Vaginal Bulge / Prolapse
What is Uterovaginal Prolapse?
What is prolapse?
Prolapse is a hernia of the vagina that a woman may feel as a bulge or pressure. This is referred to in many different ways. Sometimes it is called a “dropped bladder” or a cystocele, “dropped uterus or uterine prolapse,” “dropped vagina or vaginal prolapse,” or “dropped rectum or a rectocele.”
What is the cause of prolapse?
There are several factors that worsen or increase the probability of prolapse and these include childbearing, menopausal state, strenuous activities, coughing, obesity, smoking and hysterectomy. However, prolapse mainly results from the inherent weakness of connective tissue.
What are the symptoms of prolapse?
The classic symptom of prolapse is the perception of a vaginal bulge. This is usually felt by the patient especially when she is standing up.
If the patient has a bladder prolapse or cystocele, she may have difficulty emptying the bladder that could lead to repeated bladder infections. Sometimes, she may also have urinary incontinence.
If it is a rectal prolapse or a rectocele then the patient may need to splint the vagina in order to have a bowel movement as the stools seem to get stuck at the lowest point of the rectum in the prolapse pouch.
What are the complications of prolapse?
Mild to moderate prolapse does not typically lead to any complications, however, larger prolapses could. The prolapsed tissue may get ulcerated as it rubs against the clothes and may start bleeding.
Moreover, the underlying prolapsed organ could malfunction. For example, with a large cystocele, the bladder may not empty completely, and this could lead to repeated bladder infections with the danger of kidney infections. Moreover, the ureter (tube that travels from the kidney to the bladder) could get bent or kinked and lead to back pressure and damage to the kidneys.
Is prolapse something serious?
When the prolapse is large, it can become a serious problem especially if it is affecting the organ from emptying itself such as the bladder or causes back pressure on the kidneys due to kinking or obstruction of the ureteral tubes.
Can prolapse get worse?
There is always going to be a pull of gravity on the prolapsed organ and with us standing on our feet, it is likely that a prolapse will get worse over time.
How do we assess prolapse at our practice:
- Patients are asked to complete specific history forms and watch a video on Prolapse that explains why prolapse occurs, the types of prolapse etc.
- Patients are then examined in specific Urogynecology positions, mainly the standing position.
- Certain specific measurements of the prolapse are taken.
- Patients then undergo specific tests such as urinary evaluation if they have urine leakage complaints or bowel evaluation if they have bowel leakage concerns.
- After this thorough evaluation, the doctor sits down with the patient in our consult room and explains the entire evaluation and informs her of the next steps.
Management of pelvic organ prolapse
- Expectant management: this is when the prolapse can be simply observed over a period of time especially if it is not a large prolapse and the patient is not bothered by it.
- Pelvic floor therapy: this is mainly for prolapses that are mild or it is done postoperatively after a surgical correction of prolapse.
- Pessary Management: this is a device that is inserted in the vagina to hold the vagina in place. It does not correct the prolapse but essentially holds it back in place. It is typically indicated for elderly women who are not good surgical candidates or when a woman is pregnant or awaiting a surgical procedure. Pessary also have complications as it may cut into the neighboring organs such as the bladder or the bowel.
- Surgical correction:
- Native tissue repair: this is when the patient’s own tissues are used to put the prolapse together. It is mainly done when the prolapse is of a mild nature. With large prolapse cases, the native tissue is significantly torn and there is a higher risk of failure of the surgical correction if native tissue repair is performed.
- Graft augmentation procedure: This is typically done in patients who have a large prolapse and especially when previous prolapse surgery has failed. In this case, an outside material such as a biologic graft is used. We typically use a human biologic dermis graft which comprises of strong collagen tissue that is used to support the pelvic organs to the patient’s strong ligaments.
Do I have to have a hysterectomy as a part of my surgery?
In the United States, a hysterectomy is frequently performed for the management of pelvic organ prolapse. However, following hysterectomy, vaginal prolapse or urinary incontinence can occur.
In our practice, we do not perform a hysterectomy but do what is called a hysteropexy or uterine sparing procedure. Worldwide, more and more surgeons are performing uterine sparing procedures.
In fact, when patients were asked what they would prefer if the results were the same, over 60% of the patients chose to keep their uterus and not undergo a hysterectomy.
Reasons to consider uterine preservation include the following:
- Lesser operative time
- Lower risk of surgery
- Lower risk of injury to the bladder
- Lower risk of abdominal infections as the abdominal cavity is not opened.
- Lower risk of subsequent prolapse or incontinence.
- Keeping the cervix and uterus may have a role in sexual function while maintaining the full depth of the vagina.
What is our AUGM technique for management of prolapse:
We perform the prolapse surgery entirely from within the vagina, there are no incisions or cuts on the outside. We do not need to get into the belly cavity with the robot or an open belly technique. Dr. Khandwala has coined the term NINOS that stands for No Incision Natural Orifice Surgery. The advantage is that the recovery is very quick and speedy. Also, we do not remove the uterus. We have published extensively on this technique in the medical literature including our high success rates and low risk of complications.
Most patients go home the next day after an overnight stay and are walking and eating right away after the procedure.