Clinical Conditions

Definition

Pelvic Organ Prolapse is when the organs inside of the pelvis, such as the uterus, urethra or bladder, protrude toward or through the opening of the vagina. This is caused by a weakness in the pelvic floor, muscles and the fibromuscular connective tissue that supports and surrounds the vagina, rectum, bladder and uterus. The pelvic floor’s job is to hold these pelvic organs in place, but when it weakens the organs can fall out of their positions and stop functioning normally. When the fibromuscular connective tissue sheets that separate the vagina, bladder and rectum are damaged, vaginal hernias develop.

Symptoms

The most obvious symptom of vaginal prolapsed is a bulge protruding from the opening of the vagina. Additional symptoms of vaginal prolapsed are pelvic pressure, discomfort, feeling as if something is falling out, difficulty emptying the bladder, unwanted urine leakage, difficulty emptying the rectum, fecal incontinence and experiencing a sense of looseness or discomfort during sexual intercourse.

Cause

Even though more than 40% of all women experience some degree of prolapse in their lifetime, 14 million in the US alone, the exact cause is unknown. However, risk factors include pregnancy, vaginal delivery, hysterectomy, obesity, chronic cough, chronic constipation, repetitive heavy lifting, menopause and genetic connective tissue weakness.

Diagnosis

The presence and severity of vaginal prolapse is determined during a pelvic exam. During this exam, the anterior vaginal wall, posterior vaginal wall, top of the vagina and uterus are each evaluated for prolapse. After the exam, a stage from 0 to IV is assigned. A stage 0 prolapse means there are no prolapsed organs identifiable. A stage I prolapse means that the vaginal wall bulges down to 3 centimeters inside the opening of the vagina. A stage II prolapse means that the vaginal wall comes to or slightly through the opening. A stage III prolapse is when the vaginal wall protrudes several centimeters outside of the vagina. A stage IV prolapse is when the entire vaginal wall protrudes through the opening.

Treatment Options

Non-surgical Treatments

Kegel exercises

Kegel exercises strengthen the pelvic floor muscles. These exercises can help control stress urinary incontinence, urge urinary incontinence, overactive bladder, fecal incontinence and can help slow the progression of vaginal prolapse. Kegel exercises must be done correctly and regularly to work. With severe prolapse there is limited benefit seen.

Pelvic floor therapy

Pelvic floor therapy consists of a series of visits to a physical therapist with specialized training in the treatment of pelvic floor problems. The physical therapist uses a combination of the techniques listed below depending on the type of urogynecological condition present. With vaginal prolapse the goal of pelvic floor therapy is to strengthen the pelvic floor so as to provide support to the vagina and pelvic organs. Below are four treatment options available for pelvic floor therapy:

Biofeedback: an intravaginal device used to train the pelvic floor muscles to contract or relax correctly

Functional electrical stimulation: a device that can be used intravaginally or externally that delivers a gentle electrical current to activate or relax the nerves and muscles in the pelvis. Manual therapy – pressure applied to and released from muscles in spasm to relax them and increase blood flow to the area for healing. Often, women with prolapse subconsciously perform excessive pelvic floor contractions to the point of creating pelvic floor muscle spasms. This may create a painful condition called pelvic floor dysfunction, which in turn may lead to pelvic pain, painful sex and difficulties with urination and defecation.

Joint and tissue mobilization: gentle manipulation to help calm the muscles and nerves of the pelvis

Vaginal pessary: A vaginal pessary is a removable, diaphragm-like device worn in the vagina to support the bladder or other internal organs that are prolapsing within or through the vagina and/or decrease stress urinary incontinence. There are a variety of types and sizes of pessaries available. A pessary fitting includes two or more office visits to find a type and size of pessary that will work for you.

Surgical Treatments

Anterior colporrhaphy

An anterior colporrhaphy repairs the wall between the vagina and the bladder. A pliable piece of material called a “graft” can be placed between the vagina and bladder to strengthen the repair. There are many types of grafts available.

Posterior colporrhaphy

A posterior colporrhaphy repairs the wall between the vagina and the rectum. As with the anterior colporrhaphy, graft material can be used to strengthen this type of repair. This procedure is performed vaginally. Dr. Tyagi generally uses the pelvic floor muscles adjacent from the rectum as the “graft” material. This reduces graft complications.

Perineorrhaphy

A perineorrhaphy is the surgical repair of a weakened perineum (the area between the vaginal opening and anus). This procedure is sometimes done at the same time as a posterior repair.

Vaginal vault suspension/Uterine resuspension

A vaginal vault suspension is the surgical repair of a vaginal vault prolapsed by attaching the top of the vagina to ligaments in the pelvis with permanent sutures or graft material. This procedure can be performed vaginally or abdominally.

Hysterectomy

A hysterectomy is the surgical removal of the uterus. This is the surgery done to reduce future risk of gynecologic cancers. There is no documented benefit to prolapse repair by including a hysterectomy. A hysterectomy can be done through a vaginal or abdominal incision.

Robotic Sacropopexy or Sacrohysteropexy

In specific situations, the vaginal vault can be suspended to the back bone of the pelvis. Dr. Tyagi has done this procedure laparoscopically and robotically since 2005. A permanent graft is sutured to the vaginal walls and/or uterus and then permanently connected to the sacrum.