Prolapse

Prolapse: A health condition with many faces

Prolapse – Cystocele – Rectocele

Pelvic organ prolapse is a condition that, although not life-threatening, has a negative impact on the quality of life. A woman during her lifetime has a 10% chance of undergoing surgery for any of the above.

Pelvic organ prolapse is a gynecological hernia due to relaxation or weakening of the muscles and ligaments that support the uterus and vagina. It often occurs after childbirth as a result of injury to the pelvic floor, as a cause of chronic stress (weight, cough, constipation, etc.) or due to aging. Prolapse is manifested in different forms, depending on the affected organ:

Cystocele

Also known as “fallen bladder”. It occurs when the support between a woman’s vagina and bladder loosens, allowing the latter to prolapse into the vagina. If the cystocele is mild, patients may not have any symptoms, while in severe cases, there may be urinary incontinence or other urinary symptoms.

Rectocele

Rectocele occurs when the rectum herniates into the vagina. Severe cases of rectocele can cause difficulty in defecation.

Enterocele

It is a form of pelvic organ prolapse that happens when the small intestine protrudes through the upper vagina wall causing it to prolapse. The clinical presentation of enterocele is often similar to that of rectocele. Therefore an accurate differential diagnosis is essential for an effective treatment.

Consult your doctor if:

• You feel pressure, pain, or have a feeling of fullness in the vagina.
• You feel a bulge in the vagina or vulvar area.
• You discover a lump protruding in the vulvar area
• You experience urination problems, frequent urination, voiding difficulties or urinary incontinence.
• You feel discomfort in the groin or lower back area.
• You experience reduced arousal and satisfaction or pain during sexual activity.

The diagnosis can be achieved by a gynecological examination

Pelvic organ prolapse can be diagnosed by a detailed gynecological examination, to reveal the type and degree of the prolapse.
A detailed medical history will also be needed as it provides valuable information. Depending on the findings of the gynecological examination and the symptomatology, further investigations of the urinary system may be required, such as urodynamic testing, gynecological ultrasound, urinary tract ultrasound etc.

Non-surgical treatment of prolapse

Non-surgical treatment methods are indicated either in women with mild prolapse or when, for different reasons, they cannot undergo surgery (i.e. geriatric patients, severe health condition, etc.). These methods are not a definitive treatment of the prolapse but rather help relieve the symptoms.

Pelvic floor Physical Therapy: It includes exercises that help strengthening the muscles of the area, in order to prevent the prolapse deterioration. At the same time, it helps treating the symptoms of urinary or fecal incontinence that may coexist with prolapse.

Conservative therapy include:

Follow Up  Pelvic organ prolapse is not a life-threatening condition, and many asymptomatic patients might choose not to have any treatment. If this is the case, they are advised to avoid chronic straining, constipation, heavy lifting and weight gain.

Pelvic floor Physical Therapy:  It includes exercises that help strengthen the muscles of the pelvic area hence preventing prolapse deterioration. Additionally, it helps treating the symptoms of urinary or fecal incontinence that may coexist with prolapse.

Vaginal pessaries: It is a device that is inserted into the vagina to support the prolapsing organs. The shape and size of the pessaries vary and the device must be changed regularly to avoid the risk of trauma or infection. This treatment is indicated for geriatric, medically unfit patients and those who want to delay or avoid surgery. The use of a particular type of pessaries enable sexual intercourse.

Hormone replacement therapy: The use of local oestrogens can improve the discomfort due to atrophic vaginal changes that occur in menopausal women

Minimally invasive surgeries to treat prolapse

The primary treatment of pelvic organ prolapse is surgical. The current surgical methods are minimally invasive (laparoscopic, transvaginal). The efficacy of the surgical procedure depends on the expertise and experience of the doctor performing the surgery. A Urogynecologist can determine the most appropriate procedure for each individual patient. The treatment is adapted considering many factors, including the patient’s age and physical condition, the type and degree of prolapse, the desire for future pregnancy, etc. The current surgical procedures for pelvic organ prolapse are safe and painless, requiring minimal hospitalization and early return to normal activities within 2-3 weeks. They are usually performed under local or regional anesthesia (epidural/spinal anaesthesia).

Cystocele: Depending on the type and degree, cystocele can be repaired either by transvaginal surgery (anterior colporrhaphy, in which part of the vagina is strengthened so that the cyst “rises” to its original position) or laparoscopically.

Rectocele: It is best restored by transvaginal surgery (posterior colporrhaphy) and perinheorhaphy

Uterine Prolapse: A hysterectomy is not always necessary. Modern transvaginal or laparoscopic techniques, with or without the use of mesh, can support the prolapsed uterus in women who do not wish to have the organ removed. Often patients with uterine prolapse also have cystocele and rectocele. These defects must be repaired simultaneously with uterine prolapse to have an optimal outcome.

Dealing with prolapse – Frequently asked questions on the first date

Why do I have a prolapse ?

Pelvic organ prolapse is caused by genetic predisposition, pregnancy and childbirth, chronic increase in intra-abdominal pressure, heavy lifting, chronic constipation, chronic cough, ageing and menopause.

If I do the operation, will I suffer from incontinence?

No. This side effect can be avoided in most cases by detailed preoperative assessment and planning of the correct surgical procedure.

Will the prolapse get worse?

Prolapse, if left untreated, tends to get worse over time.

Is surgery the only solution?

No, there are also non-surgical treatment options. However, if surgery is the only suitable option, this is usually minimally invasive, painless and safe.

Will my sex life be normal again?

Yes, sexual activity is restored when a specialized doctor performs a proper anatomical restoration of the vaginal relaxation. However, sometimes sexual problems occur due to other reasons, such as psychological disorders and vaginal atrophy and not due to the prolapse surgery. In these cases, additional treatment is required for the complete restoration of a woman’s sexual life.