Prolapse is a condition where the pelvic organs (uterus, bladder, bowel in any combination) descend lower than they should be into the lower vagina or beyond where they can be felt as a lump or bulge at the vaginal opening.
Source: London health Sciences Centre
Prolapse is common, affecting up to 1 in 12 women overall, and development is associated with injury to the pelvic floor and weakening of the pelvic floor. Incidence therefore rises with age (up to half of women over 50), number of vaginal births, and being post menopausal due to loss of oestrogen. Other factors including your own inherited tissue quality and if you smoke or have chronic cough modify your risk of prolapse developing.
Many women have prolapse detected on gynaecological examination but do not have symptoms. Prolapse does not need treatment if you have no symptoms as it is not dangerous.
Common symptoms you may notice which are reasons to seek treatment include an uncomfortable vaginal lump, the lump rubbing on underwear or clothing and causing pain or bleeding, problems successfully emptying your bladder or bowels including the need to push the prolapse back inside to empty your bladder or bowels, and discomfort or difficulty with sexual activity.
So what happens in a prolapse consultation?
You will be asked questions in regards to your general health, medical disease, previous operations, symptoms from prolapse with regards to lump, bladder, bowels and sexual function as well as risk factors and protective factors for the development of prolapse as well as any other treatments you have trialled in the past and how well they worked.
This allows an assessment of your degree of 'bother' from your prolapse and likely suitable treatment options. You will also be examined to demonstrate the extent and site(s) of your prolapse and of any associated problems such as stress urinary incontinence (as prolapse treatment can unmask stress incontinence by correcting the prolapsed bladder).
Treatment options will be discussed with you, and their suitability for your case.
What options do I have?
Treatment options for prolapse include continuing on as you are, non surgical treatments with vaginal oestrogen, pelvic floor physiotherapy and/or a pessary, or surgical treatment.
In general milder stages of prolapse, women who have not completed childbearing or those who decline or are not physically well enough for surgery are best suited to non surgical care.
Women who have more significant degrees of prolapse or would prefer surgical care can have one of a number of operations, depending on the size and site of the prolapse. This may range from vaginal repairs to the front or back wall of the vagina to a vaginal hysterectomy, correction of the prolapsed upper vagina and then repairs as necessary. These operations are performed via a vaginal approach and do not involve mesh.
There are other surgical treatment options for specific situations which require your care to be transferred to a urogynaecologist and if this is required this referral and recommended practitioners will be provided to you.
What is a pessary?
A pessary is a soft silicone device inserted in the vagina as demonstrated below.
Source: Yourpelvicfloor.com (IUGA)
It supports the prolapsed tissues and can be used long term if helpful. Once stable, you will be recalled twice a year to examine your vaginal walls for irritation/injury/erosions and to change over the pessary.
Using vaginal oestrogen with the pessary reduces the risk of the vaginal tissues becoming irritated and for this reason the two are generally used together.
RIng pessaries are helpful in milder degrees of prolapse, occasionally a space occupying (gellhorn) pessary will be needed to provide relief.
Where can I find out more about surgery?
The fact sheet section contains information leaflets regarding vaginal repairs and hysterectomy for prolapse.
IUGA (International UroGynaecology Association) also have excellent brochures in the areas of incontinence, prolapse and all your treatment options.
Will my prolapse come back?
This depends on the degree of prolapse, your weight, smoking status, menopausal status, health complications, treatment chosen and condition of your remaining tissue. Recurrence is possible despite best care, and trial data shows that 20-40% of women will have a recurrence over their lifetime.
Stopping smoking, reducing your weight, and following post operative instructions will help. Should your prolapse recur, repeat surgery is generally an option for most women.