Vaginal Prolapse

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Treatment

Treatment for vaginal prolapse depends on the cause of the condition and the severity of the symptoms. In many cases, the condition gradually worsens over time and eventually requires surgery. Pelvic organ prolapse usually is treated by a urologist, a gynecologist, a urogynecologist, or a physical therapist.

In mild cases, the health care provider may recommend activity modification (e.g., avoiding heavy lifting), Kegel exercises (to strengthen the pelvic floor muscles), the use of vaginal pessaries, and estrogen replacement therapy (ERT).

Kegel exercises can help to improve pelvic organ prolapse, depending on the severity, and may slow progression of the condition. Success of these exercises depends in part on proper execution. First, the patient must be able to locate the correct muscle group by stopping or slowing the flow of urine without tensing leg muscles, or the patient can visualize squeezing the rectal muscles as if to prevent a bowel movement.

There are two types of Kegel exercise:

• Quick contractions–rapidly tighten and relax the sphincter muscle
• Slow contractions–contract the sphincter muscle and hold to a count of 3, gradually increasing to a count of 10

Exercises should be performed 10 to 15 times per session, at least 3 times each day. Kegel exercises should not be performed while urinating, because urine retention may occur.

Biofeedback may be used with Kegel exercises to reinforce proper technique. Patients visualize and identify the pelvic floor and abdominal muscles that are contracted during the exercises.

A simple instrument records small electrical signals that are produced when the muscles contract. The signals are instantly converted into audio and/or visual signs that help patients gain greater control over urinary and bowel muscle activity. Weak muscles can be activated on demand, tense muscles can be relaxed, and muscle activity can be coordinated using biofeedback.

Neuromuscular electrical stimulation (NMES) may be used, in some cases, to retrain and strengthen weak pelvic floor muscles, which can improve bladder control. Electrical stimulation of nerves in the pelvic area (e.g., the pudendal nerve) causes pelvic floor and urethral and anal sphincter muscles to contract. A probe is inserted into the vagina and a current is passed through the probe at a level below the pain threshold, causing a contraction. The patient is instructed to squeeze the muscles when the current is on. After the contraction, the current is switched off for 5 to 10 seconds. Treatment sessions lasts approximately 20 to 30 minutes.

The use of Kegel exercises, biofeedback, and electrical stimulation often are taught and monitored by a skilled physical therapist.

Vaginal pessaries are silicone or latex devices inserted into the vagina to compress the urethra, support the bladder neck, and hold the uterus in place (for uterine prolapse). Pessaries are available in different shapes and sizes and usually are fitted and inserted by a gynecologist. The largest size that can be worn comfortably is usually the most effective. Patients who are sensitive to latex or silicone cannot use these devices.

Frequent follow-up care is required when using vaginal pessaries to check for infection, pressure sores, and allergic reactions. Pressure sores are more common in post-menopausal women and estrogen cream can be used to improve the integrity of the vaginal mucosa. Tissue damage is managed by removing the pessary until the skin heals, and infections are treated with antibiotics. At each follow-up examination, the pessary is removed and cleaned thoroughly.

In women who have had a hysterectomy or in post-menopausal women, estrogen replacement therapy (ERT), which also may be combined with a progestin, may be used to improve the support structure of the pelvic area. ERT is available in pill form (oral), as a patch (transdermal), as a vaginal ring, or as a cream or gel (topical). ERT may increase the risk for stroke, blood clots, gallstones, and ovarian cancer, and should not be used in women who smoke.

Surgery
Severe vaginal prolapse that continues to worsen despite conservative treatment may require surgery. Newer, more effective surgical methods have been developed in recent years. There are a number of techniques available, depending on the type of prolapse, the severity of the condition, and the preference of the surgeon.

Because pelvic organ prolapse occurs as a result of weakened structures (e.g., muscles, ligaments) in the pelvic floor, successful surgery to correct the condition often involves using grafts (e.g., mesh-like materials, slings).

Surgery to treat vaginal prolapse is performed under regional or general anesthesia, and may be performed laparoscopically (i.e., through small incisions using tiny surgical instruments and advanced camera systems), abdominally (i.e., through an incision in the abdomen), or vaginally (i.e., through the vagina).

Surgery that is performed vaginally involves making an incision in the vaginal wall, correcting the position of the prolapsed organ (e.g., bladder, rectum, small bowel), securing the organ in place, and closing the vaginal wall.

Types of procedures that may be performed include the following:

• Anterior or posterior colporrhaphy (to correct cystocele, urethrocele, or rectocele)
• Culdoplasty (to correct the posterior fornix or posterior portion of the vagina)
• Paravaginal repair (to correct cystocele; may be performed vaginally or abdominally)
• Posterior intravaginal slingplasty (to correct vaginal vault prolapse)
• Sacral colpopexy (involves securing the prolapses organ to the sacrum [bone at the base of the spine] with synthetic mesh or natural fascia [fibrous tissue]; may be performed abdominally or laparoscopically)
• Uterosacral ligament suspension (may be performed abdominally, vaginally, or laparoscopically)
• Vaginal vault suspension (to correct vaginal vault prolapse by securing the organ to a ligament in the pelvis)

In patients who no longer wish to have children, uterine prolapse may involve removal of the uterus (hysterectomy), usually through the vagina.

In some cases, surgery to correct incontinence is performed at the same time. Surgical methods for incontinence may include suspension procedures and sling procedures.

Following surgery to treat pelvic organ prolapse, patients may be hospitalized for 2–4 days and are advised to avoid heavy lifting and avoid smoking for at least 6–12 weeks. Normal activity may be resumed after about 3 months.

Prevention

Vaginal prolapse cannot be prevented in every case. Women who are at increased risk for developing the condition should perform Kegel exercises regularly, should avoid heavy lifting, and should maintain a healthy weight.

Vaginal Prolapse, Treatment, Prevention reprinted with permission from womenshealthchannel.com
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