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Pelvic organ prolapse — Surgical treatments Most of the surgical treatments for prolapse aim to lift the prolapsed organ(s) back into place. Hysterectomy (for uterine prolapse) is the only treatment that removes the prolapsed organ altogether. The choice of surgery depends on the type of prolapse you have, your health, age, whether you want to keep your uterus or have children in the future, whether you are sexually active, the skills of your surgeon and your personal preference. If you're not happy with the surgery that has been recommended, talk with your doctor about your concerns. If you are still not satisfied, or would like a second opinion, ask to be referred to another specialist. Questions to ask your doctor about your surgical treatment options:
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Diagnosis — before your operation, you and your doctor should be confident that your diagnosis is accurate. It's very common to have more than one type of prolapse at the same time and each one should be taken into consideration when planning treatment. Tests — your doctor may give you a series of bladder tests before your operation even if you don't have bladder symptoms. This is because your prolapse may be masking stress incontinence by pushing against your urethra and preventing urine from leaking. Repairing your prolapse may fix one condition but leave you with another - incontinence. If you do have incontinence, it may be treated at the same time as your surgery for prolapse. Oestrogen cream — if you are past the menopause your doctor may suggest you use oestrogen cream temporarily for a month or two before and after your surgery. This helps to strengthen your vaginal and pelvic tissues and may improve the outcome of surgery. Be aware of the possible outcomes — as with all surgery, the degree of success depends on many factors. While surgical treatment may be successful for one woman, it may have very disappointing results for another. The surgical treatments listed below may repair your prolapse, but they may not relieve all your symptoms, and in some cases, they may make symptoms worse or cause other problems. Statistics show that about one in three women who have a surgical repair go on to have additional surgery. Treating prolapse of the bladder and urethra Anterior Repair (colporrhaphy) This procedure is used to treat prolapse of the bladder (cystocele), urethra (urethrocele) or both the bladder and urethra (cystourethrocele). The operation is done through the vagina and you will be given a general anaesthetic. It involves making a cut in the front (anterior) wall of the vagina so the bladder and/or urethra can be pushed back into place. Once this is done, the surgeon stitches together existing tissues to provide a new support for the bladder and urethra. A small portion of the vaginal wall is removed to give the vagina more strength. The main complications of anterior repair are painful sex (dyspareunia) and incontinence. Your surgeon may be able to reduce the risk of painful sex by making sure the vagina is not narrowed too much or pulled out of place during the repair. Incontinence can usually be prevented when diagnosed before surgery (see Before Surgery, above). Repair with mesh If you've had recurrent prolapse and this is not your first repair operation, mesh (synthetic or animal-based) may be used to help support the vaginal wall and keep the prolapsed organ(s) in place. This may provide better long-term support, but may also cause additional complications such as inflammation or erosion of surrounding tissues and an increased risk of painful sex. Treating prolapse of the small bowel and rectum Posterior Repair (colporrhaphy/colpoperineorraphy) Posterior repair is used to treat prolapse of the rectum (rectocele) and small bowel (enterocele). The operation is done through the vagina and you will be given a general anaesthetic. The procedure is similar to an anterior repair (above) but the doctor may first make a small cut from the base of the vagina towards the anus (similar to an episiotomy during childbirth). This makes it easier for the repair to be done. A cut is then made in the back (posterior) wall of the vagina and the rectum and/or small bowel is pushed back into place. The doctor stitches together the existing tissues to create a new support for the prolapsed organ(s) and then removes some of the tissue from the vaginal wall to make it stronger. If a cut was made at the base of your vagina, it will also be stitched back together. The main complication of posterior repair is painful sex (dyspareunia). Your surgeon may be able to reduce the risk of painful sex by not narrowing the vagina too much or pulling it out of place during the repair, but there is a high risk of experiencing painful sex after this procedure. Repair with mesh If this is not your first surgical repair, your doctor may use synthetic or animal-based mesh to help strengthen the vaginal wall and hold the prolapsed organ(s) in place. While the use of mesh tends to provide long-lasting support, it may also cause surrounding tissues to become inflamed or eroded, and studies suggest it may increase the risk of painful sex. Treating Uterine Prolapse There are two surgical approaches to treating a uterine prolapse: removing the uterus altogether (hysterectomy) or lifting it and holding it in place (suspension). Removing the Uterus Hysterectomy Hysterectomy (removal of the womb) is considered to be the most effective treatment for uterine prolapse. Despite this, it still may not relieve all of your symptoms and may lead to other health issues (see below). A hysterectomy for prolapse is usually done through the vagina, but if your uterus is very large it may need to be removed abdominally. The procedure is done under general anaesthetic and involves cutting the ligaments that hold the uterus in place, removing the uterus, closing off the top of the vagina and then shortening and reattaching the ligaments to hold the vagina up. Hysterectomy is a major operation and after having this surgery:
If you are unsure about whether to have a hysterectomy, take as much time as you need to make your decision. You may also want to get a second opinion about your treatment options. For more information about hysterectomy, see our online hysterectomy booklet. Suspending the Uterus Treatments that suspend rather than remove the uterus are recommended for women who want to keep their uterus or have children in the future. Procedures can be done either vaginally or abdominally, and there is some evidence to suggest that abdominal repairs tend to have better long-term results. Sacrohysteropexy
There are few complications associated with sacrohysteropexy but there is a risk that the mesh may wear away (erode) the surrounding tissues or cause an inflammation. In severe cases, the mesh may need to be removed. If you are planning to have children after the procedure, a pregnancy may damage the repairs and cause the prolapse to recur. To help prevent this, you may be advised to have a scheduled caesarean section rather than a vaginal birth. Sacrospinous fixation This operation holds the uterus up by stitching it to one of the pelvic ligaments (called the sacrospinous ligament) using sutures only; no mesh. The procedure is done vaginally and is therefore less invasive than sacrohysteropexy, but also has lower success rates. While complications are rare, there is a risk of damage to the pudendal and sciatic nerves that can lead to severe pain in your legs, buttocks, genitals and pelvic area. Manchester repair Manchester repair (also called Fothergill operation) is no longer commonly performed, but used to be the only surgical alternative to hysterectomy for treating uterine prolapse. The procedure is done vaginally and involves removing part of the cervix (which may be elongated) and pushing the uterus back into place by shortening the ligaments that support it. The operation has a high failure rate and many women require additional surgery, usually a hysterectomy. In addition, the entrance to the uterus may become either very narrow or very relaxed and this can cause problems during pregnancy and childbirth. Treating Vaginal Vault Prolapse Sacrocolpopexy
Complications are uncommon but there is a risk that the mesh may inflame or erode the tissue around it. If this is severe, the mesh will need to be removed. This is considered a major procedure and therefore may not be appropriate for women who are frail or in poor health. Sacrospinous Fixation This operation supports the vagina by attaching the vaginal vault to one of the ligaments in the pelvic area (the sacrospinous ligament). The procedure is done through the vagina and uses sutures only; no mesh.
Complications are rare, but can include damage to the pudendal and sciatic nerves, causing severe pain in your legs, buttocks, genitals and pelvic area. Note: Following surgery you may have mild to moderate pain in your buttocks and down one thigh. This is normal but should get better within a month. If the pain does not go away or get better, tell your doctor. Tight (anterior and posterior) repair This procedure is rarely done. It involves removing a large amount of the vaginal tissue in order to tighten and support the vagina. The main complication of this operation is severe pain. Colpocleisis (colpectomy or Le Forts procedure) Colpocleisis — vaginal closure — is another procedure that is rarely done. It closes off the vagina by stitching the front and back walls together, leaving two pencil-width channels on either side. The operation is performed vaginally and can be done using a local anaesthetic or epidural. It is only offered as a treatment option for women who have severe prolapse, are too frail to undergo any other surgical treatment and are absolutely certain they don't ever want to have sexual intercourse again. Once the vagina is sewn up, penetrative sex is no longer possible, and a vault prolapse may still recur, falling through what remains of the vagina. |
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Written by Tamara Beus and published in printed format (2003) by Women's Health
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This procedure uses a strip of synthetic mesh to hold the uterus in place. The operation is done abdominally, either through a 15cm cut just above the pubic hairline or through keyhole surgery (laparoscopy). The doctor attaches one end of the mesh to the cervix and top of the vagina and the other to a bone (sacrum or sacral bone) near your spine. Once in place, the mesh supports the uterus.
This procedure uses synthetic mesh to support the top of the vagina. During the operation, the doctor stitches one end of the mesh to the top of the vagina and the other end to a bone near your spine (called the sacrum or sacral bone). It is done abdominally, either through keyhole surgery (laparoscopy) or a larger cut just above the bikini line. Sacrocolpopexy has a higher success rate than sacrospinous fixation (below).