Pelvic organ prolapse is a condition in which the muscles and fascia supporting the pelvic organs become compromised. Without the proper support structure, the bladder, rectum, uterus or small intestine can fall out of place (prolapse) and bulge into or protrude out of the vagina. A complete prolapse, which is considered a worst-case scenario, occurs when the entire vaginal canal comes out of the vagina, virtually turning inside out.
Unfortunately, pelvic organ prolapse is extremely common, particularly as women age. According to urogynecologist Ahmet Bedestani MD at East Jefferson General Hospital, by the time a woman reaches her 70s, she has about an 11-15 percent chance of having experienced some aspect of prolapse and the symptoms associated with it.
Symptoms depend on the type of prolapse a patient has but range from lower back pain and a feeling of fullness in the pelvic area to urinary incontinence, painful intercourse and stool leakage, among others. While there are no definitive causes, women are at higher risk if they have had trauma to the pelvic floor, a midline episiotomy, a hysterectomy, are post-menopausal, overweight, have a family history of the condition or an instrumental delivery.
"About 20-30 years ago, we used to perform forcep deliveries, and you would actually reach in and clamp around the fetal head and pull out," Bedestani says. "That sometimes causes significant trauma. The results were first, second, third and sometimes forth degree lacerations meaning the whole vaginal and pelvic floor muscles could be ripped up to and even through the rectum."
Midline episiotomies are also thought to contribute to a woman's risk of prolapse. These surgical incisions were commonly performed in the 1970s during childbirth. The incision was made to enlarge the vaginal opening and ran in a vertical line from the bottom of the vagina toward the rectum. However, this style of episiotomy often ripped into the rectum. Now, most obstetricians either use a mediolateral (slanted) episiotomy or none at all.
Another medical procedure linked to this condition is hysterectomy. "Research has shown that attention must be given to restoring the uterosacral-cardinal ligament complex to prevent vaginal vault prolapse after hysterectomy, which has been reported to be as high as 18 percent," Bedestani says.
Age and weight are factors, too. As we age, supportive tissues naturally weaken and excess weight puts more stress on all of the organs as well as the support systems. Family history and ethnic background could be another indicator of potential prolapse. "There is a definite founder effect to pelvic organ prolapse," Bedestani says. "French-Canadians, for instance, tend to have softer tissue and a greater prevalence of prolapse than African-American women."
Female pelvic medicine and reconstructive surgery is the newest sub-specialty of medicine, with the first board exam taking place in 2013. These delicate operations are often performed inside the vagina with only a few centimeters to work and no room for error. In the wrong hands, results can be worse than the prolapse. Physicians began performing mesh surgeries to act as a scaffolding to help women with specific areas of prolapse. Instead of removing excess, protruding skin, which leads to tightening (imagine a bad facelift in a very sensitive area), the mesh slings help support the prolapse. Statistically, mesh proves to be a very effective treatment option, but poor execution and bad press has made some patients leery of the procedure.
There are several other surgical options, however, so patients and physicians don't have to rely on transvaginal mesh or surgeries that cause vaginal tightening. The key is to work with a surgeon who has a lot of experience in female reconstructive surgery. "One of these types of surgeries, for example, is a uterosacral ligament repair, and it works very well," Bedestani says. "But it's done through the vagina, and it's very technically challenging. ... It's kind of like finding a needle in a haystack, but if you are properly trained, it's not that hard."
Robotic technology is another important development in the world of pelvic organ prolapse repair. The da Vinci Robotic System's ability to navigate the presacral space (located between the rectum and the sacrococcygeal part of the spine) with 10 times magnification in three dimensions allows this technically challenging surgery to be performed safely, improving long-term results.
The takeaway is that new technologies are improving things drastically for women as they age. "I don't think it's too much in this day and age for a woman to ask to be free of these kinds of issues," Bedestani says. "If you are suffering from that aspect of pathology in your life, you should know very good treatment is out there."