Dr. Kevin Stepp, MD - Urogynecology and Laparoscopic Surgery - Cleveland, OH
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What is Prolapse?

(Also called pelvic organ prolapse, uterine prolapse, vaginal prolapse, bladder prolapse, cystocele, rectocele, or enterocele.)

Pelvic organ prolapse with or without urinary incontinence is very common. In fact, even though it may not be talked about much, minor degrees of prolapse affect up to 50% of all women who have had a vaginal delivery, while 20% have symptoms that require them to seek care. One in 9 woman will have surgery for prolapse or incontinence in her lifetime.

Normally, a woman’s pelvic organs are supported by the muscles of the pelvis. Her uterus, vagina, bladder, and rectum are held over the muscles that provide support to keep the organs in place. If the muscles or supportive connective tissue is weak, damaged, or stretched, eventually any or all of the organs can begin to slip downward into the vagina. Occasionally, if left untreated, the organs can actually protrude outside of the vagina or body.

The early symptoms of this can be a feeling of pressure at the end of the day, feeling like one is sitting on something all the time, feeling something protruding when wiping after voiding, an altered urinary stream or difficulty initiating voiding. Sometimes a woman will experience altered sensation with intercourse or feel like her partner is hitting something. Women with prolapse may also experience bladder or bowel symptoms such as difficulty controlling urges or incontinence with coughing, sneezing, exercising, and other activities.

 
What causes prolapse or pelvic floor disorders?

Although the exact cause of prolapse is not known, vaginal child birth is the most important risk factor. Certainly the birth weight and number of children a woman has can increase her risk, but even a single small child can lead to prolapse or urinary incontinence. We don’t completely understand it yet, but we believe it is related to muscle and nerve damage that can occur with vaginal delivery. Not every woman who delivers her child vaginally will get prolapse and not every woman with prolapse has delivered a child vaginally. Even a cesarean section does not completely eliminate the risk for prolapse or incontinence. So there most be other factors. We think the next most important factor is related to genetics. Pelvic floor disorders are more common among siblings with prolapse or incontinence. Other factors that can increase a woman’s risk are anything that put chronic straining or stress on the pelvic organs (chronic cough, obesity, constipation or repetitive heavy lifting).

How is prolapse treated?

First, if a patient is not bothered by prolapse, she may not need any treatment at all. In general, treating prolapse is about quality of life. Patients should be reassured that this is common and except in rare situations, can usually be observed without treatment. However, patients should also be reassured that if they are bothered by prolapse or incontinence, there are many treatments available that can help them get back to normal life.There is no reason to live with prolapse or incontinence if it bothers you or affects your quality of life.

Nonsurgical treatments

Kegel exercises or physical therapy can help strengthen the pelvic muscles. This is helpful with urinary incontinence and may delay the development of prolapse. However, it is unlikely that exercises alone will repair significant vaginal prolapse.

Pessaries are removable rubber or silicone devices that can be placed in the vagina to hold the organs in place. Once appropriately fitted, a pessary can be removed and cleaned on a regular basis by the patient for as long as she would like. Pessaries often work well, but the prolapse will likely return if pessary use is stopped. Therefore, we recommend pessaries for young woman who may want to have more children, women who have a medical condition that makes surgery inadvisable, or for women who would like to post-pone surgery for some period of time – perhaps to take care of an ill family member or when it may be more convenient for her schedule.

There are also several ways to surgically treat prolapse – many of which are minimally invasive. In general, the options that will be offered to a woman will depend on the training and experience of the surgeon. There is no one right answer for all patients. We suggest a consultation with a fellowship-trained urogynecologist to determine which option is best for each patient. Click HERE for a description of the different types of surgeries for prolapse repairs.

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