Treatment of Vaginal Prolapse

 

Like most things, prolapse occurs in different levels of severity. In mild forms of prolapse, no treatment is necessary & it is reasonable to see what will happen with time. In most women, their prolapse will slowly worsen with time. Exercise, straining, & sex will not significantly cause the condition to get worse; although the prolapse may make these activities uncomfortable. In severe forms of prolapse, the pelvic organs may be completely outside forming a bulge the size of a grapefruit, & immediate treatment is necessary. It is important to have clear goals for treatment of prolapse. Sometimes it is impossible to know whether a symptom, for example back pain, is due to prolapse or something else, & you may not know the answer until after the treatment. As a rule of thumb, once the tissue starts to come outside of the vaginal opening, it is time to start thinking about treatment. Once the tissues come outside, they will rub on clothing & may become chapped or even develop ulcers & bleeding. There are no medical or exercise therapies for prolapse, & treatment options consist of using a mechanical device called a pessary or surgery.
Using a Pessary

Using a pessary is a safe & effective way to improve prolapse without surgery. We have cared for hundreds of women using pessaries, some for fifteen years or longer without problems. Pessaries do not require a lot of maintenance, & you are not usually even aware of it being in place- there’s just no bulge anymore!

Women have used different materials as pessaries for centuries in order to improve their prolapse symptoms. Modern pessaries are made of silicone or plastic. They are biologically inert, so they do not cause infection, & discharge is rare. Older pessaries were made of latex which caused a lot of odor & had to be cleaned & replaced frequently. Pessaries come in many shapes & sizes, depending on the type of prolapse & your anatomy.

Ring with diaphragm pessary

Ring with diaphragm pessary

 

Dish with support pessary

Dish with support pessary

How do Pessaries Work?

Pessaries simply hold the tissue in place by mechanically supporting the vaginal tissues as seen in these diagrams.

 

Prolapse of the bladder & uterus

Prolapse of the bladder & uterus

 

Pessary in place

Pessary in place

You can sometimes feel the pessary at the opening of your vagina, especially when you strain or use the bathroom. This is normal. You can push it inside if you wish. Most pessaries cannot be positioned incorrectly.

 Goals of Treatment

The goal of using a pessary is to improve your prolapse in an attempt to avoid surgery, or as a temporary measure until surgery can be performed. The pessary will not permanently fix your prolapse, but it may prevent it from getting worse.

Risks of Using a Pessary

 Many women use pessaries for years without problems. The risks of using a pessary are very low. In older women the vaginal tissues can become very thin, & the pessary can rub the tissue & cause some spotting. If this occurs, you should call us & let us know, & we will have you come in for a check. It is sometimes necessary to remove the pessary & use local estrogen cream or tablets in the vagina for a while to help it to heal. You can usually continue to use the pessary, but may need to continue using estrogen vaginally to avoid more spotting. It is very safe for most women to use estrogen vaginally because, unlike taking hormone pills, very little vaginal estrogen is absorbed into your bloodstream. If spotting becomes a recurrent problem, the pessary may not be an option for you.

Using the Pessary

Once the pessary is in place, you usually will not feel it. Depending on your prolapse, you may still feel a bulge at the opening of your vagina, but it should be much better. You can do your regular daily activities including exercise & house work. It is not necessary for you to remove the pessary or clean it unless you choose to do so.   We will see you back initially in four months to ensure the pessary is working well for you. We will make sure the pessary fits well, & inspect the vagina to make sure it is not getting irritated by the pessary. You can remove the pessary for sexual intercourse, but that is not absolutely necessary as long as you are comfortable.  If you do remove your pessary, simply wash it with soap & water, & replace it when you are ready. Do not microwave or boil the pessary.

It is important to avoid constipation & hard straining, & you can use an over the counter stool softener (such as pericolace or docusate) or a fiber product (such as Metamucil or Citrocel) if increasing fiber & water intake in your diet does not work.

It is often easier to empty your bladder with the pessary in place. Some women may note an increase in urine leakage with activity with the pessary in place. This is usually due to the pessary “unkinking” the opening of the bladder. If leakage is due to a weakness in the muscle surrounding the opening of the bladder, it can be treated in the office. We will usually change the pessary to a new one every few years as they tend to get a little stiff.

 Follow-Up

Once you have been fitted with a pessary, we will see you back in about 4 months to see how you are doing. After that we will see you every 6 months. You should feel free to call 670-5665, extension 313 or 315 with any problems or questions about your pessary.

 

Surgery for Vaginal Prolapse   tennis women           

 When prolapse is causing significant symptoms & a pessary is not an option, it is reasonable to consider surgery. Surgery can range from simple outpatient procedures with minimal recovery, which general gynecologists can perform, to advanced reconstructive pelvic surgery procedures requiring hospitalization & a month or 2 of recovery, which are performed by Urogynecologists, like Drs Theofrastous & Howden. Our philosophy is that surgery is a last resort, but when the decision is made to proceed with surgery it is vital to be evaluated by a skilled & experienced doctor to determine the best procedure. If the correct procedure is not performed, it is likely that you will require another surgery down the road. It is also generally recommended to delay prolapse surgery until childbearing is complete, since delivering a baby vaginally would disrupt the surgical repair. For women with severe problems who desire more children surgery may be performed, but delivery by caesarian section is generally recommended. Tobacco use increases the risks of anesthesia, & is a major risk factor for poor healing.

The challenge for the surgeon who treats women who suffer from vaginal prolapse is to perform a durable procedure which will restore normal anatomy & allow normal bladder, bowel, exercise & sexual function. Unfortunately the tissues we are dealing with are damaged & inherently weak, & surgery does not make them stronger. Surgery will fix the tears in the tissues & return the vagina to it’s normal position; but the tissues are still inherently weak & vulnerable. Fortunately, most women who undergo surgical repair are not going to deliver a baby after that & damage the tissues, but wear & tear will still occur with time. Surgery raises the threshold for developing prolapse, but everything has a breaking point. Risk factors for recurrent prolapse include obesity, lung disease (including smoking), constipation, & developing prolapse at a young age.

Most women with vaginal prolapse have lost support of more than one area of the vagina. This becomes increasingly true with time. It is vital that all areas of significant prolapse are repaired. Otherwise, it is almost certain that those unrepaired areas of prolapse will worsen & require further surgery. It is often necessary to perform several procedures at the same time to reduce the risk of subsequent prolapse & surgery. Sometimes, despite the best surgical repair of their vaginal prolapse, women will develop prolapse of a different area of the vagina surgery. This is not surprising due the inherent weakness of those tissues, but it is frustrating. The old adage “if it is not broken, don’t fix it” applies. The risk of subsequent vaginal prolapse can be minimized by undergoing evaluation & treatment by a surgeon who is an experienced expert in repairing vaginal prolapse.

Vaginal Grafts
Our approach to new surgical treatments is very cautious. We do not start using new techniques until there is considerable scientific evidence that they are safe & effective. We believe that new procedures should be better than more established procedures & more cost effective.

In 2011 the FDA expressed concern that complications after vaginal grafts are “not rare,”  including vaginal mesh exposure & pain with sex. The FDA is now requiring manufacturers of vaginal grafts to perform studies proving safety & efficacy. We believe those studies should have been performed before the devices were approved for use. At this point we do not use vaginal mesh. The FDA has no concerns over the use of mesh abdominally or the use of mesh in pubovaginal slings for incontinence. Both have long records of safety & efficacy.

Surgery for Bladder Prolapse– The most common operation performed for prolapse is to repair bladder prolapse, or a cystocele. The medical term is “anterior repair” or “anterior colporrhaphy” . This is often referred to as a “bladder tack,” although that is not a medical term & may include other procedures. The surgery for bladder prolapse consists of fixing the hernia by finding the tear in the tissues & sewing them back together, & sometimes sewing the vaginal tissues back to the side of the pelvis (a “paravaginal repair”). By itself, this procedure usually does not improve bladder control.

Surgery for Rectal Prolapse– This is the next most common prolapse surgery & is called a “posterior repair” or “posterior colporrhaphy.” This surgery involves finding the tear beneath the vagina which has caused the hernia, & sewing it back together to the opening of the vagina. If the opening of the vagina is widened the torn tissues & muscles will be sewn back together to create a normal vaginal opening (a “perineorrhaphy” or “perineal repair”).

Surgery for Uterine or Vaginal Cuff Prolapse– If the uterus is well supported & not causing problems, it is not necessary to remove it . If the uterus is dropping  significantly, & you have completed childbearing, a hysterectomy is usually recommended. For women who desire to maintain their ability to have children, or women who wish to retain their uterus, a procedure can be done to suspend the uterus; but it is not certain that surgery will hold up. Once a hysterectomy has been performed, the top of the vagina (“cuff”) is then secured in place. Hysterectomy by itself will not cure prolapse.

The major decision to be made by you & your surgeon is whether to perform an abdominal or vaginal procedure. Hysterectomy can be performed either way, but the prolapse procedures are very different. Not all surgeons are trained or skilled in both methods, & it is reasonable to stick with what they are experienced with. Drs Howden & Theofrastous have performed hundreds of each type of these procedures & will discuss these decisions with you.

Abdominal Vaginal Suspension Surgery– The abdominal suspension of the upper vagina is called a sacral colpopexy. The sacral colpopexy was developed over 30 years ago & has a very good safety & effectiveness record. Dr Theofrastous & Dr Howden are among the few pelvic surgeons who are able to performthe surgery using a laparoscope to avoid a large abdominal incision. A cone of fine mesh material is then attached to the top of the vagina with several permanent stiches, & then it is anchored to the bone in the sacral area. The space between the mesh & the bowel is then closed (a “cul-de-plasty”). The surgery is not around any nerves of the spine, they are on the backside. This procedure provides excellent support for the top of the vagina as well as some support to the upper bladder & back of the vagina. Most women go home the day after surgery.

Vaginal Vault Prolapse LS ASC

Sacral Colpopexy with Supracervical  Hysterectomy– When the uterus is part of the prolapse & an abdominal approach is planned, it is not necessary to remove all of the uterus. As long as there is no history of abnormal Pap smears due to abnormal cells on the cervix (“dysplasia”), the lower part of the uterus, or cervix, can be left in place. Leaving the cervix in place reduces the potential complications of surgery, the chance of infection after surgery, & the small chance of the mesh becoming exposed in the vagina.

Uterovaginal Prolapse LS SCH ASC

Vaginal Suspension Surgery– It can be difficult  to envision, but most prolapse surgery can be accomplished safely & effectively through the vagina. This is due to instruments which help visualize the pelvis, good surgical assistants & lighting. In general vaginal surgery is the way to go if possible. The recovery & discomfort following surgery are much less than with abdominal surgery, & the surgery has the potential for fewer complications. The drawback of a vaginal approach to suspending the vagina using your own tissues is that numerous medical studies have shown that it is not as good for a long-term success as procedures which use mesh. The vaginal suspension procedure consists of attaching each side of the top of the vagina to a ligament or to the side of the pelvis. If the tissues across the top of the vagina are strong enough, this will provide a durable result. Unfortunately there is no way to tell how strong those tissues are, & chances are that they are not very strong or the prolapse would not have occurred in the first place. While short term success rates are generally good, long term success rate can be as poor as  50-80%.

The Prevention of Leakage after Suspension Surgery

 Many women with significant prolapse are at risk of developing leakage after their prolapse if a procedure is not done at the time the prolapse is fixed. This is called “occult” or “potential” incontinence due to the fact that prolapse may hide a leakage problem by kinking or compressing the urethra. Many studies have shown that if a sling is not performed, there is a significant risk of leakage after surgery.

LS ASC GSI

We always evaluate the possibility of postoperative leakage before surgery with bladder testing. If there is leakage when we simulate how the surgery will affect the position of your bladder & upper vagina (a “barrier reduction test”), we usually recommend performing a midurethral pubovaginal sling at the time of your prolapse surgery.

LS ASC TVT

What is the Right Procedure for You?

The choice of the right procedure depends on your type of prolapse, how severe the prolapse is, your health, & lifestyle. Other factors include age, whether hysterectomy is necessary, sexual activity, prior surgery, & anatomy. Ultimately, it is your decision. Your surgeon will discuss these issues with you & honor your wishes.

Experience Matters!

Numerous studies have shown that good outcomes depend on having an experienced surgeon. Surgeons who perform a procedure rarely have more problems during surgery, & their patients have more problems afterward. Drs. Theofrastous & Howden are the most experienced pelvic surgeons in North Carolina. Physicians throughout the region & surrounding states send their patients to us for expert care. Because of the  large number of women who are sent to see us, we have performed thousands of continence & pelvic support procedures, & our outcomes are among the best in the nation.

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