Prolapse

Women’s Health in Kent

Mr Rowan J Connell MD MRCOG Consultant Obstetrician and Gynaecologist

Prolapse

There are pictures of prolapse at the end of this section which may shock you.

Interactive prolapse diagram (for GPs)

A prolapse occurs when the ligaments, walls of the vagina and the pelvic floor muscles (which should all act as a supporting sling holding the pelvic organs in place) become too weak to do this effectively. There are different types of prolapse.
• A cystocele is a bulging of the bladder through the wall of the vagina. The operation to repair a cystocele is called an ‘anterior repair’.
• A rectocele is a bulging of the rectum through the wall of the vagina. The operation to repair this is a ‘posterior repair’.
• A uterine prolapse occurs when the uterus (womb) and the cervix gradually ‘drop down’ through the vagina. The operation for a uterine prolapse is a ‘vaginal hysterectomy’.
The ‘sling’ can become weakened for many different reasons. The most common reasons are childbirth and pregnancy. However, repetitive heavy lifting, straining for constipation and chronic coughing (as with smokers or for those with chest conditions) can also be to blame. When oestrogen levels within the tissues decrease eg following the menopause, this also worsens the elasticity and strength in the sling.

A prolapse can cause any of the following symptoms;
• A dragging sensation / ‘heavy’ feeling down below.
• A feeling of pelvic fullness or pressure.
• A feeling as if something is actually falling out of the vagina.
• A pulling or stretching in the groin area or a low backache.
• Painful intercourse.
• Spotting or bleeding from the vagina.
• Urinary problems, such as involuntary release of urine (incontinence) or a frequent or urgent need to urinate.
• Difficulty with bowel movements, such as constipation or needing to support the back of the vagina to have a bowel movement.

Quite often these symptoms are worse towards the end of the day as the pelvic floor muscles tire, like any other muscle, and thus gradually withdraw support from the ‘sling’.
Treatment decisions should take into account which organs are affected, the severity of your symptoms, and whether other medical conditions are present. Other important factors are your age and sexual activity.

USEFUL TIPS TO HELP PREVENT/REDUCE A PROLAPSE
Pelvic Floor Exercises Providing strength to the sling that supports your organs in place, by exercising the pelvic floor, the sling is strengthened and this then has the ability to lift / reduce a prolapse. By timing a pelvic floor lift, if you are able to do this correctly, ‘just before / during’ a lift, laugh, cough or sneeze, etc (termed ‘the knack’) the downward movement of the organs during these moments can be counteracted a little. Occasionally oestrogen supplements can help the pelvic floor strength to return – your GP or Consultant will advise you if this is appropriate for you.
Lifting Wherever and whenever possible, avoid repetitive or heavy lifting. Similarly avoid heavy pushing and pulling. Use a trolley when going shopping and avoid lifting very heavy bags in and out of the car. Be mindful of housework eg avoid lifting the hoover etc up and down the stairs. For parents / grandparents, avoid lifting toddlers whenever possible.
Standing Try to take regular breaks as standing for prolonged lengths of time causes the muscles to tire. Take regular breaks to lie down or sit down. For housework activities such as ironing - try to do this seated, for example.
Weight Maintain a weight that is appropriate for your body size. Whilst being overweight may not be the cause of a prolapse, any ‘extra’ weight can worsen a prolapse. By losing any excess weight, symptoms can be eradicated.
Constipation Avoid constipation at all costs since the straining caused by constipation weakens and damages the connective tissue and muscles in the pelvis.
Sports Avoid any exercise that involves ‘straining’ your tummy eg sit-ups or high impact exercises such as running, step aerobics etc as these can aggravate / worsen a prolapse. These, following rehabilitation of the pelvic floor muscles, or surgery, may be resumed but wait until your Consultant or specialist Physiotherapist advise you that it is safe to do so.

PROLAPSE is a common and often distressing complaint, affecting about a third of women attending gynaecology clinics.
It becomes commoner as you get older, have more children and go through the menopause. It does, however, affect 2% of young women who have not had children but who have a congenital weakness of their supporting tissues.

Treatment options
Physiotherapy.
Physiotherapy (see our links) helps by tightening the pelvic floor muscles, and although it will not help specifically with uterovaginal prolapse, it does help with the symptoms.

Pessaries.
(Please use this link).
There are a number of different pessaries available, and each type is used for different types of prolapse. They are fitted by a doctor or nurse, and need to be checked every few months.

Surgical options.
There are numerous variations on surgical correction of prolapse.
Vaginal repair, refers to a minimal access (through the vagina) technique of strengthening the front wall (anterior) or back wall (posterior) of the vagina.
We sometimes use a special stitch - a sacrospinous fixation (SSF) or mesh to help strengthen the repair. Mr Connell has been trained and trains in Europe. He has used the stitch, mesh and ribbon (link) for nearly a decade, with excellent results. He is part of a National study looking at the outcome of traditional repairs and mesh repairs.
Traditionally gynaecologists perform vaginal hysterectomy for prolapse. Mr Connell tries to conserve the uterus if at all possible.

When the womb (or the top of the vagina in a woman who has had a hysterectomy) prolapses out of the vagina, then more radical surgery is required. We can use a ribbon (IVS) which replicates the uterosacral ligaments to give the elasticity back to the vagina.
We can stitch the womb or vagina to a ligament close to the bone on one side of your anus (you can feel the bone when you sit down). This is called a sacrospinous fixation (SSF).

PICTURES OF PROLAPSE

Conditions we treat

Operations (full list)

Mesh for repairs

Contact us

NHS Practice:

Maidstone and Tunbridge Wells Hospitals

Hermitage Lane

Maidstone ME16 9QQ

Secretary: Diane McGraw

Tel: 01622 224601

Private Practice:

Somerfield Hospital

Maidstone

Spire Hospital

Tunbridge Wells

Secretary: Frances Crawford

Tel: 01622 683988