I have a problem with the vaginal or uterine prolapse

What is a prolapse?

A prolapse of the pelvic organs occurs when the pelvic organs (womb, bladder, bowels) slip from their normal position and bulge into the vagina, a descent of the vaginal wall, or a prolapse that includes the vaginal opening. Prolapse affects a total of 3% of women from 20 to 80 years of age, but after the menopause 41% of women suffer a prolapse of the womb with 38% after its previous removal. At some time in their lives, around 1 in every 9 women (11%) undergo surgery due to a prolapse before they reach their 80th year and 30% of these are operated on again due to long-term problems or their recurrence.

What are the signs of a prolapse?

A prolapse manifests itself through a range of symptoms which have a negative effect on the quality of life of the woman. Individual symptoms can be expressed to varying degrees, and are divided into symptoms of the womb, vagina, sexual and bowel.

Urinary symptoms: difficulty initiating urination, urinary incontinence, the sense of inadequate emptying of the bladder, frequent urination, nighttime urination, the urge to urinate.
Vaginal symptoms: the feeling of bulging in the vagina or at the opening of the vagina, the feeling of something pulling during physical activity or during the day, discomfort from contact of the prolapsing organs with clothing, hygiene problems.
Sexual problems: pain during intercourse , fear of sexual intercourse due to the prolapse.
Bowel symptoms: constipation, the need to press on the rear vaginal wall to fascilitate the emptying of the rectum, undesirable flatulence or soiling, the frequent need to defecate.

What are the types of prolapse?

The descent mainly concerns the uterus and vaginal walls. The The prolapse mostly concerns the womb and vaginal walls. The area of the pelvic floor is divided into the anterior, medium, and posterior compartments. The prolapse is often a combination of more than one compartment.

Prolapse of the anterior compartment

This prolapse is called cystocele or uretrocele depending on whether it leads to the prolapse of the bladder or the uterus through the vaginal wall. This is the most common form of prolapse.

Prolapse of the medium compartment

This is the most serious type of prolapse, whereby the womb (or upper region of the vagina in women who have had the womb removed) slips through the vagina. It is therefore necessary to attach/suspend the womb, the cervix, or the upper part of the vagina to the pelvic structures to which these structures were originally attached

In up to 2/3 of cases, the prolapse is combined with one of the anterior compartment. In this case it is most important to immobilize the previously mentioned structures: the womb, the cervix, or the upper part of the vagina.

Prolapse of the posterior compartment

This involves the situation whereby the end part of the colon (rectum) arches into the rear vaginal wall (rectocele) or a part of the small intestine arches into the upper part of the vagina – between the womb and rectum (enterocele).

For your better imagination, here are some of the different types of descents in the following animated:

How is an examination conducted of a woman with a pelvic organ prolapse?

At the recommendation of your doctor, or even after your own considerations, you can make a first appointment with our urogynecological surgery by telephone. Our number is 377 105 295. We make every effort to complete the examination during this one visit.

In the course of this visit you will undergo a special urogynecological examination which ascertains the extent of the prolapse as well as the state and function of the pelvic floor. While performing this examination, your overall quality of life and the extent to which this prolapse effects you is our priority. An essential part of this examination is a urogynecological ultrasound performed by a specialist.

On the basis of this information and your overall condition, we can discuss the possible solutions to your problem with you. Your own opinions play a significant role in selecting the appropriate solution because only you can know to what extent this prolapse is affecting your life.

What are the possible solutions for resolving a prolapse?

The general medical approach divides these into conservative and surgical.

Conservative treatment

Is is necessary to note that the possibilities for conservative solutions for a prolapse are fairly limited and generally not very effective. A thorough urogynecological examination, including an expert urogynecological ultrasound, will provide you with information as to whether a conservative approach has any medical potential in your particular case.

Physiotherapy

This consists of exercising and strengthening the weakened muscles of the pelvic floor. However, it is relatively common for this muscle to be separated from the point of its connection to the bone and therefore its exercising cannot have any desired effect.

Pessary therapy

The basis of this intervention is the fitting of an elastic ring above the level of the main muscle of the pelvic floor. The ring should be as large as possible to prevent it from slipping out, and yet at the same time not so big that it might cause the loss of the the ability to urinate, constipation, pain, or even tissue damage.

Surgical solutions

The choice of surgery depends on a variety of circumstances: the extent and type of prolapse, the specific symptoms, and overall state of health.

An operation to close the vagina

This type of operation is currently only recommended for women whose overall state of health rules out any other type of operation as well as rendering any future sex life impossible. The operation, called a colpocleisis, is carried out at our clinic with no need for a general anaesthetic and so can be performed on women in practically any state of health. The basis of this approach is to close the vagina in such a way that the vaginal walls are connected and eventually grow together.

Reconstructive surgery

The aim of this surgery is to return the prolapsing structures to their original positions with the possibility of a sex life.

How the selection of the type of operation is made in your case

For each case of prolapse there may be a different operation that is appropriate for it. Pilsen’s Center for Pelci Floor Disorders at the University Hospital has one of the most technically advanced teams, not only in the Czech Republic, but throughout the world. This is down to the dedication and hard work of the entire urogynecology team which specializes in these types of operation.

The main factors which decide which type of operation is right for your case are whether, and to what extent, the medium compartment is affected (meaning prolapsing of the uterus, the cervix, or the upper section of the vagina), whether the muscle which supports the pelvic floor is damaged, your own personal symptoms, and the overall condition of your health. Age is not a deciding factor in itself.

A separate issue is whether or not to retain the uterus. This is why the overall extent of the procedure is only finalized after agreement with you and with full respect to your wishes. Then it is even possible, if you so wish, to plan conception and pregnancy.

The vagina and how we can approach this problem

It is currently possible to perform a so-called classical operation – vaginoplasty (possibly combined with hysterectomy) when a defect is found in the dividing structure between the vagina and the bladder or rectum, the closing of which involves bringing their peripheries closer together.
This procedure is only independently appropriate for isolated prolapse which occursin approx. 40% of women with prolapse.

Were this procedure to be applied to all women suffering a prolapse, the risk of it’s possible failure would be somewhere between 30-50%.

So for the remaining 60% of women, it is necessary to resolve the prolapse of the medium compartment, meaning the uterus (womb), the cervix, or the upper part of the vagina. As part of the vaginal approach, the use of non-absorbable stitches or meshes, which attach the cervix or upper edges of the vagina to a solid structure of the pelvis such as the sacrospinous ligament. The operation is called sacrospinale fixation, or sacrospinal fixation with the use of mesh. The risk of failure of this type of operation is around 10%.

Abdominal approach

Known as abdominal sacrocolpopexy, this is the gold standard operation for reconstructing a pelvic organ prolapse. The disadvantage is the incision made on the abdomen, the longer recovery, and the difficult approach to the space between the vaginal vault and the rectum. This is why we, at our clinic, prefer the laparoscopic approach for this type of operation, which achieves at least as good results and involves a much faster recovery.

The laparoscopic approach

A laparoscopic sacrocolpopexy is an operation whereby the vaginal vault (and if necessary the uterus or cervix) is attached to a ligament that is positioned in front of the spine with the help of a non-disolvable mesh. This operation is extremely effective and reliable. The risk of failure of this type of operation is around 1% with the lowest risk of postoperative complications such as pain or the mesh breaking down into the vaginal vault. This operation is associated with the best results for improving the quality of the patients sex life. This operation is also recommended for women who wish to retain the uterus, and who might be planning a future pregnancy. The experience of our urogynecological with this laparoscopic approach is one of the most extensive in Europe.

Is it necessary to use a mesh?

Traditional operations don’t require artificial material. They do, however, carry a higher risk of failure. The mesh used can also be made of disolvable biological material. In this case though, current results suggest a higher risk of failure than when a non-disolvable maesh is used. When non-disolvable mesh is used, then its laparoscopic (abdominal) application is prefered. In cases where the woman cannot have a laparoscopic or abdominal operation, then a vaginal mesh is an appropriate alternative.

What else we solve