DEAR MAYO CLINIC: I am 54 and have had two pregnancies. I was recently diagnosed with vaginal prolapse and am not sure where to begin with treatment. I've heard I may need surgery, but are there other options? What is the best long-term treatment?
ANSWER: Pelvic organ prolapse is a common pelvic floor disorder that occurs when normal support of the pelvic floor is weakened or damaged. If the muscles and layers of connective tissue of the pelvic floor weaken and stretch, the pelvic organs, which include the vagina, cervix, uterus, bladder, urethra, intestines and rectum, can fall downward — prolapsing or herniating — to or past the opening of the vagina.
Prolapse of the uterus, bladder (cystocele) and rectum (rectocele), and vaginal wall can lead to a feeling of pelvic pressure or fullness, or a feeling of a bulge within the vagina. In some cases, these symptoms may be mild in the morning but worsen as the day goes on.
A number of factors can lead to vaginal prolapse, including previous pregnancy, vaginal childbirth and aging. Chronic constipation, chronic coughing, prior pelvic floor injury, lack of estrogen in the body after menopause, and repeated straining or heavy lifting over time also can contribute to weakening of the vaginal muscles and supportive tissues. Your genes also can influence the likelihood of developing prolapse. Smoking and obesity contribute to the risk of prolapse development, too, so maintaining a healthy weight and lifestyle are important.
If vaginal prolapse does not cause symptoms, or if you can manage your symptoms and they do not disrupt your daily activities, you may not need treatment now. Self-care measures, such as performing exercises called Kegel exercises to strengthen your pelvic muscles, may reduce your symptoms. Over time, however, the muscles and ligaments supporting your vagina may continue to weaken and prolapse could worsen. Because of that, it is important to follow up with your health care provider as time goes on to monitor your symptoms and the severity of the prolapse. Treatment is based on symptoms.
As prolapse progresses, you may feel increased vaginal pressure or fullness, and even see or feel a bulge near the opening of the vagina. Urinary problems, such as difficulty with urination, urinary urgency and frequency, sensation of not emptying the bladder, or leakage of urine, can occur. Some women also experience difficulty passing bowel movements, and feel the need to strain or push.
Once symptoms become bothersome, you should seek medical help to discuss your options. Conservative therapy includes working with a pelvic floor physical therapist and talking with your health care provider about lifestyle and behavioral changes. Nonsurgical therapy in the form of a pessary — a small silicone device inserted into the vagina to prevent the tissue from prolapsing — is also an option to consider. Pessary therapy requires an appointment with your health care provider for fitting and teaching of self-management. In some cases, women are not comfortable managing a pessary and schedule regular visits with their health care provider for pessary care. Pessaries are a good option for women who do not want surgery or have medical conditions making surgery risky. They can be used for as long as a woman desires.
For more severe cases of vaginal prolapse or when other measures do not help, surgery can be a useful treatment option. Surgery involves repairing the damaged or weakened tissue, as well as reconstructing the vaginal support, so the vagina will stay in place.
Pelvic reconstructive surgery can be performed through incisions in the vagina, through the abdominal wall, or through a series of small incisions in the abdomen where a surgeon can place laparoscopic or robotic instruments. Minimally invasive surgery performed through the vagina or with small incisions in the abdomen — laparoscopic or robotic — may decrease postoperative discomfort and shorten recovery time.
Prolapse surgery seeks to restore pelvic floor anatomy, and improve quality of life and function. Depending on your anatomy, surgery may be needed to support the top of the vagina, or the vaginal apex. The top of the vagina can be suspended to a women's ligaments, but sometimes graft material is placed abdominally to replace the body's natural supports. It is also common to repair the front wall of the vagina to provide support to the bladder, which is known as cystocele repair, and the back wall of the vagina to provide support to the rectum, which is known as rectocele repair.
As you consider surgery, be sure to ask questions. The various surgical approaches have different risks and benefits. Talk to your surgeon about these issues, and possible long-term side effects and complications. In some cases, vaginal prolapse can recur even after surgery. Ask your surgeon about this possibility and if there are ways to reduce your risk of recurrence.
Take time to understand all your treatment options before you proceed, so you can make a well-informed choice that fits your needs. Treatment for pelvic organ prolapse should be tailored to your overall health, lifestyle and personal goals. — Dr. Anita Chen, Obstetrics and Gynecology, Mayo Clinic, Jacksonville, Florida