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PELVIC ORGAN / VAGINAL PROLAPSE

Overview:

 

Vaginal prolapse is a lack of support for the pelvic structures (Uterus, intestines, bladder, rectum) that results in a hernia or bulging of these organs into the vagina. Women with this problem often have the sensation of pressure in the pelvis or “something falling out of me.” In more extreme cases the prolapse is outside the vagina and will block the flow of urine and or bowel movements. The condition is usually painless but can cause “discomfort”. The symptoms tend to worsen as the day progresses and you are up on your feet.

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This condition has various degrees of progression. It is a quality of life condition. No one knows exactly why it occurs. It is associated with childbirth, obesity, chronic straining (constipation, heavy lifting), and smoking. It can also occur for no reason at all.
There are both surgical and non-surgical ways to treat prolapse. The key to proper management of your prolapse is a detailed evaluation.

Evaluation of prolapse:

There are multiple portions of the vagina that can be involved in prolapse. It is important to determine which portion(s) of the vagina and what underlying organs (bladder, rectum, uterus, intestines and to what degree)) are involved in your prolapse. Part of your evaluation may involve cystoscopy and urodynamics.

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Cystocele: protrusion of the bladder into the vagina. It involves the anterior segment of the vaginal wall.

Rectocele: protrusion of the rectum into the vagina. It involves the posterior segment of the vaginal wall.

Enterocele: protrusion of the intestine into the vagina. It involves the apical segment of the vaginal wall.

Uterine prolapse: protrusion of the cervix and uterus into the vagina. It involves the apical segment of the vaginal wall

All of these types of prolapse may occur together or separately and to varying degrees. In some cases prolapse does not cause any symptoms. When prolapse is bothersome it is very important to determine what portion(s) of your prolapse is causing your particular symptoms.

SURGERY:

Traditionally surgery is either performed through the abdomen or through the vagina and may involve a hysterectomy when indicated. Any surgical option that is offered whether it is vaginal, abdominal, or robotic should be based on your specific physical exam, goals of surgery, and potential complications. It must be individualized for you. No one procedure can fix everyone. Vaginal procedures are most commonly performed. Traditionally they used to be performed by suturing the native tissues together. These techniques rely on the patient’s native tissue and scarring to hold the prolapse segment in place. There can be a higher failure rate with these, but other potential complications are also avoided so your doctor will discuss this option with you and why it may or may not be a good option for you. Outcomes for vaginal repairs can be improved as far as a longevity repair standpoint by adding a graft material to augment the patient’s native tissues. These grafts can be either biologic or synthetic. Synthetic grafts have shown to be superior as far as longevity of repair is concerned, but there are potential complications associated with any graft material and as such the benefits and risks must be weighed together with your goals. Abdominal or robotic procedures typically use a graft material but the rates of graft complications are lower. Abdominal approaches have shown to have the best longevity to date. Robotic procedures emulate these abdominal procedures and as such are expected to have the same outcomes. However, abdominal and robotic repairs are only useful for a select group of patients. There are many factors we use to determine the approach or combination of approaches that is appropriate for you. We individualize your options because everyone is different and should be treated as such.

NON-SURGICAL MANAGEMENT:

  • PESSARY
    The pessary is the mainstay of non- surgical management of prolapse. A Pessary is a silicone vaginal insert that holds prolapse in place. Pessaries are available in many sizes and shapes. It is typically inserted and removed by the patient. With a properly fit pessary you wont even know its there.
  • Pelvic floor exercises (KEGEL EXERCISES)
    These exercises help to strengthen the pelvic floor musculature. This exercise will not reverse prolapse but may prevent or at least slow down the progression of prolapse.