Pelvic Organ Prolapse

Vaginal relaxation or pelvic organ prolapse are terms used to describe the relaxation, sagging, or protrusion of the vaginal opening and the walls of the vagina, sometimes including the uterus. This can result from pregnancy, childbirth including spontaneous as well as vacuum and forceps deliveries, heavy lifting, chronic cough, and obesity.

“My Bladder is Falling”

Anatomically the vaginal opening and vaginal walls contain fat and thin connective tissue that supports the surrounding structures.

The anterior or front wall of the vagina is directly under the bladder. Any relaxation or tearing in this tissue results in sagging of the anterior vaginal wall more commonly called a cystocele (what some women describe as a fallen bladder). Typical symptoms of this include vaginal pressure and bulging, difficulty emptying the bladder, and urgency of urination.

Surgery involves opening the tissue of the vagina to expose the underlying connective tissue and repairing the damage or tear in the tissue, trimming the excess vaginal tissue, and suturing the anterior wall tissue back together reducing the bulge and slightly narrowing the vagina. This is called an anterior repair or colporraphy.

The posterior or back wall of the vagina is directly above the rectum. Any relaxation or tearing in this tissue results in a bulge called a rectocele, and leads to difficulty completing a bowel movement, needing to support or splint the area to completely evacuate, and gaping/sagging of the vaginal opening. Surgery involves opening the tissue of the vagina from the perineum (space between the vagina and anus/rectal wall) and up along the back wall of the vagina, repairing the damage or tear in the connective tissue, trimming excess vaginal tissue, and suturing the posterior wall tissue back together, often including building up the perineum and reducing the size of the vaginal opening  posterior repair or colporraphy and perineorraphy. 

Vaginal “rejuvenation/tightening” surgery is essentially another name for the above common procedures done for vaginal relaxation, cystocele,and rectocele.

Most of the time, women seeking relief of the symptoms above qualify for anterior and posterior repairs and the surgery can be covered by insurance.

A traumatic childbirth can lead to tearing in any of the walls of the vagina and the vaginal opening. Depending on desire for future childbearing and delivery, repairs can be done vaginally to restore the vaginal anatomy and sexual wellness.

What if the uterus is falling? The uterus can prolapse down the vaginal canal along with the anterior and posterior walls. The symptoms are similar to the above, vaginal pressure and bulging, as well as pelvic heaviness. Typically, if the uterus is involved in the prolapse, hysterectomy or removal of the uterus with or without the fallopian tubes and ovaries is done, followed by suspension of the vagina to ligaments in the pelvis to prevent further prolapse in the future. This can be done laparoscopically with the Da Vinci robot, vaginally, or through an open abdominal incision. An open incision is usually only done when a patient is combining her surgery with a tummy tuck or abdominoplasty. Coordination with plastic surgery is done in this case.

If the prolapsed uterus is moderate to severe, mesh is used to secure the vagina or small segment of the cervix left in place, to a strong ligament along the inner surface of the sacrum.This is called sacral colpopexy and is the gold standard surgery for advanced prolapse.  Why mesh? The mesh used for this procedure has very low risk <3% of poking through the vaginal tissue and causing need for additional surgery and has not been called into question.

What is vaginal vault prolapse? After hysterectomy, the vagina can be described as a tube. The very top of the tube can become detached and turn the vagina inside out. This is vault prolapse and causes symptoms of pressure and bulging. The surgical repair involves suspending the vagina to either ligaments in the pelvis or with mesh to the ligament along the sacrum. Typically this is done laparoscopically with the Da Vinci robot.

Hysterectomy is defined as removal of the uterus, either through an abdominal incision, laparascopic or robotic assisted laparoscopic, or vaginal routes.

Removal of the tubes and ovaries is often done if a women is over the age of 50 years or in menopause.

Hysterectomies are a common gynecologic surgery that is done for many conditions:

abnormal bleeding, fibroids, prolaspe, and sometimes pain.

The route of hysterectomy is individualized to each patient and their condition.

No matter which route is chosen, hormonal status and sexual function should be reviewed before any surgery.

Most patients spend one night in the hospital.

Post operative restrictions include no lifting > 15# and pelvic rest for 8-12 weeks.

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