Pelvic Organ Prolapse (POP)

Minnesota Urology has providers that specialize in female urology.

Our providers have dedicated their careers to helping patients with conditions of POP, as well as other problems in the pelvic area. We understand the complexities of POP — that not all women’s vaginas are the same — and we know when and how to fix it. Individualized care is the norm. And with something as complex as POP, individualized care is essential.

At Minnesota Urology we have specialists who are the leaders in our community, nationally and internationally. Our female urology providers have all received extra specialized fellowship training related to the care of patients with POP, incontinence, bladder/bowel dysfunction and other pelvic-related concerns. We have helped design and participated in many successful research trails dealing with prolapse and incontinence. Some of our doctors have trained urologists and gynecologists in our community and beyond in the performance and use of advanced therapies, and act as a resource for them when they have problems or questions of their own. You should choose Minnesota Urology because we have the most expert team of providers and offer the widest range of options, including conservative and advanced therapies. We will work with you to define our individual problem and come up with a specific plan that addresses your concerns.

What is pelvic organ prolapse?

POP is when the walls of the vagina have lost support and strength and fall down — and sometimes out the vaginal opening. The organs behind those vaginal walls can then fall down with the walls and “herniate” out the vagina. Behind the front wall of the vagina is the bladder; behind the back wall of the vagina; and at the top of the vaginal canal is the uterus, or in someone who has had a hysterectomy, the vaginal cuff or apex.

What are the symptoms of POP?

The main symptom of significant POP is the feeling of a bulge at or out the vaginal opening. Associated with this can be the feeling of heaviness or pressure in the vagina, pelvic or lower back areas. Sometimes bleeding and discharge can be seen when the prolapse hangs out the vagina and rubs on underwear/pads.

Other symptoms are usually related to the part of the vagina that is bulging. A prolapsing bladder can cause some irritating urinary voiding symptoms such as urinary urgency, frequency, and even incontinence — involuntary urinary leaking. In severe bulging prolapse of the bladder, a “kinking” effect of the urethra can make it hard to void and empty the bladder. A slower, trickling stream might be noted, as well as intermittent start-stop flow, or even having to push or strain in order to urinate.

A significant prolapsing rectum is associated with problems with bowel movements, such that stool gets trapped in the bulge and requires straining and “splinting” — pushing on the bulge — in order to defecate. This happens most commonly with poor quality stools such as small, hard pieces — rabbit pellets –, but can also happen with softer, formed stools if the bulge is large enough.

What causes POP?

POP doesn’t happen overnight, but usually progresses slowly over time. Any constant strain on the pelvic or vaginal area over time can result in POP. Primary examples include pregnancy and vaginal deliveries, other pelvic surgeries (such as hysterectomy), and high-impact activities that put a lot of strain on the pelvic area (running, jumping, pounding, heavy lifting, straining). When the ligaments (supportive structures) to the vagina and pelvic organs are weakened or disturbed, they can no longer support the vagina and/or organs behind the vaginal walls. The process is very much like a hernia, except that the herniating or bulging process is happening in/out the vagina, rather than in the groin.

How can POP be prevented?

Kegel exercises! Keeping the muscles in and around the vagina and pelvic area strong through a program of good core strengthening (Pilates, yoga) is most helpful for prevention. But sometimes, in the cases when the supportive ligaments have been acutely damaged (such as during a traumatic vaginal delivery, or during a hysterectomy); exercises can’t prevent the inevitable falling down or prolapsing process.

What can be done about POP?

Observation – if it’s not associated with bothersome symptoms.

Pessary – a flexible vaginal insert that helps hold the prolapsing parts up in the vagina. Best is when a woman can manage the pessary herself, by taking it out 1-2 times/week overnight to decrease the chances of infections or erosion.

Surgery – to correct the defects in the vaginal/pelvic areas that are responsible for the prolapse.

Does all POP need to be fixed?

NO! Just because a physician sees a bulge on vaginal exam, does not mean it needs to be fixed. Only POP that is associated with symptoms (bulge, urinary, bowel) should be addressed, since it is these symptoms that we are trying to correct.

What kind of surgical options are available?

Under the surgical umbrella for POP repair there are a lot of options, because the best way to correct one woman’s prolapse isn’t necessarily the best way to fix another woman’s prolapse. POP is a very complicated issue, since it can involve many compartments or organs in the vagina, and therefore be associated with many different symptoms. Again, the main goal of surgery is to correct the symptom that is directly related to the POP.

Briefly, the options concerning the route of surgery include surgery done through the vagina (with no incisions on the outside); through the abdomen, usually with an incision across the pelvic area; or through the abdomen with a few scattered small incisions for laparoscopic tools (done traditionally or with the assistance of the “robot”). The type of surgery depends on the compartment that needs to be fixed; cystocele repair for the bladder, rectocele repair for the rectum, vaginal vault suspension for the top of the vaginal canal (possibly uterine-sparing, or when not recommended, then a concomitant hysterectomy), and a concomitant anti-incontinence procedure when necessary.

Sometimes these procedures can be done with the patient’s own native tissue. But when the prolapse is so large, and the remaining tissue is so weak, a traditional native tissue repair doesn’t always last. Recurrence rates for symptomatic prolapse have been reported at 30-45% following traditional repairs — meaning that a second procedure will be necessary in the future to yet again fix the problem. The addition of permanent mesh in the vagina is meant to decrease this chance for recurrence and provide the woman with a long-lasting repair. The mesh is a soft piece of material that gets incorporated into the vaginal tissue to provide it with strength, and therefore durability. It is the same mesh used for other hernias in the body (abdominal, groin) and has been used for many years. Whether or not mesh would be beneficial for your POP repair depends on many factors; thus getting back to that very individualized care. Rest assured you will be counseled thoroughly about the nature of your prolapse, the options available to fix it, including the possible advantages of mesh.

What is a sacrocolpopexy?

A sacrocolpopexy is a type of surgery done for pelvic organ prolapse. This procedure has been used since the 1950s and is considered “the gold standard” for pelvic prolapse repair, with success rates of 80 to > 90%.

Robotic Surgery for Uterine or Vaginal Vault Prolapse – da Vinci® Sacrocolpopexy

As many as 50% of all women who have given birth vaginally have some degree of pelvic organ prolapse. Once women enter menopause and experience decreased estrogen levels, they are at about the same risk for prolapse as a woman who had a vaginal delivery.

Women who suffer from uterine or vaginal vault prolapse that requires surgery now can benefit from the da Vinci® Surgical System. This robot-assisted surgery system allows doctors to perform laparoscopic and some complex surgeries with greater precision and control than traditional surgery. Some formerly invasive surgeries can even now be performed laparoscopically using da Vinci.

Benefits of Robotic Surgery for Uterine or Vaginal Vault Prolapse (Sacrocolpopexy)