What is Pelvic Prolapse? What are the Symptoms?

by Kathleen Kobashi, MD Virginia Mason Medical Center (Seattle, WA)

Pelvic prolapse (PP) is a general term referring to the “falling down” of the pelvic floor.  Patients have a variety of complaints depending on which compartment of the pelvic floor or vagina is falling (see below).  Prolapse often results from weakness of the supporting structures of the pelvic floor following vaginal childbirth, or due to some degree to hormone changes and aging.  PP is a common problem amongst women with an estimated 11% of women undergoing surgery for PP by the age of 80 years1.  The National Center for Health Statistics found that 16.3% of hysterectomies were performed for prolapse between 1988 and 19902.  In 1996, 600,000 hysterectomies were performed in the United States3; therefore, by inference >90,000 hysterectomies were performed for PP that year.

The vagina is located between the bladder and the rectum.  At the top of the vagina are the uterus and cervix.  Following a hysterectomy, the top of the vagina is typically surgically attached to the ligaments that once supported the uterus.  There are essentially three compartments of the vagina or vaginal vault: the front (adjacent to which is the bladder), the back (adjacent to which is the rectum), and the top of the vagina (where the uterus is located).  Any or all of the three compartments can fall, including the top of the vagina, regardless of whether the uterus remains or has been removed by hysterectomy.  A common misconception by many women is that once the uterus has been removed, there is “nothing left” to “fall down.”  On the contrary, patients are just as susceptible to weakening of pelvic support with resultant prolapse.

Many patients are completely asymptomatic from PP.  In these cases, no intervention is typically necessary.  On the other hand, patients may actually see or feel a “ball” or bulge within or protruding from the vagina.  Between these two extremes, patients will describe a variety of symptoms.  Those who have bladder prolapse, referred to as a ”cystocele,” may describe (1) leakage of urine with coughing, sneezing or laughing, (2) a sensation of sudden urgency to urinate, often resulting in leakage of urine before she is able to reach the restroom, (3) difficulty starting or maintaining a strong urinary stream, (4) difficulty emptying her bladder to completion, or (5) the need to push the bulge back into the vagina in order to urinate.  Patients whose rectum or back wall of the vagina is falling, a.k.a. “rectocele,” may describe that they must push the ball back into the vagina or place pressure on the skin outside of the rectum in order to facilitate their bowel movements.  Finally, a patient with prolapse of the top of the vagina may describe any combination of the above or simply that the presence of the bulge is bothersome to her.

There are surgical and non-surgical options to address pelvic prolapse.  An excellent non-surgical option is a pessary, which is similar to a diaphragm.  It is inserted into the vagina and holds the pelvic structures in place.  Pessaries come in various shapes and sizes and should be fit to the individual.  In the past, surgical techniques for prolapse repair included sewing the weak tissues together that had relaxed to allow the prolapse to occur.  Not surprisingly, these techniques were only approximately 50% successful.  With the recent introduction of various graft materials, the weak pelvic floor can be reconstructed and reinforced with a strong and durable repair.  Success rates using graft reinforcement are in the range of 90-95%.  Ask your doctor about the current options to treat prolapse as repair can result in a tremendous quality of life improvement for many women.

 

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