As a woman ages, and as certain stressors are placed on the female pelvic floor (such as childbirth and repetitive heavy lifting), the pelvic muscles and surrounding supportive tissues become weak and can no longer hold the female organs in their proper place. The result is pelvic organ prolapse. The female organs can begin to push through the vaginal opening causing a bulge.
Symptoms of Pelvic Organ Prolapse (or POP)
- Vaginal or pelvic pressure
- Lower abdominal or lower back pain
- An obvious or physical “bulge” protruding from the vaginal opening
- Difficulty with urination due to a physical “kinking” of the urethra
- Difficulty with defecation due to a possible stool-trapping rectocele
- Having to “splint” or push the vaginal organs back into place in order to empty the bladder or have a bowel movement
- Difficulty with intercourse or painful intercourse
- A worsening of symptoms with standing, lifting or coughing
Types of Pelvic Organ Prolapse
- Cystocele – The connective tissue between the bladder and vagina weakens, allowing the bladder to push down into the vagina. (fig cys)
- Rectocele – The connective tissue between the rectum and vagina weakens, allowing the rectum to push upward into the vagina. (fig rec)
- Uterine Prolapse – The connective tissue holding the uterus and cervix weakens and allows the uterus and cervix to drop into the vagina.
- Vaginal Vault Prolapse – Happening in women who have already had a hysterectomy, this type of prolapse occurs when the top part of the vaginal apex (or “cuff”) drops into the vagina.
- Enterocele – These often accompany vaginal vault prolapse and are caused by the small intestines pushing against the back wall of the vagina creating a bulge.
Diagnosis and Treatment
Our providers will perform a pelvic exam, and possibly a rectal exam as well. They may use a special instrument similar to a speculum, called a Sims retractor, to help identify the source of the bulge (i.e., figure out if it is a cystocele, rectocele, or other prolapse). The exam is not, generally, painful, and only take a minute or two to complete. Our providers may ask you to cough, bear down, or push in order to produce the prolapse at its fullest. In addition, you may be examined in more than one position (standing vs. lying down) if the initial exam is unclear.
Once your type of prolapse has been identified, our providers will have a detailed discussion with you on the best ways to address your prolapse. Some patients do not desire or do not qualify for surgery; they may be best treated by pelvic strengthening exercises or by the placement of a pessary to help reduce their prolapse. The AAFP has a nice resource on pessaries located here.
Other individuals with pelvic organ prolapse will qualify for a surgical repair, and our providers will ensure all your questions are answered pertaining to your repair. You should leave the office with a thorough understanding of your type of prolapse and what it will take to fix it.
Surgical options for repair of pelvic organ prolapse range from traditional vaginal approach surgeries to laparoscopic and even robotic repairs.
Will I need Mesh for my prolapse repair?
This is certainly a popular subject right now. Television ads by attorney groups can be seen on a daily basis. Patients need to understand the following: Despite what the attorney commercials are stating, there is no FDA recall on transvaginal mesh or mesh slings for incontinence. The FDA released a warning about the dangers of transvaginal mesh only, not a warning on slings for incontinence, and certainly not a general recall.
Studies looking at vaginal mesh erosions place the national mesh erosion risk around 8-10%. Always ask your doctor what their mesh erosion rate is. This is information that any surgeon should be honest and forthcoming with. According to AUGS (The American Urogynecologic Society), surgeons who wish to use mesh should have ample training in mesh placement, a thorough understanding of pelvic anatomy, and have experience in pelvic reconstructive surgery. We at UT Urogynecology agree with the American Urogynecologic Society’s statement and support the use of mesh only in certain individuals and by qualified physicians. Patients should understand that, in the right hands, transvaginal mesh is a safe and effective means of treating more severe or recurrent forms of Pelvic Organ Prolapse.
Not everyone with prolapse needs transvaginal mesh. More often than not, our patients can have repairs using their own tissue, avoiding the need for mesh augmentation. The question of whether or not you will need mesh will be answered by your pelvic exam. If our providers believe you need mesh for your repair, they will discuss the repair along with all the risks, benefits, alternatives, and indications during your visit. It is always your choice to proceed with a mesh repair or request a repair without the use of mesh.
While our providers have a low mesh complication rate, they have experience in helping those with mesh complications, and can handle anything from simple in-office treatments to full removal of the mesh. If you have had a mesh repair and are experiencing complications from it, please call and schedule a visit with us. We have helped several individuals get back to a normal life again.