Pelvic Organ Prolapse

POP occurs when the uterus or part of the vaginal canal becomes lax and protrudes out of its original position.

The prolapse is due to the progressive weakening of the supporting tissues of the uterus and the vagina in situations such as pregnancy and childbirth, especially difficult and prolonged labour.

The supporting tissues become even weaker when you enter the menopause and as you grow older. If you are involve in strenuous physical work, or suffer from chronic cough and constipation, you have an increased tendency to develop POP.

Other causes include congenital weakness of the pelvic floor muscles, ligaments and fascia, and collagen deficiency.

There are several degrees of severity of POP:

• Mild or 1st degree prolapse

When the prolapse is still within the vagina

• Moderate or 2nd degree prolapse

When the prolapse is just outside the vagina

• Severe or 3rd and 4th degree prolapse

When the prolapse is completely outside the vagina

You may present with one or more types of prolapse:

• Cystocoele

When the top of the vagina supporting the bladder prolapses downwards into and outwards beyond the vagina.

• Rectocoele / Enterocoele

When the bottom of the vagina supporting the rectum or small intestines respectively prolapses upwards into and outside of the vagina.

• Uterine prolapse

When the back of the vagina supporting the uterus prolapses into and beyond the vagina.

• Procidentia

When there is prolapse of the uterus and vagina, including the bladder, completely outside the vagina.

• Vault prolapse

When the back of the vagina prolapsea into and outside of the vagina after a previous hysterectomy.

Some of the symptoms are included below.

• A dragging sensation in the lower abdomen and pelvis
• A swelling sensation in the vagina
• Backache that progresses through the day
• A lump outside the vagina
• Vaginal bleeding and discharge
• Difficulty in walking, sitting
• Difficulty in passing urine and motion
• Difficulty or inability to have sex
• Anxiety, depression because of of reduced femininity, secondary to the lump
• Inability to have sex
• Fear that lump below may be a growth or cancer

Kindly note that they are not listed in any order of frequency of presentation but may be related to the severity/degree of your prolapse.

You are advised to see your gynaecologist or urogynaecologist to receive a complete evaluation of your condition.

A complete management programme may involve lifestyle changes, pelvic floor rehabilitation, use of topical (local) oestrogen cream and/or vaginal tablets to improve post-menopausal vaginal dryness and thinning, vaginal pessaries to support your prolapse and urodynamics investigations before surgical intervention.

Surgery for POP will depend on the severity and type of prolapse. The commonly performed vaginal operations include:

• Anterior repair or anterior colporrhaphy for repair of cystocoele (bladder prolapse).
• Posterior repair or posterior colpoperineorrhaphy for repair of rectocoele and enterocoele repair, as required
• Vaginal hysterectomy to remove the uterus (womb) from the vaginal route, and repair of the back of the vagina to the uterosacral ligaments (strong ligaments between the back of your womb to your sacrum [back of your pelvic bone]). Both Fallopian tubes and ovaries may also be removed, especially if you are post-menopausal, just as in abdominal (open) or laparoscopic (key hole) hysterectomy. This will also depend on the condition of your ovaries from a pelvic ultrasound scan performed before your operation and on inspection of your ovaries during surgery, your personal preference, the severity of your prolapse.
• Vault prolapse surgery by supporting your vaginal vault to the Sacrospinous ligament, a strong ligament situated on the side wall of your pelvis to the side of your sacrum. This operation is known as Sacrospinous ligament fixation.

The advantages of vaginal surgery are:

• Natural orifice surgery
• No abdominal incisions, wounds or scars
• Less pain
• Fewer complications
• Shorter surgery
• Shorter duration of hospitalisation
• Cost effective
• Quicker recovery
• Faster return to normal activities and work

*All the above advantages hold true for vaginal hysterectomy when compared to abdominal (open) and laparoscopic (key hole) hysterectomy.