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Prolapse of the uterus, vagina and bladder
Genital prolapse, also known as descent, is a condition that affects many women.
This problem occurs when the uterus, bladder, or the back part of the large intestine descends from its normal position, which can lead to various symptoms and affect the quality of life.
Milan Milenković MD, PhD explains what causes prolapse, how it manifests, and what contemporary options of treatment are available for those facing this challenge.
What is uterine prolapse?
Prolapse or descend of the pelvic/genital organs is a condition when one or more organs descend from their normal position into the vagina. It can be:
- uterus;
- urinary bladder;
- the final part of the large intestine (rectum);
- vaginal apex if the uterus was previously removed;
- small intestine.
Prolapse of the uterus, bladder, intestines and vaginal apex occurs when there is weakness of the muscles, ligaments or connective tissue of the small pelvis or the pelvic floor.
A descend/prolapse can be compared to a hernia that occurs in the front abdominal wall where there is a "weak spot" where the internal organs can pass through the abdominal wall.
- The prolapse of the urinary bladder, that is cystocele is manifested by lowering of the anterior vaginal wall.
- The descent of the final part of the large intestine, that is rectocele is clinically manifested as weakness of the posterior vaginal wall.
- Uterine prolapse is when the uterus descends from its normal anatomical position into the vagina.
- Prolapse of the vaginal apex is manifested by the descent of the vaginal apex when the uterus has previously been removed.
- Prolapse of the small intestine into the vagina enterocele.
Sensation of pressure in the vagina and small pelvis;
- Part of the vagina of is visible outside the vaginal opening and increases during the day, physical exertion or coughing;
- Difficult urination or bowel movements;
- Vaginal pain;
- Pain and discomfort during sexual intercourses;
- Involuntary flow of urine (stress incontinence) and stool may be associated with genital prolapse.
It is assumed that over 50% of women have some form of a prolapse, but only 10-20 have symptoms that require treatment.
Genital organ prolapse can be classified as:
- I Stage - the leading part of the vagina descends into the upper part of the vagina;
- II stage – the leading part of the vagina descends down near the opening of the vagina;
- III stage – the leading part of the vagina descends and partially comes out of the vagina;
- IV stage – the leading part of the vagina is completely out of the vagina
Diagnosis and indications
All types of prolapse of the uterus, vagina, intestines or a combination of prolapses that cause symptoms and reduce the quality of life are indications for treatment, either conservative or surgical.
The diagnosis of prolapse is made by gynecological and ultrasound examination. Sometimes a magnetic resonance imaging is sometimes performed.
How to return the uterus/ bladder? Treatment of prolapse/descent of genital organs
- For menopausal women with prolapse, local estrogen therapy in the form of vaginal suppositories or vaginal creams is recommended;
- A vaginal pessary is most often in the form of a ring made of silicone or a material that does not cause a tissue reaction and is placed in the vagina in order to lift "lowered" organs, and is most often used to lift the bladder and uterus. It is used in older women, in women who do not want surgical treatment or surgery is contraindicated due to some other disease, as well as before surgery to alleviate symptoms. Patients who have a vaginal pessary are monitored every 3-6 months. Mechanical irritation can be the cause of bleeding from the vagina, and then the pessary is temporarily removed.
- Strengthening the muscles of the pelvic floor, so-called Kegel exercises
Operative treatment of genital organs prolapse in women may be necessary in several situations.
Operative treatment of prolapse/descent is necessary when the patient has discomforts that reduce her quality of life, that is, when they represent a functional and aesthetic problem. These are the most common:
- the tissue "bulging out" from the vagina, especially at physical effort, and represents an aesthetic problem;
- difficult in emptying or the impossibility of emptying the bladder and colon;
- pain and discomfort during sexual intercourses;
- involuntary leakage of urine;
- feeling of weight and pressure in the vagina and small pelvis.
- when treatment with vaginal pessaries did not give results.
What procedures are used in the Gyn-Fertility Clinic Milenković?
* It is often a combination of prolapse/descent, for example prolapse of the uterus and anterior vaginal wall or a combination of prolapse of the anterior and posterior vaginal wall, so that the necessary operative corrections can be performed in one surgical procedure.
Prolapse of the anterior vaginal wall occurs when the bladder fascia weakens or when the ligaments that connect the vagina to the pelvic wall weaken (so-called paravaginal defect).
Correction of the anterior vaginal wall-cystocele or lifting of the bladder and anterior vaginal wall (colporrhaphy anterior) is done by making an incision on the anterior vaginal wall and " separating" the vagina from the bladder and the bladder fascia, which supports the bladder.
- The operation consists of lifting the bladder by "strengthening" the fascia with a special surgical technique or by "stitching" the vagina to the wall of the small pelvis, the so-called "white line" of the muscles surrounding the vagina (Latin m. levator ani).
- Synthetic meshes can also be used to lift the bladder, but they are used less often due to the increased risk of complications.
The operation lasts for 30-90 minutes and is most often performed under general or spinal anesthesia, but it can also be performed under local anesthesia. - During the operation and several hours after the operation, the patient has a catheter in her urinary bladder.
- It can be performed as day surgery, or with a stay in the hospital for 1-2 days, which depends on the age and general condition of the patient.
- After the operation, it is advised to take time off from work and heavier physical exertion, as well as avoiding sexual intercourses for 4-6 weeks.
- Vaginal estrogen therapy is recommended for menopausal women.
Correction of the posterior vaginal wall, rectocele (colporrhaphy posterior) is performed by making an incision on the posterior vaginal wall and separating the vagina from the rectal fascia and that is from the rectum itself. The rectum is the final part of the large intestine, and the fascia is the supporting tissue of the rectum. Then, by surgical method, the fascia is strengthened, which returns the rectum to its normal anatomical position.
- A technique where the muscles are used (m. levator ani) to support the rectum so that it returns to its normal anatomical position. Synthetic meshes can also be used to support the urinary bladder, but they are used less often due to the increased risk of complications. When only rectocele correction is done, no urinary catheter is needed, but the assessment is individual.
- The operation lasts for 30-90 minutes and is most often performed under general or spinal anesthesia, but it can also be performed under local anesthesia. It can be performed as day surgery, or with a stay in the hospital for 1-2 days, which depends on the age and general condition of the patient.
- After the operation, it is advised to refrain from work, heavy physical exertion and avoiding sexual intercourses for 4-6 weeks.
- Vaginal estrogen therapy is recommended for menopausal women.
This intervention depends on the decision and assessment of whether the uterus will be removed (vaginal hysterectomy ) and then fix the vaginal apex to the ligaments in the small pelvis or “preserve” the uterus by removing a part of the uterus cervix and lifting-fixing the uterus using the existing uterine ligaments.
- This second method is known as "Manchester repair ”.
- The assessment of which method will be used is individual and the decision is made in consultation with the patient. Simply removing the uterus without fixing the vaginal apex will not solve the problem of uterine prolapse. When the uterus is removed, that is, when a vaginal hysterectomy is performed, the uterus is first freed from the surrounding organs, so that the blood vessels and connections of the uterus with the surrounding tissue will be surgically fixated. After the removal of the uterus, the vaginal apex is fixed to certain ligaments in the small pelvis, which will be a support and prevent the descent/prolapse of the vaginal apex after the removal of the uterus.
- Surgery for prolapse/descent of the uterus, when that organ is not removed (Manchester repair), is done by first separating the urinary bladder from the uterus, then removing a part of the cervix then a part of the cervix is removed and the uterus is "firmed-lifted" using the already existing ligaments-connections of the uterus.
- Uterine prolapse surgery lasts for 60-120 minutes, and is performed under general or spinal anesthesia, and usual stay in the hospital is for 1-2 days. A catheter is placed in the patient's urinary bladder during the operation and several hours up to one day after the operation. It is advised to refrain from work, avoid sexual intercourses and heavy physical exertion for 4-6 weeks.
- Correction of uterine prolapse can be done laparoscopically when a synthetic mesh is used that connects the back wall of the uterus and the sacral bone.
Operative correction of prolapse on the vaginal apex after the removal of the uterus is performed by making an incision in the upper part of the vagina, then the vaginal apex is sutured to the ligaments in the small pelvis with a non-absorbable suture.
- The operation is performed under general or spinal anesthesia, it lasts up to 60 minutes, and the patient usually stays for one day in the hospital. It is advised to refrain from work and abstain from sexual intercourses for 4-6 weeks.
- Vaginal estrogen therapy is recommended for menopausal women.
- Surgery of the prolapse of the vaginal apex can also be performed laparoscopically with the help of a synthetic mesh.
Operative correction of the prolapse of small intestine-enterocele is performed by making an incision in the upper part of the vagina, between the uterus and the end of the large intestine, by opening the abdomen cavity, lifting the part of the intestine that is in the vagina and then sewing the peritoneum to a tissue so that it does not allow the intestines to descend into the vagina again.
- The operation is performed under general or spinal anesthesia, it lasts about 60 minutes and can be performed as day surgery or the patient stays in the hospital for one day.
- It is advised to refrain from work and physical exertion, as well as abstinence from sexual intercourses for 4-6 weeks.
- Vaginal estrogen treatment is recommended for menopausal women.
Prevention of prolapse/descent of genital organs
- Training with exercises that strengthen the muscles of the pelvic floor;
- Maintaining normal body weight and avoiding obesity;
- Proper nutrition, which will ensure regular emptying of the bowels and avoiding constipation;
- Cessation of smoking/nicotine use;
- Bend your knees and hips when lifting something heavy, especially if you do it often.
Prognosis of descent/prolapse
The conclusion of our detailed consideration of genital organ prolapse brings us to an important point: ignoring symptoms and delaying treatment will not lead to improvement. On the contrary, the condition can only worsen or remain unchanged, which can significantly affect the quality of your life. It is important to understand that, without an adequate approach to treatment, prolapse symptoms will not magically disappear. Do not let prolapse affect your daily life. Do not hesitate to contact us and find out how we can help you regain control of your health; together we will explore the solutions that are most adequate for your specific case.
Author: Milan Milenković MD, PhD
