What are the different options for treatment of prolapse?

All too often we take our bodies for granted.  It’s not until something goes awry that hindsight comes into play.  But we can only do so much, and even those of us with the very best of intentions can be hit by unforeseen circumstances.  So in spite of the years spent performing our obligatory pelvic floor exercises, an operation such as hysterectomy, ill health or even a traumatic childbirth (to name but a few), could result in any one of us suffering pelvic organ prolapse (POP).

Considered too ‘embarrassing’ to discuss, and retaining its place as a taboo topic of conversation, many of us are reluctant to broach the subject of prolapse with friends, let alone a doctor.  Indeed, some of us find the prospect of talking about it almost as distressing as the prolapse itself.  This sadly leaves a number of women ill-informed about the varying treatment options available to them.

What are the treatment options?

When it comes to the symptoms associated with prolapse, every woman is unique.  So, whether pain or loss of sensation has led to an uninspiring sex life and relationship problems, stress incontinence has you too embarrassed to leave the house, or that heavy feeling between your thighs has you feeling incredibly self-conscious, there is a treatment that’s right for you.  The type and severity of your prolapse will determine the method used to treat it; however, the only way to completely repair a moderate or severe prolapse is through surgery. However, prolapse surgery won’t necessarily prevent further prolapses if you don’t strengthen up your pelvic floor muscles.  Your surgery will repair your prolapse but it may not relieve all your symptoms. As with all treatments, its success depends on many factors. While surgery may be successful for one woman, another may have disappointing results. About one in three women who have a prolapse surgical repair develop another prolapse over time but only a third of these have more surgery.

Surgery isn’t recommended where prolapse is mild and doesn’t interfere with everyday life.

Lifestyle Changes

Who’s it for?

It sounds simple doesn’t it?  Well, for those that have a mild prolapse (stage one, and in some cases stage two), implementing a few small changes to your daily routine could help to alleviate the symptoms you are experiencing as a result of your prolapse.

What does it entail?

Need some motivation to shift those extra pounds?  Well, achieving a healthy weight can strengthen the pelvic floor, thereby easing the associated symptoms and preventing your prolapse from worsening.  It is also important to avoid heavy lifting and any activities that put undue pressure on the abdomen; that includes straining when going to the toilet.

Pelvic Floor Exercise

Who’s it for?

Pelvic floor exercise is vital for everyone that has suffered a prolapse, regardless of the severity. A weak pelvic floor is the primary cause of prolapse (which can occur for a number of reasons), but exercising the muscles will rebuild strength and increase support for each of the pelvic organs.  It is even recommended that those undergoing surgery perform strengthening exercises in the weeks prior to it, in order to improve the outcome.  Pelvic floor muscle (PFM) strengthening is an important strategy in resolving and preventing vaginal prolapse, bladder weakness and the inability to fully empty the bowel. A 2010 research reports that following a 6-month program of PFM strength exercises women can improve or reverse a Grade 1/2 pelvic organ prolapse (POP). Furthermore, PFM strengthening will help prevent further organs from prolapsing, this is especially important for those women

What does it entail?

Much like any other work out, pelvic floor exercise will tone the muscles over time and increase their strength.  They also help to increase the circulation into the pelvic area, this is both beneficial for exercising and post-surgical recovery. Targeted pelvic floor muscle exercises will help to ‘lift up’ the prolapsed organ/s and more importantly, stop then descending down any further. Pelvic floor exercise can be performed in one of two ways, either manually or with an electronic device.  Manual ‘Kegels’ can be done easily at home or at work as follows;

  • Squeeze your anal passage as if restricting wind
  • Squeeze the urethra as if stopping the flow of urine
  • Whilst lying down squeeze the pelvic floor muscles, lifting inwards and upwards – this position will minimise the drag on your pelvic floor

Although manual pelvic floor exercise can be hugely beneficial, it is believed that 50% of women are unable to produce an effective muscle contraction [1].  This results in just 40% of the correct muscles being exercised.  Many women opt instead for electronic devices which are capable of targeting 90% of the muscles.  These devices use neuromuscular electronic stimulation (NMES) to stimulate a contraction within the pelvic floor.  The small current is introduced to the body via a probe or electrodes.

For more information regarding electronic pelvic toners go to our online shop and look at the Kegel8 range.

HRT (hormone replacement therapy)

Who’s it for?

Where prolapse is attributed to the menopause, HRT may be used as a viable treatment option.  It may also help to relieve some of the symptoms associated with prolapse, such as vaginal dryness and discomfort during sex.

What does it entail?

The chances are, if you’re going through the illustrious ‘change’, you’ve already heard the term HRT.  So, what is it exactly?  Well, when our bodies go through the menopause we experience a natural decline in female hormones (progesterone and oestrogen).  This lack of oestrogen could cause the pelvic floor to become weak and, as such, result in prolapse.  It is believed that increasing this level of oestrogen with the use of HRT could help to rebuild strength in the vaginal walls and pelvic floor.  However, there is little evidence to suggest that this method should be used to treat POP directly.  HRT is available in a number of different forms, including tablets, cream, patches, a vaginal ring or an implant.

What are the side effects?

With so much controversy surrounding HRT and all of the side effects purported to be linked to it, it may not be a treatment that you wish to consider.  Worryingly, HRT has been linked to cancer and also has a number of potential short term side effects including bloating, headaches and depression.

Pessary

Who’s it for?

Typically used to treat those with a uterine prolapse, a pessary is likely to be offered as a temporary solution for pregnant women, women who have given birth, or those awaiting surgery.  In some cases it will be employed as a permanent resolution.  This is often the case where a woman does not wish to have, or is unsuitable for, surgery.

What does it entail?

A device similar to a diaphragm or a cervical cap is inserted into the vagina to help support the pelvic area and ‘hold up’ the prolapsed organ.  A ring pessary is the most common amongst women who have suffered severe prolapse but are unable to, or do not wish to undergo surgery.  Once inserted, you should not be able to feel the pessary; however it will need to be replaced every 3-6 months.  Not only will a pessary treat the prolapse itself, it can also improve some of the associated symptoms, including urinary urgency and incontinence.

What are the side effects?

In some cases having a vaginal pessary can lead to adverse side effects, including vaginal discharge and bleeding. Other side effects, though rare, may include UTIs, bacterial vaginosis (imbalance of usual bacteria found in vagina), bladder weakness, difficulty with bowel movements and problems having sex.

Surgery

Where prolapse is extremely severe, surgery could be the best and, indeed, the only option.  Many of us are all too aware of how debilitating pelvic organ prolapse can be, affecting not only physical wellbeing, but emotional wellbeing too.  Surgery is the only way to completely repair it, and where other treatments have proved unsuccessful, or the prolapse is too serious, surgery could take great steps towards vastly improving quality of life.

What are the different surgical options?

The type of surgery performed very much depends on the type of prolapse suffered.  The most common procedure is pelvic floor/vaginal wall repair; however, the following are also implemented as ways to repair pelvic organ prolapse;

Posterior Intravaginal Slingplasty

What’s it for?

Vaginal Vault prolapse; only women who have had a hysterectomy can have a vaginal vault prolapse (where the top of the vagina falls in on itself).

What does it entail?

A synthetic mesh, or suspension string, is inserted into the vagina, to support both the sagging organ and the vagina.  This procedure may be carried out under general or spinal anaesthetic.

Obliterate Surgery

What’s it for?

Uterine Prolapse, Vaginal Vault prolapse.

What does it entail?

Typically performed on older women, or those with extremely severe cases of prolapse, the organ which has dropped is moved back into place and the vaginal opening sewn shut.  This is a highly effective treatment, but it does mean that sexual intercourse is no longer possible.

Hysterectomy

What’s it for?

Uterine Prolapse

What does it entail?

Completely removing the uterus is sometimes elected as a way to treat/repair uterine prolapse.  However, it can also increase the risk of other types of prolapse, including vaginal vault prolapse where the top of the vagina falls in on itself.

Vaginal Wall Repair

What’s it for?

Bladder Prolapse (Cystocele), Small Bowel Prolapse (Entrocele) and Rectal Prolapse (Rectocele)

What does it entail?

An incision is made into the anterior (front) or posterior (back) wall of the vagina. The layers of tissue supporting the pelvic organs are then tightened up, strengthening the walls and offering additional support.

Sacrospinous Fixation

What’s it for?

Uterine Prolapse, Vaginal Vault prolapse

What does it entail?

An incision is made in the vagina through which stitches are sewn to a strong ligament (sacrospinous ligament) in the pelvis, and then attached to the cervix or vaginal vault.  This essentially holds up the prolapsed organ and provides greater support.

Sacrocolpopexy

What’s it for?

Uterine Prolapse, Vaginal Vault prolapse

What does it entail?

A piece of synthetic mesh/suspension string is attached to the upper back wall of the vagina and fixed to a ligament in the lower back.  This keeps the pelvic organs in place and provides additional support for them.

What are the risks of surgery?

It is important to note that, as with any kind of procedure, prolapse surgery carries with it some degree of risk.  Before committing to go ‘under the knife’, we would urge you to explore all other options, particularly performing pelvic floor exercises.  Pelvic floor exercises can ensure other pelvic organs do not prolapse, interfering with the function of your bladder or bowel and also improve any surgical outcomes. Side effects from surgery may include bleeding/infection, constipation, damage to neighbouring organs, painful sex and problems with passing urine.  There have also been recent reports of mesh erosion, where the material used to support the pelvic organs has eroded over time.  This risk, although minimal, could result in further complications.

Approximately 1/3 of women that have prolapse surgery may need more than one operation as there is a 25-30% chance that it could return, or a different type of prolapse could develop [2].  Additionally, although surgery will repair the prolapse itself, in some cases the associated bladder/bowel symptoms do not improve.  It typically takes approximately 6 weeks to recover after surgery.

Sources

[1] Johns Hopkins University Press Blog, (2012). The Doctor Is In: Women’s pelvic health, fact or fiction?. [online] Available at: http://jhupressblog.com/2012/10/09/the-doctor-is-in-womens-pelvic-health-fact-or-fiction/ [Accessed 4 Aug. 2014].

[2] Bladderandbowelfoundation.org, (2014). Prolapse Treatments – Bladder and Bowel Foundation. [online] Available at: http://www.bladderandbowelfoundation.org/bladder/bladder-problems/prolapse-treatments.asp [Accessed 4 Aug. 2014].

[3] http://www.nih.no/om-nih/aktuelt/nyhetsarkiv/2010/mars/the-effect-of-pelvic-floor-exercises/

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