Pelvic organ prolapse (POP) is the descent of one or more parts of the vagina and/or uterus. Woman may experience displacement of the anterior, posterior or apex of the vagina, and often there is a combination. This is referred to as a cystocele, rectocele and enterocele.
Although the prevalence of POP identified on exam may be anywhere from 41 to 50 percent, only about three percent of women in the US report symptoms of a vaginal bulge. This discrepancy is likely because many women who suffer from POP are asymptomatic. POP is only considered a problem if it is causing symptoms (eg. pressure) or sexual dysfunction, or it is impairs function of the normal lower urinary tract or bowel. Risk factors for developing POP include parity, vaginal deliveries, age, obesity, connective tissue disorders, menopausal status and chronic constipation. There are approximately 30,000 POP surgeries a year in the US. As the population ages, POP can result in significant costs to the healthcare industry.
There are several ways to manage POP. First, after the physical exam and history diagnose the problem, women should be counseled on nonsurgical options. For example, fiber supplementation and use of an osmotic laxative may improve defecatory dysfunction. Pelvic muscle exercises may improve and even slow the progression of symptoms. Local estrogen may help with vaginal irritation that is associated with POP. Women considering treatment for POP are often offered a pessary. Up to 92 percent of women can be fitted successfully with a pessary. A pessary cannot only be therapeutic, but also diagnostic—one can determine if there are voiding issues with reduction of the POP. Surgery is indicated for women who are bothered by their prolapse and have failed or declined the conservative treatments. There are various vaginal and abdominal approaches to repair prolapse.
A robotic sacroculpopexy can address all three levels of pelvic support (anterior, posterior and apical). It involves placement of a synthetic mesh graft from the apex of the vagina to the anterior longitudinal ligament of the sacrum. Ideal candidates are women who are young, severe grade 3or 4 prolapse, shortened vaginas, and those women who have other intra-abdominal pathology.
Abdominal sacroculpopexy with mesh is associated with lower risk of rerrrent POP but may be associated with more complications compared to a vaginal repair with native tissue. A robotic approach also allows the surgeon to perform other intraabdominal surgeries, specifically hysterectomy and oophorectomy. If a woman desires to retain her uterus, then one can also perform a robotic hysteropexy.
Vaginal prolapse can often be managed through a vaginal approach. Prolapse of the bladder, known as cystocele, can be reduced through an incision in the top wall of the vagina. If the very top of the vagina is also lax and descending down the vaginal canal, a procedure called a sacrospinous fixation can be performed where the top of the vagina is secured to ligaments on the sacrum. For prolapse of the back wall of the vagina, known as a rectocele, vaginal surgery to repair is recommended.
As in every case, it is important to discuss the goals of surgery with the patient. For example, an older non-sexually active woman who desires improvement from symptomatic POP may be a better candidate for an obliterative surgery rather than reconstructive surgery. Another example is a woman who is worried about mesh who may prefer a vaginal approach with native tissue.
The long-term data is still in the process of being collected, but one thing is for sure, surgeons who are well versed the female pelvic anatomy and who perform many surgeries have the best outcomes.
Urology centers of Alabama provides state of the art care for our female patients. We have three female urologist who are experienced in treating women and are well versed in urinary incontinence, prolapse and other issues unique to women. Dr. Nicole Massie is Subspecialty Certified in Female Pelvic Medicine and Reconstructive Surgery. Dr. Paula Rookis’ areas of specialty are female urinary incontinence, voiding dysfunction, vaginal prolapsed, and stones. Dr. Rupa Kitchens’ clinical interests are kidney stones, bladder and prostate cancer and female urology.
Drs. Nicole Massie and Paula Rookis specialize in urology medicine with Urology Centers of Alabama.
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