Genital prolapse or pelvic organ prolapse is the protrusion of the pelvic organs into or out of the vaginal canal. Most cases are the result of damages to the vaginal and pelvic support tissues due to childbirth or due to chronically elevated intra-abdominal pressure. Several types of different types of pelvic prolapse exist.
Prolapse can occur individually or in combination with a prolapse of another pelvic organ. Generally more than one organ is involved. Patients typically notice a mass or protrusion from the vagina followed by pelvic pressure and backache. Some patients may also have one or more symptoms of urinary incontinence, urinary retention, sexual dysfunction and difficulty with bowel movements.
Definitions
- Complete Genital Prolapse (Total procidentia): Protrusion of entire female organ out of vagina.
- Uterine Prolapse: Protrusion of the uterus into or through the vagina.
- Vaginal Vault Prolapse: Protrusion of the top of the vagina into the lower portion of the vagina or through the vagina totally inverting it. This occurs in post-hysterectomy patients.
- Cystocele: Protrusion of the bladder into or through the vagina.
- Rectocele: Protrusion of the rectum into or through the vagina.
- Enterocele: Protrusion of bowel into or through the vagina.
- Urethrocele: Protrusion of the urethra into the vagina.
Treatment of Pelvic Organ Prolapse
Treatment for pelvic prolapse may be either medical or surgical. Medical or conservative options include the following:
- Pessary: A device inserted into the vagina to support the prolapsed organs.
- Pelvic floor muscle exercises: May be done in conjunction with pessary use. The exercise strengthens the muscles in the pelvic floor, and may enhance the ability to retain the pessary in the vagina.
- Hormone replacement therapy: Improves the quality of the vaginal tissue.
These measures may relieve symptoms and reduce the prolapse. However, some women may not tolerate pessary use, and some prolapses are not sufficiently relieved by pessaries, exercise, or hormonal replacement therapy, in which case surgery may be the desired option.
Surgical options involve reducing the prolapse and, in many cases, restoring normal anatomy. There are many types of procedures available, each addressing a specific prolapse or defect.
- Uterine prolapse: The treatment of choice is the laparoscopic uterine suspension unless pathology involving the uterus is detected, in which case a hysterectomy is necessary. Laparoscopic uterine suspension is usually done in conjunction with a vaginal vault suspension — a procedure which attaches the apex of vagina to strong ligaments toward the back of pelvis to support the vagina. The surgery is a very simple and quick procedure with a short recovery time
- Vaginal prolapse: Vaginal vault suspension, a technique which attaches the vagina to strong ligaments toward the back of the pelvis to support the vagina likewise is a very quick and effective procedure.
- Cystocele: Three different types of cystoceles are the 1) paravaginal defect cystocele which accounts for approximately 80-85% of all cystoceles; 2) transverse defect cystocele, acounting for about 10–15% of cystoceles; and 3) midline defect cystocele, representing approximately 5% of cystoceles. The treatment for cystoceles must be tailored to its cause. An anterior colporrhaphy (bladder tack done through vagina) is seldom indicated except for repair of the midline defect cystocele. The paravaginal defect and the transverse defect type of cystocele can be repaired laparoscopically with excellent outcomes when performed by an experienced laparoscopic surgeon.
- Rectocele: A posterior colporrhaphy procedure repairs or closes the defect in the strong tissue overlying the rectum. A new surgical technique of using principles of site-specific defect repair has evolved with less discomfort for the patient and better long-term results.
- Enterocele: An enterocele repair procedure closes the defect in the strong tissue on the top of the vaginal wall and restores the integrity of the fibromuscular structure of the vagina.
All of the above procedures can be done either vaginally or laparoscopically. Laparoscopic repair is preferable because the laparoscope permits better visualization of the specific pelvic floor defects. The superior visibility of the defects greatly enhances the surgeon’s ability to perform the repair.
The Women’s Surgery Center has extensive experience with genital prolapse surgery. The center has one of the largest series of laparoscopic repair of genital prolapses in the world. One of the pioneers in the field of laparoscopic genital prolapse surgery, Dr. Liu frequently lectures and performs live surgery demonstrations of these techniques at major national and international conferences.
Laparoscopic Repair of Female Organ Prolapse
The goal of laparoscopic repair of female organ prolapse is to restore normal functioning by correcting the organ-supporting defects in the pelvis. The supporting system in the female pelvis is complex and dynamic rather than static. There are basically two systems in the pelvis that provides the active and passive support of pelvic organs to their proper places. The active, dynamic support of the female organs comes primarily from levator ani muscles, a pair of special muscles in the pelvis. These muscles maintain a certain tone even during the resting phase. The muscle is strong and can contract forcefully when needed. Yet it is quite flexible, resilient, and also renewable.
When the levator ani muscles are damaged due to childbirth or to a constant increase in intra-abdominal pressure, as in a chronic lung disease due to asthma or heavy smoking, constipation, or heavy lifting and straining activities, the levator ani muscles are no longer able to maintain their efficient contractility. and they lose the resting tones to support the female organs in their proper places. A great strain is then placed on the passive support system of the pelvis which is provided by the endopelvic fascia (a tough fibrous sheet) within the pelvis. Unfortunately, the endopelvic fascia, being a fibrous tissue consisting of collagen, elastin, and smooth muscle fiber, is poorly suited to support the pelvic organs, which are under constant gravitational pull and frequent bouts of increased in intra-abdominal pressure. Exposed to prolonged pressure and tension, the endopelvic fascia stretches and eventually breaks, resulting in loss of support to the pelvic organs. Thus vaginal prolapse and urinary and/or fecal incontinence occur.
The prolapse rarely bothers the patient when she is lying down and resting, only when she is up and carrying on her normal daily activities in either standing or sitting positions. Any physical stress such as coughing, sneezing, or lifting usually aggravates the prolapse. To accurately evaluate the site and degree of the prolapse, the patient should be examined in an erect position rather than on her back. She must be thoroughly evaluated, and the prolapse clearly observed by the physician under different physical stresses (coughing, bearing down, straining), before she is counseled to have reconstructive surgery.
Because the defect in the pelvic floor support usually is multiple and not limited just to the obvious component, the entire pelvic floor supporting system must be thoroughly evaluated before and during surgery, and all defects must be reconstructed at the same time of surgery.
Our surgical goals for our patients with uterovaginal or vaginal prolapse are 1) restoration of the normal vaginal depth and axis, 2) relief of the symptoms of pressure, and 3) maintenance of satisfactory sexual function.
Advantages of Laparoscopic Surgery
Advantages of laparoscopic surgery are numerous. A superb view of the pelvic floor can be obtained and the pelvic supporting defects can be clearly identified because of superior visualization with a bright light directly on the deep pelvis and great magnification provided by the laparoscope. Moreover, unlike the traditional vaginal or abdominal surgical approach, the laparoscopic approach permits the surgeon to not only see the supporting defects clearly, but to also feel the defects by performing a vaginal examination under direct laparoscopic view during the procedure. This permits the surgeon to place the sutures precisely and effectively. With the traditional vaginal repair surgery for prolapse, the surgeon is almost totally dependent upon tactile feeling to guide the surgery which unfortunately can result in either over or under repair at the defects. An additional advantage of laparoscopic surgery is that pictures of the surgery can be taken or the entire surgery can be videotaped for future reference and for the patient to see the actual surgery later. Furthermore, the minimal invasive nature of laparoscopic surgery results in greatly reduced the postoperative pain and discomfort and shortened hospitalization and recovery period.
Laparoscopic Surgery for Uterovaginal and Vaginal Prolapse
The prolapse of uterus and vagina is one of the most frustrating and embarrassing disorders confronting the modern woman, who, with increased life expectancy, is interested in maintaining her femininity and capacity for sexual activity. Because a prolapsed uterus or vagina is just a manifestation of the breakdown in the pelvic floor supporting system, the condition generally coexists with other types of genital prolapse such as cystocele, rectocele, and enterocele. Therefore, the reconstructive surgery for uterovaginal or vaginal prolapse is just part of the total repair of the pelvic floor, which is necessary for the restoration of normal anatomy and function.
The length of the vagina in a normal adult female is approximately 10-12 cm. In a standing female, the lower 1/3 of the vagina is pointing 90 degree to the floor and her upper 2/3 of vagina is in an angle almost parallel to the floor and directly toward her lower backbone. The vagina is basically supported on three different levels in the pelvis. The support of the upper 1/3 of vagina comes from the uterosacral ligaments, a pair of very strong fibromuscular structures that originate from lateral aspects of sacrum (the lowest part of the spine), going around the rectum and attaching to the cervix (the mouth of womb) and upper part of vagina. These ligaments pull the top of vagina and cervix toward the sacrum and forms the normal axis of vagina. The middle third of the vagina is held in place by the lateral attachments of the fascia to the pelvic side wall. The lower third of vagina is blending into and merging with the fibromuscular tissue surrounding the opening of the vagina and anus. It is of utmost importance for the readers to understand that the uterus, per se, has no bearing or effect on the vaginal support. In other words, a hysterectomy should not be considered as part of repair surgery for uterovaginal or vaginal prolapse unless there is distinct pathology of the uterus. In order to restore the vaginal depth and axis, all three levels of support must be attended at the time of surgery.
Surgical Procedure
The patient is under general anesthesia, and the laparoscope is inserted into the abdominal cavity through a small 1/2-inch incision inside the navel. Additional three or four ¼-inch incisions in the lower abdomen may be needed for more laparoscopic instruments during surgery. The laparoscope is connected to a small, highly sophisticated and sensitive video camera. Thus the deep pelvic structures are greatly magnified onto three high resolution video monitors, permitting the entire surgical team to have a superb view of the operative field. Laparoscopic surgery differs greatly from the traditional surgery in that the surgery is almost entirely guided by electronic eyes which can deliver the magnified view of the operative field onto the video monitor. The surgeon performs the surgery with eyes focused on the video monitor instead of on the patient, and the entire surgical team has the same clear view of the surgery.
Under the view of the laparoscope, the individual supporting defects are visualized and reconfirmed by digital vaginal palpation, and the defect repaired with precise placement of permanent non-absorbable sutures through the laparoscope. Frequent digital vaginal examinations are performed throughout the surgery to ensure that all defects are repaired. Because of excellent visibility of the operative field through the laparoscope, the blood vessels in the pelvic area can be either avoided or sealed by electrocautery or suture ligation, thus minimizing the blood loss.
Several laparoscopic surgical techniques can be used to repair the uterovaginal and vaginal prolapse. Dr. Liu’s current surgical technique is to use presacral uterosacral ligaments to re-suspend the apex of vagina and cervix (if the patient still has a uterus) to restore the depth and axis of the vagina. The presacral uterosacral ligament is a strong fibromuscular tissue which can withstand great strain. To demonstrate the strength of the presacral uterosacral ligaments at an anatomy conference for surgeons, Dr. Liu put in a large suture through the presacral uterosacral ligament and hooked the suture to a 30-pound weight; it held the weight without any problem!
For those patients with marked prolapse, a paravaginal repair is usually necessary at the same time of the surgery to reattach the midvagina to the pelvic side walls. Over the past 16 years, Dr. Liu has been doing laparoscopic surgery for uterovaginal and vaginal prolapse with outstanding long-term results. Unlike traditional vaginal surgical repair, there is minimal, if any, cutting or trimming of the vagina; therefore, there is absolutely no risk of making the vagina too narrow or too short, both of which are the major long-term complications of surgical repair of vaginal prolapse.
Laparoscopic Surgery for the Repair of Cystocele
Support for the bladder and urethra (the tube between the bladder and the opening of vagina) is provided by a strong layer of fibromuscular sheet that overlies the linings of the anterior vaginal wall; this is the pubocervical fascia. Above, it attaches to the upper part of vagina and cervix of uterus, and laterally it attaches on each side to the pelvic side wall. The pubocervical fascia supports the bladder and the urethra by forming a shelf, allowing the bladder neck and the proximal part of urethra to be compressed in an anterioposterior fashion during the periods of stress (coughing, sneezing, laughing, or lifting heavy objects). When this supporting mechanism becomes loose due to trauma of childbirth or to other reasons, the stability of this supportive layer of fascia diminishes and may ultimately fail, leading to the formation of cystocele and the development of stress urinary incontinence if the fascial defect involves the support of the bladder neck and proximal urethra.
In 1976, Dr. Colin Richardson, after careful clinical observations and cadaver dissections, proposed and emphasized that the vast majority of cystocele is not caused by the stretching or attenuation of the pubocervical fascia, but that it is a result of a “break” of the pubocervical fascia from its attachments to the pelvic side walls. He called this defect “paravaginal defect,” and he strongly advocated the use of paravaginal repair, instead of traditional vaginal anterior repair (anterior colporrhaphy), for the treatment of cystocele. His concept of cystocele and proposed treatment has been endorsed by virtually all the leading urogynecologists in the country.
Technique of Laparoscopic Paravaginal Repair for Cystocele
The patient is under general anesthesia and a laparoscope is inserted into the abdominal cavity through a small half-inch imbilical incision. The peritoneum (the lining of the abdominal and pelvic cavity) above the bladder and behind the pubic bone is opened through the laparoscope and the retropubic space (a space in the pelvis where the bladder and its supporting ligaments are located) is entered and dissected. With a bright light shinning directly into the retropubic space and the magnification provided by the laparoscope, a clear view of the retropubic space is projected onto the high resolution TV monitor through a highly sensitive video camera that affords the surgeon superb visualization of the anatomy of the retropubic space. The paravaginal defects can be easily detected by the surgeon. A digital vaginal examination under the direct observation of the laparoscope is performed to reconfirm the presence and extent of the defects, and the defects are then repaired with several interrupted sutures with permanent stitches through the laparoscope. Three different types of paravaginal defects exist that can be identified through the laparoscope, and each defect should be treated differently according to its own type of defect.
With positive intra-abdominal pressure created by pneumoperitoneum during laparoscopic surgery, paraviginal defects become much more apparent. Digital vaginal examination under the direct viewing through the laparoscope affords the surgeon with additional tactile assessment of the defects. Thus the findings of the paravaginal defects during surgery not only confirm the preoperative findings, they dictate the ultimate procedures to be performed. At the end of the reconstructive surgery, repeat digital vaginal examination under direct laparosopic view allows the surgeon to be confident that all defects have been repaired. Dr. Liu has been performing the paravaginal defect repair for the past 16 years with highly positive outcomes, attributable to the laparoscopic approach that permits the magnified visualization, perfect identification of the defects, and precise placement of the sutures. As the popular saying goes, “If you can’t see, you don’t know what you are missing.” How true this is in surgery!
Frequently Asked Questions
Should genital organ prolapse be treated with surgery?
The answer is yes if the patient is symptomatic. Prolapse is a hernia (breakdown or separation of strong fascial tissue through which organs or tissue protrude) in the pelvic area, and the treatment of choice for a hernia is surgical repair. Although prolapse of the genital organs seldom leads to serious medical illness, it certainly can make a woman’s life uncomfortable.
Surgical repair of prolapse can be performed through large abdominal incisions, or through incisions high up inside the vagina, or, more recently, through the laparoscopic approach. Because often more than one supporting structure of the pelvis develops weakness or tears, repairs must be made in more than one area. The laparoscopic approach to genital organ prolapse is superior to the traditional method in that it provides
- A greatly magnified and clearer view of the pelvic floor defects.
- More precise suture placements.
- Less blood loss.
- Diminished postoperative pain and discomfort.
- Shorter hospitalization.
- Much quicker recovery.
What causes the cystocele and what can be done about it?
Cystocele, or bulging of the bladder, is one of the most common pelvic organ prolapse. A cystocele results from tearing and separating of the supporting connective tissue around the bladder. The fascial tissues that support the bladder are connected to the muscles and bones on the pelvic side wall. When this fascial connective tissue is torn away from the pelvic sidewalls, the bladder drops downward. This is called a paravaginal defect, the most common cause (80-85%) of cystoceles. To repair these tears, the surgeon must suture the torn side attachments back together. This repair, called a paravaginal repair, pulls the bladder back to its normal position. It may be performed through an incision up inside the vagina, or through a large incision into the abdomen, or through tiny incisions in the navel and abdominal walls using laparoscopic techniques. Regardless of the type of incision made, the goal is to repair the tissues and return the bladder as close to its original position as possible.
What can be done if the rectum is bulging (rectocele)?
Childbirth or chronic constipation can injure the supporting tissues of the rectum. Weakened or torn tissue cannot hold the rectum down in its proper place, and the rectum bulges up inside the vagina. Surgery will restore and repair these weakened or torn fascial connective tissues. This fascial connective tissue supporting the posterior wall of the vagina and keep rectum in its proper position is called rectovaginal septum. In normal female, the rectovaginal septum is fused with perineal body at the lower end. The vast majority of the rectoceles occur because of the tear between the rectovaginal septum and perineal body. Rectocele repair involves opening the wall between the vagina and the rectum and identifying the torn parts of rectovaginal septum and perineal body. Each tear is sutured and closed individually. The rectovaginal septum is reconnected to the perineal body and the fascia of the levator ani muscles in a procedure called a site-specific rectocele repair. Once the tears have been fixed, the rectum should be restored to its anatomic position, and the supporting tissue should be strong enough to keep the rectum in its proper place.
Traditional rectocele repair depends on thick and inflexible scar tissue formation over the rectum and plication of the levator ani muscle to the middle for support of the posterior vagina. However, scar tissue in the vagina and plication of the levator ani muscle to the middle commonly leads to painful intercourse. One study found that almost 30% of women had stopped having intercourse after a traditional rectocele repair surgery. Scar tissue formation is difficult to remove. The site-specific repair repairs only the torn parts of the supporting tissue (rectovaginal septum and perineal body), resulting in much less scar tissue and a decreased chance of painful intercourse. The patient requiring rectocele repair should specifically ask her physician about site-specific repair as this is a fairly new procedure.
What is an enterocele and what can be done about it?
The vagina is a tubular-like structure surrounded and supported by tough fibromuscular connective tissue called endopelvic fascia. Because of its strong fascial sheath, it does not stretch well and breaks under prolonged chronic pressure. On the other hand, forming the lining of the vaginais the vaginal epithelium, which can be stretched endlessly without tearing under pressure. When a break occurs in the endopelvic fascia, the vaginal epithelium is no longer separated from the pelvic peritoneum (lining of the pelvis), and an enterocele, a bulging, out from the top of vagina, results whenever the patient in an upright position. Frequently, loops of small intestine can be trapped inside the large “enterocele sac” producing pressure and discomfort.
The treatment for enterocele is repair and restoration of the integrity of the fascial layer of the vagina. This can be done vaginally but, in our opinion, is best done laparoscopically because of the excellent visibility of the pelvic fascial defects afforded by laparoscope.
What can be done if the uterus is dropping down?
Various surgical techniques are used to repair a prolapsed uterus. With recent improved understanding of the pelvic floor anatomy and pathophysiology of the pelvic floor supporting system, we now know that the uterus has no functional role in pelvic floor supporting system. This means that a hysterectomy has no effect on the surgical outcome. Therefore, a hysterectomy is not recommended during the repair unless there is evidence of uterine pathology at time of surgery.
Traditional repair for prolapsed uterus is performed either vaginally or through a large abdominal incision. Both approaches involve the removal of uterus (hysterectomy). With the vaginal approach, the apex of the vagina is attached to healthy portions of the ligaments (uterosacral ligaments or sacrospinosus ligaments) inside the pelvis. And with abdominal approach, a mesh graft is used, with one end of the mesh attached to the apex of vagina and the other end of mesh attached to the inner surface of the sacral bone (sacro-colpopexy). Either surgery is considered a major reconstructive undertaking and requires a prolonged recovery period for patient.
In1992, Dr. Liu developed the laparoscopic presacral uterosacral ligament suspension for the treatment of uterovaginal prolapse, with excellent long term outcomes. This laparoscopic surgery provides excellent visualization of deep pelvic structure including the fascial defects. The procedure can be performed much more quickly compared to either the traditional vaginal sacrospinosus ligament suspension or abdominal sacrocolpopexy. The patient’s postoperative recovery is rapid, and the complication rate is extremely low. The only drawback to this procedure is that the surgeon must possess extensive knowledge and understanding of pelvic floor anatomy and high proficiency in laparoscopic surgery, because the procedure involves extensive laparoscopic suturing which is difficult to master.
Can prolapse reoccur after surgery?
Even with increased understanding of the functional anatomy and pathophysiology of the pelvic floor supporting system and with advancement in surgical procedures, issues yet remain. One challenge is how to improve the quality of inherently weakened fascial tissue within the pelvic floor supporting system. Another challenge is for patients to learn how to effectively avoid conditions causing increased pelvic pressure.
The two basic supporting systems of the pelvic floor are 1) the active supporting system from levator ani muscles and 2) the passive supporting system from endopelvic fascia. Prolapse is the result of breakdown of both active and passive supports of pelvis. Surgery can only restore the integrity of endopelvic fascia, but not the levator ani muscle. The dysfunction of levator ani muscle is the result of injured pudendal nerves that innervate the muscle. These nerves can be damaged during childbirth, especially with prolonged second stage of labor, and difficult forceps delivery. These nerves can also be damaged in conditions such as chronic constipation, chronic respiratory problems such as asthma, emphysema, and other problems causing chronic coughing, and chronic heavy lifting. Dysfunctional levator ani muscles eventually result in prolapse of pelvic organs.
With current surgical technology, the pelvic floor can be restored to its normal anatomic position by repairing defects in the endopelvic fascia. However, some prolapses may still reoccur after the repair surgery for the following reasons: 1) Injured pudendal nerves that control the levator ani muscles of the pelvis cannot be rejuvenated. No matter how well the endopelvic fascia and other supporting structures are repaired, if the nerves are unable to carry the signals from the brain to the muscles, the muscles will not work properly. 2) Some women are born with weak supporting tissue. If the endopelvic fascia is inherently weak, no amount of repair work will prevent it from falling again. With aging, the quality and strength of the supporting tissues naturally weaken. 3) If the medical conditions that caused chronic elevation of pelvic pressure in the first place cannot be corrected, then the repair may not be sustained. Hence, some women undergoing repair for their prolapses may require additional surgery later in their life.
No long-term outcomes of any surgery can be guaranteed. But we have found that a well done surgery by a proficient, experienced laparoscopic surgeon who has repaired all defects, coupled with meticulous postoperative care and life style changes such as the avoidance of constipation and heavy lifting and the practice of pelvic muscle exercise, the majority of our patients do enjoy long-term results with satisfaction.