Utero-vaginal prolapse

The walls of the vagina have elasticity to facilitate intercourse and childbirth. If the support is weakened a vaginal prolapse may develop. The prolapse may involve the uterus, which descends into the vagina and may eventually protrude from the vaginal opening. The concept that all vaginal prolapses relate to the uterus (Figure 30.1) is incorrect. Sometimes it is the front or back walls of the vagina which are bulging with associated distortion of the bladder (cystocoele Figure 30.2) or rectum (rectocoele Figure 30.3). If you have had a hysterectomy the vault of the vault (top) of the vagina can prolapse. Sometimes the bowel may prolapse under the posterior (back) wall of the vagina (enterocoele Figure 30.4).

What are the symptoms associated with vaginal prolapse?

Usually there is a feeling of 'something coming down? or vaginal discomfort. Some women are aware of a dragging ache in the pelvis. The degree of vaginal prolapse does not necessarily match the severity of symptoms that you may experience. Sometimes we find quite marked vaginal prolapse but the patient has no symptoms. Other women report quite severe symptoms although there may be only minimal prolapse. Most backaches are due to problems in the back, although, on occasion, repair of a vaginal prolapse may provide some relief.

Why have I developed a vaginal prolapse?

Vaginal prolapse is usually seen in women who have had children delivered vaginally. It is unusual to see a prolapse in ladies who have never had children. Vaginal delivery of a large baby is particularly likely to weaken the vaginal supports, and there is greater likelihood of prolapse if you have a large family. After the menopause, the reduced levels of oestrogens may further weaken the vaginal support.

Overweight women are stretching the vaginal support (pelvic floor) as well as their backs and joints. Patients with chronic cough (e.g. smokers), or others with constipation may similarly weaken their pelvic floor.

I have a vaginal prolapse. Should it be treated?

If a vaginal prolapse is causing problems for you treatment is advisable. In deed, the only reason to treat a prolapse is to alleviate symptoms.

Many women have lax vaginal walls but are not aware of any problems: they may, for instance, be told that they have a vaginal prolapse when they are examined at a well woman clinic. If there are no symptoms there is probably no reason to recommend surgery. For reassurance, a further examination at six monthly or yearly intervals may be sensible.

How can my vaginal prolapse be treated?

The treatment of choice has been surgery to repair your pelvic floor. In some circumstances, where other illness preclude this, or if it is your preference, an internal support pessary, usually a ring, may be fitted by your gynaecologist. For hygienic reasons these rings should be replaced at three or four monthly intervals.

The use of pessaries to treat vaginal prolapse is becoming increasingly popular. A ring pessary can be introduced into the vagina to support some vaginal prolapse and reduce symptoms. If the vaginal outlet is enlarged, the ring may slip out. Shelf pessaries have been useful for many patients with vaginal prolapse when the ring is not suitable.To evaluate a simplified protocol for pessary management women with symptomatic pelvic organ prolapse who opted for pessaries were enrolled in a prospective simplified protocol for pessary management. After the initial pessary fitting, they were seen at 2 weeks for reexamination and thereafter at 3- to 6-month intervals. One hundred ten women (mean age 65 years) were enrolled, and 81 (74%) of them were fitted successfully with a pessary. Life-table analysis showed that 66% of those who used a pessary for more than 1 month were still users after 12 months and 53% were still users after 36 months. The severity of pelvic prolapse did not predict the likelihood of pessary failure except in cases of complete procidentia. Patients complaining of stress incontinence were less likely to have a successful pessary fitting and more likely to opt for surgery. Current hormone use and substantial perineal support do not predict greater likelihood of pessary fitting success. No serious complications from using the pessary were observed in the study sample. It was concluded that stringent guidelines calling for frequent pelvic examinations during pessary use can be relaxed safely. Pessaries can be offered as a safe long-term option for the management of pelvic prolapse.⁹⁷⁰¹There is some evidence that pessaries prevent progression of vaginal prolapse and that they may reverse it.⁰²⁰¹

What happens during a pelvic floor repair?

This depends on what parts have prolapsed and the degree of uterine descent (Figure 30.1; Figure 30.2; Figure 30.3 and Figure 30. 4). If there is a cystocoele (Figure 30.2) or rectocoele (Figure 30.3) the vaginal skin is dissected off the underlying bladder or rectum, and the excess skin is removed. Two layers of stitches are introduced to restore the vagina into its correct position.

Should there be a major degree of uterine prolapse, it may be necessary to remove the uterus vaginally – vaginal hysterectomy (hysterectomy). If there is a lesser degree of uterine prolapse just the neck of the womb (cervix) may be taken away and the ligaments previously attached to the neck of the womb are then stitched into the lower part of the uterus to keep it in place. This is called a Manchester repair or Fothergill procedure.

What can I expect after a pelvic floor repair?

You will probably need to be in hospital for a week. On return from the operating theatre you will have a fine tube (drip) in one of your arm veins with fluid running through. Most surgeons will have introduced a bandage in the vagina (pack) and a catheter into the bladder. Usually the drip and pack come out the day after surgery and the catheter is removed three to five nights after the operation. As soon as your bladder is functioning without difficulty and you are feeling ready you will be able to go home.

It is important to avoid stretching the repair particularly in the first weeks after surgery. The stitches dissolve during the first three weeks and the body will gradually lay down strong scar tissue over a few months.

It is usual to have a consultation with your gynaecologist about six weeks after the operation. After that assessment, you should be able to resume most activities, including sexual intercourse. It is advisable to avoid heavy lifting for a few more weeks and even then care should be taken.

What are the risks of a pelvic floor repair operation?

The general risks of surgery are discussed in surgery risks. The risks of hysterectomy (hysterectomy) are discussed in Q 24.21. During pelvic floor surgery your gynaecologist will be tailoring the vagina so that the symptoms related to the laxity will be resolved whilst not making the vagina too tight. On occasion the vagina may still feel too loose or too tight.

How successful are pelvic floor repair operations?

The majority of operations are successful. Failure is more likely to occur if you are overweight, if you are a smoker or if constipation is a chronic problem. These problems should be corrected, if possible, before surgery. In postmenopausal women who have not had HRT the tissues may be weak. There is often merit in treating the vagina with local oestrogen (Q 28.2) before surgery. Again, care to allow the repair to heal in the weeks after surgery must be emphasised.

When there is vaginal prolapse causing discomfort, surgery is likely to provide symptomatic relief. If there is vaginal prolapse and stress incontinence, surgery may resolve both problems. When urgency is the major bladder problem, it may not respond to surgery if the cause is detrusor instability. Urodynamic studies may be considered before operating (Q 29.22).?Occasionally a second operation may be required if the vaginal prolapse recurs. Success rates from a second operation are lower.

What should be done if I have a vaginal prolapse and plan a pregnancy?

Clearly there is no reason to refrain from pelvic floor exercises. The question of surgery is more difficult to answer. The benefits of surgery for vaginal prolapse or stress incontinence may well be lost after another vaginal delivery. If the pregnancy is to be fairly soon, a support vaginal ring pessary may relieve some vaginal prolapse symptoms. If surgery has been performed, the obstetrician may offer Caesarean section delivery next time, particularly if stress incontinence has been successfully treated.

Support groups

Members of a support group, provide each other with various types of help and information for a particular shared difficulty.

A support group may also provide ancillary support, such as serving as a voice for the public or engaging in advocacy.

Support groups maintain interpersonal contact among their members in a variety of ways.

Support groups also maintain contact through printed information rich newsletters, telephone chains, internet forums, and mailing lists.

Support groups offer companionship and information for people coping with diseases or disabilities. Support groups may not be appropriate for everyone, and some find that a support group actually adds to their stress rather than relieving it.

Evaluation of the quality of Web sites is discussed in (internet information). You may find that several general women's health sites may help you (internet information). The following are more specialised relevant Web sites:-

DISCLAIMER

The aim of this web site is to provide a general guide and it is not intended as a substitute for a consultation with an appropriate specialist in respect of individual care and treatment.

Utero-Vaginal Prolapse

What is a vaginal prolapse?