Vaginal prolapse, or pelvic organ prolapse, occurs when one or more pelvic organs (such as the uterus, bladder, or rectum) slip from their normal positions into the vaginal canal. This condition arises due to the weakening of muscles and tissues in the pelvic area, which can no longer adequately support the pelvic organs in their natural positions. Pelvic organ prolapse is common among many women; however, its symptoms can be so mild that it goes undiagnosed until they undergo a healthcare examination, such as a pelvic exam. Prioritizing pelvic health is essential because vaginal prolapse tends to worsen over time when left untreated.

Once vaginal prolapse occurs, it will not resolve itself. It is imperative to seek appropriate treatment to prevent it from worsening and to alleviate discomfort and painful symptoms. There are numerous vaginal prolapse treatment options available today, and your healthcare provider can guide you in selecting the most suitable treatment plan.

Types of Vaginal Prolapse

There are various types of vaginal prolapse, each named according to the associated pelvic organ. Below, we outline these types:

1. Cystocele (Bladder Prolapse): This occurs when the tissues and muscles that support the bladder weaken, causing the bladder to descend into the vaginal canal.
2. Rectocele: Rectocele is a form of vaginal prolapse in which the rectum bulges into the vagina, often leading to constipation or other difficulties with bowel movements.
3. Uterine Prolapse: The descent of the uterus into the vagina can lead to discomfort as it tugs on ligaments. If this condition progresses, the uterus may protrude from the body, resulting in both pain and bleeding.
4. Vaginal Vault Prolapse: Vaginal Vault Prolapse occurs when the upper part of the vagina descends into the vaginal canal or outside the body, causing pain and discomfort.

Symptoms and Complications of Vaginal Prolapse

In mild cases of prolapse, you may not notice any symptoms, and often, healthcare professionals diagnose women during a pelvic exam. However, in more severe cases of vaginal prolapse, women may experience some of the symptoms listed below:

• A sensation of something protruding through your vagina.
• Pelvic organ pain.
• Discomfort while lifting heavy objects or standing.
• Increased frequency of urination.
• Difficulty inserting period products like tampons and menstrual cups.
• A feeling of fullness in the vagina.
• Bowel issues.
• Difficulty with sexual intercourse.
• Pressure in the pelvic area.
• Urine leakage or a constant urge to urinate.
• Lower back pain.

Causes and Risk Factors of Vaginal Prolapse

Several factors contribute to and increase the risk of pelvic organ prolapse, including:

1. Childbirth: Vaginal deliveries, especially during prolonged labor and the delivery of a baby weighing more than 9 pounds, increase the risk of prolapse.
2. Surgery: People who have undergone a hysterectomy (surgery to remove the uterus) may be at a higher risk of bladder prolapse. This is because the removal of the uterus leads to the loss of support that the uterus previously provided to the bladder.
3. Lifting Heavy Objects: Excessive physical activity and lifting heavy weights exert pressure on the abdomen and can weaken pelvic tissues and muscles.
4. Chronic Cough and Constipation: Persistent coughing and straining due to constipation can weaken muscles and tissues in the pelvic floor, elevating the risk of prolapse.
5. Menopause: As women go through menopause, their estrogen levels decrease, which can cause the vaginal tissue lining to thin out.

Non-surgical Treatment Options

For mild cases of prolapse, it is advisable to explore conservative treatment options before considering surgery. Pelvic floor exercises, such as Kegel exercises, can effectively strengthen the pelvic floor muscles. When used in combination with other conservative treatments, they can be very effective, but it does require dedication and time.

Doctors often prescribe pessaries as a common treatment option. A pessary is a medical device inserted into the vagina to provide support to the prolapsed pelvic organ. Various types and sizes of pessaries are available, and your healthcare provider will help you find the one that fits you best. It's important to note that pessaries may not be suitable for all women. Some may find them uncomfortable, while others may struggle to keep the pessary in place due to weak pelvic floor muscles.

Changing lifestyle habits and diet is also crucial. For women experiencing bowel difficulties, increasing fiber intake and staying hydrated can be beneficial. Regular exercise and maintaining a healthy weight are equally important aspects of managing prolapse.

However, if your prolapse has progressed to a severe stage and conservative treatments prove ineffective, your doctor may recommend surgery.

Surgical Options for Vaginal Prolapse

Several surgical methods are available to address vaginal prolapse. Your doctor will discuss the most suitable surgical approach for your specific case:

1. Colporrhaphy: Colporrhaphy involves providing support and reinforcement to the muscles and tissues in the pelvic floor. Anterior colporrhaphy focuses on the front wall of the vagina, primarily addressing bladder prolapse, while posterior colporrhaphy targets the back wall of the vagina, mainly for rectocele.
2. Sacrocolpopexy: Sacrocolpopexy is a procedure that utilizes surgical mesh or other materials to strengthen and support the prolapsed organ. It can be performed through an abdominal incision or using laparoscopy.
3. Hysterectomy: Hysterectomy is a treatment option for uterine prolapse, involving the partial or complete removal of the uterus. It is a major surgical procedure that can be performed vaginally (vaginal hysterectomy) or through an abdominal incision (abdominal hysterectomy). It's important to note that women who undergo this surgery can no longer become pregnant, so this is a significant consideration.

Your doctor will carefully evaluate your condition and discuss the benefits and risks of each surgical option to determine the most appropriate course of treatment for you.

Which factors should I consider to determine whether to proceed with the surgery?

Before deciding on surgery, it's essential to take several factors into consideration:

1. Effectiveness of Conservative Treatments: Evaluate whether you have tried non-invasive treatment options for prolapse and whether they have been effective. Pelvic organ prolapse, while burdensome, is not a life-threatening condition. Therefore, it is advisable to explore non-surgical treatments first due to the associated risks and potential side effects of surgery.
2. Future Pregnancy Plans: Consider whether you have intentions of getting pregnant in the future. Certain surgical prolapse procedures, such as hysterectomy, render you unable to conceive.
3. Underlying Medical Conditions: Assess whether you have underlying medical conditions that may contraindicate surgical treatment, such as heart disease.
4. Acceptance of Surgery's Limitations: Be aware that surgery may not offer a permanent solution for everyone. Although many women experience success with prolapse surgery, it is not always a permanent fix. Some individuals may encounter post-surgery prolapse and require additional surgical interventions in the future.

Potential Risks of Surgery

As with any surgical procedure, there are associated risks and potential complications. However, these risks can be minimized by selecting a skilled surgeon and diligently following pre and post-operative care instructions. Potential risks include:

• Infection
• Bleeding
• Anesthesia-related complications
• Recurrence of prolapse
• Damage to surrounding pelvic organs

It is crucial to discuss these considerations and potential risks thoroughly with your healthcare provider when making decisions about prolapse surgery.

Minimally Invasive Techhniques

Laparoscopic surgery is a minimally invasive technique that uses a laparoscope, slender rod with a camera at its tip. This procedure is conducted through small incisions, each less than 1 inch in length. The laparoscope provides a clear view inside the body, enabling the surgeon to perform the surgery. It offers several advantages, including faster recovery times, reduced pain, and smaller incisions compared to traditional surgery.

Robotic-assisted surgery is also a minimally invasive approach similar to laparoscopic surgery, but it involves the use of robotic arms equipped with surgical tools, enhancing precision and control. Compared to conventional surgical methods, it offers faster recovery times and smaller incisions.

Advantages of Minimally Invasive Surgery in Terms of Recovery

The benefits of minimally invasive surgery include:

• Smaller incisions, resulting in less pain and quicker recovery.
• Reduced risk of blood loss during the procedure.
• Enhanced internal visibility of the body using advanced tools, allowing for precise and controlled completion of complex tasks.

Recovery and Aftercare

Recovery duration varies based on the type of surgery but typically involves a hospital stay of 1-3 days. Adhering to your surgeon's post-operative care instructions is crucial for a swift and stable recovery. This entails refraining from physical or strenuous activities, avoiding heavy lifting, and abstaining from intercourse until fully healed. Your doctor may prescribe pain medications to ensure a comfortable recovery, and the use of hot/cold packs can help alleviate discomfort.

Success Rates and Complications

Vaginal prolapse surgery boasts a high success rate for many women. However, this outcome depends on various factors, including the patient's overall health, age, medical history, thorough pre-operative evaluation, the surgical technique employed, and post-operative care. It's important to recognize that surgery may not yield permanent results for everyone, and some women may experience prolapse symptoms again, requiring additional surgery. Surgical procedures also carry potential risks and complications, such as bleeding, infection, or damage to surrounding pelvic organs. Therefore, selecting a skilled surgeon and engaging in a comprehensive discussion of your concerns before undergoing any surgical procedure is of utmost importance.

Supervising Doctor of This Article

Koichi Nagao, MD PhD

Professor, Department of Urology, Toho University Faculty of Medicine
Director of Urinary tract reconstruction center, Toho University Omori Medical Center
Director of Reproduction Center, Toho University Omori Medical Center

Professor Nagao specializes in plastic surgery in the field of reproductive medicine. He completed eight years of plastic surgery training at Showa University before majoring in urology at Toho University. With his meticulous surgical techniques and careful examinations that combines urology and plastic surgery, Professor Nagao became a Board Certified Specialist with multiple associations including the Japanese Urological Association, the Japan Society for Reproductive Medicine, and the Japanese Society for Sexual Medicine.