About Pelvic Organ Prolapse (POP)

Pelvic organ prolapse occurs when the walls of the vagina have lost support or strength and fall down, sometimes out of 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. 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 has had a vaginal delivery.

• What are the symptoms of pelvic organ prolapse?

  The main symptom of significant pelvic organ prolapse is the feeling of a bulge at or out of the vaginal opening. You also may feel a heaviness or pressure in the vagina, pelvis, or lower back area. Sometimes bleeding and discharge can be seen when the prolapse hangs out of the vagina and rubs on underwear or 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, but can also happen with softer, formed stools, if the bulge is large enough.

• What causes this condition?

  Pelvic organ prolapse doesn’t happen overnight, but usually progresses slowly over time. Any constant strain on the pelvic or vaginal area over time can result in prolapse. 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, such as running, jumping, pounding, heavy lifting or straining. When the ligaments (supportive structures) to the vagina and pelvic organs are weakened or disturbed, they can no longer support the vagina and organs behind the vaginal walls. The process is very much like a hernia, except that the herniating or bulging process is happening in and out of the vagina, rather than the groin.

• How can pelvic organ prolapse 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 cases when the supportive ligaments have been acutely damaged, such as during a traumatic vaginal delivery or during a hysterectomy, exercises alone can’t prevent the inevitable falling down or prolapsing process.

• What can be done?

  There are several methods for addressing pelvic organ prolapse:

  • Observation, if the condition is not associated with bothersome symptoms.
  • Pessary, a flexible vaginal insert that helps hold the prolapsing parts up in the vagina. We encourage women to manage the pessary herself by taking it out one or two times a week overnight to decreases chances of infections or erosion.
  • Surgery to correct defects in the vaginal and pelvic areas responsible for the prolapse. 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 more than 90%.
• What kind of surgical options are available?

  We have many options for your unique situation. Pelvic organ prolapse is a very complicated issue, since it can involve many compartments or organs in the vagina and therefore be associated with many different symptoms. The main goal of surgery is to correct the symptom that is directly related to the prolapse. Options 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 a robotic system). 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 your own native tissue, but when the prolapse is large and the remaining tissue is 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 fix the problem. The addition of permanent mesh in the vagina is meant to decrease this chance for recurrence and provide you with a long-lasting repair. The mesh is a soft piece of material that is incorporated into the vaginal tissue to provide it with strength and durability. It is the same mesh used for abdominal or groin hernias and has been used for many years. Whether or not mesh would be beneficial for your repair depends on many factors. Rest assured, you will be counseled thoroughly about the nature of your prolapse and the options available to fix it, including the possible advantages of mesh.

  As with any surgery, benefits cannot be guaranteed, as surgery is specific to each patient and each procedure. Your treatment options will depend on a number of factors, including your age and health or personal condition.

  Is robotic surgery right for me?

  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 enables doctors to perform laparoscopic and some complex surgeries with greater precision and control than traditional surgery. Some formerly invasive surgeries can now be performed laparoscopically using the da Vinci. The benefits of robotic-assisted surgery for uterine or vaginal vault prolapse (sacrocolpopexy) are:

  • Significantly less pain
  • Less bone loss
  • Fewer complications
  • Less scarring
  • Shorter hospital stay
  • Faster return to normal daily activities

   

  Does all pelvic organ prolapse need to be fixed?

  NO! Just because a physician sees a bulge on your vaginal exam does not mean that it needs to be fixed. Since the objective of treatment is to address symptoms, only prolapse that is associated with symptoms, such as a notable bulge or urinary or bowel issues, should be addressed.