Medically, a prolapse means ‘falling out of place’. It’s most commonly linked to organs in the female pelvic region. A prolapse occurs when organs shift or drop down out of the natural anatomical position. Moderate to severe cases happen when an organ descends so significantly that it actually protrudes out of the female vagina or rectum.
Muscle weakness in the pelvic muscle frequently causes organ prolapse. Common causes of a weakened pelvic muscle are the birth of a large baby, very long labor during birth, excessive lifting, or chronic constipation and hard pushing during bowel movements. One method of treatment for a pelvic organ prolapse is a surgical procedure called a Sacrocolpopexy.
Pelvic Organ Prolapse
When an organ drops from its normal position, usually, this gradual process is medically called a pelvic organ prolapse (POP). The prolapse can involve the uterus, bladder, vagina, and or intestines, any or all of them are included in the general diagnosis called a female genital prolapse. Acute cases can be painful, frightening, and many women first recognize it when they feel something protruding through or at the opening of the vagina. Advanced pelvic organ prolapse cases will likely require a surgical procedure called a Sacrocolpopexy.
Genital organ prolapse is most commonly associated with prior childbirth issues and gradually becomes more prevalent as women age. The underlying cause is usually of a weakened pelvic muscle structure that was damaged years earlier. Without the necessary muscle support, the connective tissue lining the muscles permanently stretches and then organs such as the uterus or bladder can drop.
Pelvic Organ Prolapse Grading Systems
Pelvic organ prolapse is graded by one of three main systems, and in some cases will need diagnostic imaging with special testing procedures. The main three grading systems are Shaw’s System, the Baden-Walker and Pelvic Organ Prolapse Quantification systems (POP-Q) all rate pelvic organ prolapse.
Shaw’s System focuses primarily on a prolapsed uterus or bladder. Testing methods and possibly X-rays, are sometimes necessary to determine the severity of the pelvic organ prolapse and to decide if a Sacrocolpopexy or other surgical procedure is required.
#1. Shaw’s System
Shaw’s system for pelvic organ prolapse uses two sets of standards to evaluate the degree organ compromise. The posterior and anterior walls of the vaginal canal are graded by calculating the distance of organ drop.
#2. Baden-Walker System
The Baden-Walker System uses five grades. They measure the level of pelvic organ prolapse descent. Zero designates standard positioning for all organs tested.
After zero, the Baden-Walker scale grades up from 1 to 4. 1 indicates a mild case of pelvic organ prolapse, whereas 4 shows full descent outside ot the hymenal ring and protruding outside of the body . A 4 rating invariably requires a Sacrocolpopexy type procedure.
#3. Pelvic Organ Prolapse Quantification System (POP-Q)
Cases with less obvious symptoms may require a voiding cystourethrogram, or urodynamics. These are X-rays and measurements taken during urination. The X-rays are often necessary to determine the severity of the pelvic organ prolapse. Cystourethrograms and Urodynamics are also sometimes used to help coordinate a treatment plan or provide a diagnosis to decide if surgery is needed.
Symptoms of Pelvic Organ Prolapse
Minor cases of organ prolapse may not have visible symptoms. The severity of the symptoms will indicate the level of pelvic organ prolapse. More advanced warning signs, such as extreme pain, warrant additional tests. Extremely severe symptoms may require an emergency room visit to put the prolapse back inside until surgery can be done.
- A painful pulling sensation inside the vaginal walls.
- An abnormal heavy feeling inside the vagina or rectum.
- An obvious bulge of tissue coming from the vagina.
- Abrupt urine leakage, particularly when lifting something very heavy or difficult bowel movements.
- Recurrent urinary tract infections.
- Pain during sexual intercourse.
- Vaginal discharge and irritation.
These symptoms need to be evaluated by an exam of the female genitalia soon. A pelvic exam is the only way to accurately determine the severity of pelvic organ prolapse and determine if a surgery such as a Sacrocolpopexy is necessary.
Treatment Procedures for Pelvic Organ Prolapse
In almost all situations, moderate to severe pelvic organ prolapse symptoms of dryness and irritation will slightly improve with Estrogen vaginal cream or non-hormonal medication such as Osphena. The prolapse itself won’t change, that still needs treated. The first, but important nonsurgical step is pelvic physical therapy. This will attempt a number of muscle strengthening techniques as an alternative to or in preparation for prolapse surgery. Also, many times a pessary can be inserted to help lift the prolapsed organs in place before surgery or instead of surgery. A pessary needs to be fitted in a doctor’s office and is placed in the vagina to lift the prolapsed organs. Many woman use a pessary permanently if they are unable to have surgery due to medical or personal reasons. Additionally, many women will use a pessary temporarily until they decide to have surgery or until they are able to schedule a prolapse surgical procedure.
What Is Sacrocolpopexy?
One of the most common and most successful methods for repair a pelvic organ prolapse is the surgical procedure Sacrocolpopexy. It is a reconstructive procedure most commonly performed through a small abdominal incisions. It is minimally invasive and can correct mild to significant grade levels of pelvic prolapse descent.
The procedure elevates the vaginal apex, including the bladder, by using a graft to lift and support the prolapsed tissues. The graft is usually a polypropylene mesh that lays over the prolapsed area and lifts it by anchoring to the sacral promontory (upper sacral area). The most way to do this is through a minimally invasive surgical procedure called a laparoscopy. To accomplish this, the robotic surgical system is most commonly used and surgery is accomplished with minimal pain and discomfort. Patients usually don’t have any incisions in the vagina since this procedure is done laparoscopically and lifts from inside the abdomen.
Understanding the risks of the surgical procedure is important. Proper surgical positioning is also very important to prevent a risk of injury. Injury to the femoral nerve can occur by hyper-extension at the hip. Peroneal nerve damage may result from leg compression against the stirrup if not correctly positioned and properly padded. Surgical staff in a robotic case know that proper positioning during robotic cases dramatically reduces injury risk.
Polypropylene mesh will be required to lift the prolapsed vagina, bladder, and/or cervix to the sacral promontory, (upper sacral area), and therefore erosion needs to be prevented and future risk of it minimized. This is done with long-term medication that keeps the vaginal mucosa healthy, pliable, moist, and prevents thinning of the vaginal skin. Something similar to the kind of thinning on the back of an older persons hand. As long as these medications are used then the risk of erosion is greatly minimized. The two current medication options are Osphena or Estrogen cream. Unfortunately, there are no other non-mesh procedures that work as well. The procedures that don’t use the the mesh for support have much higher short-term failures and don’t last as long. Also, in order to prevent infections during and after surgery, antibiotics are used during the surgery and the first 24 hours.
Patients notice the prolapse is gone the moment they wake up after surgery. Patients recover much better than they expect with this procedure, especially since it routinely takes 3-4 hours. Most patients report minimal pain in their pelvis or abdomen. They do feel fatigued for several weeks because their body is using a lot of energy to heal. Patients still shouldn’t lift more than 10lbs for 6 weeks and no sex for 6 weeks. However, walking outside, up and down stairs, and driving is acceptable the day after surgery. Expect to take 6 weeks off of work, but if you have a sit-down job then you could go back as soon as you feel ready. Patients go home the next day and are able to eat regular food the same day as surgery in most cases.
Summing It Up
Pelvic organ prolapse is very common and can be problematic for women of all ages. The severity of the prolapse frequently is related to childbirth challenges and chronic lifting on the job for long periods of time. The significance of the symptoms from pelvic organ prolapse is another reason all women should schedule regular annual pelvic exams.
If detected in the early stages, there are more treatment procedures available to the physician. Once the surgery is necessary, Sacrocolpopexy is a minimally invasive surgery that produces long-term successful results.