic Floor Repair.

Your surgeon has particular expertise on pelvic floor repair after training and working for several years in a large pelvic floor unit (Flinders Medical Centre) (see gallery). The most essential part of the surgery is to restore support to the vaginal apex.

The most common procedures to restore vaginal apex support are:

Laparoscopic Sacral Colpropexy

This is a keyhole procedure. A mesh sling is attached to the top of the vagina and anchored to the sacral promontory (a bony landmark in the pelvis). This will elevate the vaginal vault.

This procedure is considered the gold standard in the treatment of pelvic prolapse. It is performed in women who have had a hysterectomy and have a prolapse of the vaginal vault. It takes about 60-90 minutes. You will be in hospital for two days. You will return to normal activities after about 2-3 weeks. Your surgeon will see you one week after discharge from hospital to monitor your progress.

Laparoscopic Sacral Hysteropexy

This is a keyhole procedure. A mesh sling is attached to the posterior cervix and posterior vaginal wall to elevate the uterus. The mesh sling is anchored to the sacral promontory (bony landmark in the pelvis).

This procedure will allow the uterus to be conserved. It takes about 60 minutes to perform. You will be in hospital overnight. You will return to normal activities after about 2-3 weeks. Your surgeon will see you one week after discharge from hospital to monitor your progress.

Total Laparoscopic Hysterectomy and Sacrocolpopexy

A Total Laparoscopic Hysterectomy is performed. Then the mesh sling is attached to the vaginal apex and anchored to the Sacral Promontory (bony landmark in the pelvis).

This is performed for women with a large uterine prolapse. You will be in hospital for two days. You will return to normal activities after about 2-3 weeks. Your surgeon will see you one week after discharge from the hospital to monitor your progress.

Subtotal Laparoscopic Hysterectomy and Sacrocolpopexy

A Subtotal Laparoscopic Hysterectomy is performed. The uterus is removed but the cervix is conserved. Then the mesh sling is attached to the cervix and anchored to the sacral promontory (bony landmark in pelvis)

You will be in hospital for about two days

Laparoscopic Uterosacral Ligament Hysteropexy

This is a keyhole procedure. The uterus is elevated by re-attaching the posterior cervix to the uterosacral ligaments. This is an ideal procedure for women with postpartum prolapse who are planning future pregnancies and for whom pessaries are ineffective.

The procedure avoids mesh. It is considered a temporary procedure- not a long term treatment option. It takes about 30 minutes to perform. You will be in hospital overnight. You will return to normal activities after about 2-3 weeks.

Your surgeon will see you one week after discharge from the hospital to monitor your progress.

Laparoscopic Paravaginal Repair

This is a keyhole procedure. The anterior wall of the vagina is elevated using sutures on either side of the bladder neck. This procedure will treat anterior (bladder) prolapse. It can also address stress incontinence. It is done in conjunction with a Laparoscopic Mesh Sacrocolpopexy to elevate the vaginal apex.

You will be in hospital for two days. You will return to normal activities after about 2-3 weeks. Your surgeon will see you one week after discharge from the hospital to monitor your progress.

Anterior Coloporrhaphy

This is a vaginal procedure to address a moderate degree of cystocele. The anterior vaginal wall is opened to reveal the bladder prolapse. The prolapse is reduced and held in place with a ladder of slowly absorbing sutures. The vaginal skin is closed with a rapidly absorbing suture. This procedure takes about 30 minutes to perform. You will be in hospital overnight. You will return to normal activities after about 2-3 weeks. Your surgeon will see you one week after discharge from the hospital to monitor your progress.

Posterior Colporrhaphy

This is a vaginal procedure to address a moderate degree of rectocele. The posterior vaginal wall is opened to reveal the rectal prolapse. The prolapse is reduced and held in place with a ladder of slowly absorbing sutures. The vaginal skin is closed with a rapidly absorbing suture. This procedure takes about 30 minutes to perform. You will be in hospital overnight. You will return to normal activities after about 2-3 weeks. Your surgeon will see you one week after discharge from hospital to monitor your progress.

Perineorrhaphy

This is a vaginal procedure performed to treat a gaping introitus. A small incision is made at the posterior introitus and minimal dissection performed at the perineum. Sutures are placed to build up the perineal body and treat the gaping introitus.

This procedure takes about 30 minutes to perform. You will be in hospital overnight. You will return to normal activities after about one week. Your surgeon will see you one week after discharge from the hospital to monitor your progress.

Sacrospinous Colpopexy

This is a vaginal procedure to elevate the vaginal apex to the sacrospinous ligaments. It is performed in conjunction with a posterior colporrhaphy. It is reserved for those women who are medically unfit for a laparoscopic procedure. It takes about 45 minutes to perform. You will be in hospital for two days. You will return to normal activities after about 2-3 weeks. Your surgeon will see you one week after discharge from hospital to monitor your progress.

Complications of Vaginal Prolapse Surgery

Every surgical procedure may be associated with certain risks and complications. The possible complications after the surgeries for vaginal prolapse include pain, infection, bleeding, recurrence of symptoms, injury to ureters, and perforation of rectum and bladder.

The complications are usually mild and can be treated accordingly.

The advantages of choosing minimally invasive surgery is that the defects can be clearly identified, incisions are small, postoperative pain and discomfort are reduced, shorter duration in hospital, and quicker recovery.

Post Operative Expectations

Most women will require some form of oral analgesia for about one week. Constipation is very common after pelvic floor repair procedures.

Your surgeon will give specific advice to help you to address this problem. You are advised to avoid heavy lifting and straining for at least 3 months.

Your surgeon will arrange for you to be reviewed by a physiotherapist with a special interest in pelvic floor disorders. Ongoing pelvic floor exercises and lifestyle modifications to avoid heavy lifting will ensure a long term cure.

Your surgeon may also recommend ongoing use of an oestrogen cream which is known to enhance tissue strength and promote healing