by Caspar Stromayr
of an examination
of a patient with a prolapse
and its reduction using
a pessary made of sponge
bound by twine, sealed with
wax and dipped in butter
Genital prolapse is a distressing condition, which afflicts human females mainly due to an anatomical design flaw. It occurs less frequently in other animals. A detailed description of the female anatomy can be found on this website under vagina dialogues and will not be repeated here.
It occurs when the pelvic organs (uterus, bladder, rectum) protrude into the vagina from their normal positions due to loss of elasticity of the normal support structures, collectively known as connective tissue (ligaments, muscle and fascia). Although childbirth is the most commonly identifiable causative factor, a lot depends on the type of connective tissue one inherits from their parents as well as other subtle insults such as chronic constipation or cough, menopause, obesity or rarely, pressure from an abdominal/pelvic tumour.
Types of prolapse
There are a number of different types of prolapse. The prolapse of a pelvic organ may occur independently or along with other pelvic organ prolapse. Prolapse is graded according to severity. A first degree prolapse occurs when the organ has descended a short distance into the vagina, a second degree when it has descended far enough to reach the vaginal opening and a third degree (procidentia) when it is protruding through the vaginal opening.
Uterine prolapse - involves the descent of the uterus and cervix down the vaginal canal due to weak or damaged pelvic support structures.
Cystocele - where the tissues supporting the wall between the bladder and vagina weaken, allowing a portion of the bladder to descend and press into the wall of the vagina.
Urethrocele - where the urethra (tube leading from the bladder to the outside of the body) descends and presses into the vagina. A urethrocele rarely occurs alone, instead usually accompanying a cystocele. The term cystourethrocele is used to refer to the prolapse of both part of the bladder and the urethra.
Rectocele - where the tissues supporting the wall between the vagina and rectum weaken allowing the rectum to descend and press into the wall of the vagina.
Enterocele - is similar to a rectocele, but instead involves the Pouch of Douglas (area between the uterus and the rectum) descending and pressing into the wall of the vagina.
Vaginal vault prolapse - is where the top of the vagina descends, usually following a hysterectomy
Symptoms vary from person to person and are due to both the degree and volume of prolapse but also the sensation experienced as the support structures are stretched, thus an early small prolapse may cause more distressing symptoms than a large procidentia. The symptoms may vary from backache to the presence of a lump; from urinary to bowel symptoms; from sexual to psychological problems.
A good history needs to be obtained followed by a physical examination, particularly of the abdomen and genital area. This may need to be carried out in the standing or lying on the left side, knee-chest position. It may also be necessary to carry out special test such as an ultrasound scan of the abdomen and anal sphincter or pressure studies of the bladder or rectum. These tests are not always required as they are don't always add to knowledge or predict outcome.
The aim of any treatment is to restore anatomy but more importantly to restore function and relief symptoms. Treatment also depends on the general fitness of the patient.It may be limited to addressing the cause such as constipation, a pelvic mass, chronic cough or hormone deficiency. Pelvic floor exercises have a role in prevention or arresting the progress of a small prolapse. Most women already do these exercises, with or without supervision.
Conservative measures using pessaries of various types may be recommended especially for those not fit or unable to have surgery.
The type of surgery involved in prolapse repair depends on the desired outcome, fitness and other factors such as the desire to have more children. It is best discussed in detail with your gynaecologist.