Gynaecologist Perth | Specialised in vaginal prolapse
Vaginal ProlapseSymptoms, Causes and Treatment
What is vaginal prolapse?
I will tell women that a prolapse is only as important as the symptoms that it causes, and if you do not have any symptoms, you do not have a prolapse. Well, at least not one that matters, no matter how bad a doctor may think it is. Prolapse is a common problem, particularly as you age. It is a weakness of the supports of the vagina, which leads to the “inside” trying to come “out.” In the worst cases, the vagina may even turn inside out.
What are the causes of vaginal prolapse?
ObesityObesity is another important contributing factor, particularly if the weight is predominantly abdominal weight, as that abdominal weight needs to be supported by the pelvic floor muscles. As obesity is becoming more of a problem for our society, it has important implications.
Prolapse is much more common in postmenopausal women. The vaginal tissues, which are very oestrogen-dependent, become thinner and weaker without oestrogen support.
Medical conditionsOther medical conditions can contribute significantly. Chronic constipation with chronic straining is an important provocative factor. Chronic cough associated with chronic respiratory diseases such as asthma can be a factor as well.
Family historyFamily history is important. Tissues vary in their strength between people, and we have no good test to determine tissue strength. If your mother had a prolapse, you may have weaker tissues and are at greater risk.
ExerciseExercise is generally a very good thing and better muscle tone in any of the body generally produces better muscle tone in the pelvic floor. However, heavy weight-lifting exercise can produce hernia in men and prolapse in women.
Sexual activitySexual activity is, again, generally a very good thing to maintain. Using the tissues encourages blood flow and helps keep tissues vital. Orgasm is an excellent way to produce the most powerful contractions of the pelvic floor.
How does a prolapse present?
Cystocele (or prolapsed vaginal wall)This is when the front vaginal wall, or the back wall of the bladder, prolapses.
RectoceleWhen the back wall of the vagina, or the front wall of the bowel, prolapses.
How does a prolapse present?
Cystocele (or prolapsed vaginal wall)
This is when the front vaginal wall, or the back wall of the bladder, prolapses.
When the back wall of the vagina, or the front wall of the bowel, prolapses.
Vaginal prolapse or rectocele symptoms
Women will complain of pressure in the pelvis. The may notice a protrusion out of the vagina. It may affect the bladder in different ways, voiding more often. Symptoms can be leaking and difficulty emptying the bladder completely.
It can also affect bowel function, making it difficult to empty the bowel. Sometimes you need to support the prolapse to allow the bowel to empty.
Decreased sensation with intercourse is another symptom, which can affect both partners. Some of the decrease in sensation in the women relates to damage of the pelvic nerves, especially if compressed and damaged after childbirth.
Tests and diagnosis
The diagnosis is largely clinical. History and examination are the mainstays of the diagnosis.
Additional tests may include possible ultrasound and bladder function test, but neither are absolutely required
How common is a vaginal prolapse and what can I do when I do have it?
Vaginal prolapse treatment
Surgical devices of all shapes and sizes have been used for a century to try to support prolapsing tissue. For the right woman, it can provide excellent treatment. Ring pessaries are the most common today. To be retained, the posterior wall needs to be reasonable. With a bad rectocele, the device will just be expelled.
It may be the only option if there is a significant surgical risk, especially in older women. It is possible to learn how to take the pessary out and put it back, but most women are not comfortable doing that.
It is usually not an option if a woman is sexually active, either. They can lean on the vaginal walls and produce some ulceration of the vaginal skin. They need review and change, but less often over time.
Native tissue repair
Traditional surgical vaginal prolapse repair is called native tissue repair. The name implies that the support comes from shortening the stretched tissue in the front and back of the vagina and stitching the tissues back together.
It then heals — as any operation will heal — by laying down scar tissue. Scar tissue takes time to achieve maximum strength, most achieved by around six weeks after an operation. Scar tissue is not as strong as the tissue was before the prolapse occurred, so I describe it as making the best of weak tissues, not returning to the pre-prolapse state. “You can’t make a silk purse out of a sow’s ear”.
Given that native tissue repair has good but not excellent results, and given the difficulty of recurrent prolapse, there have been attempts to put implantable tissue in to support the vagina.
Fishnet-like tissue has been sewn under the vaginal skin to add support. This is the “mesh” that you may have heard of. It was borrowed from general surgery, where surgeons have and continue to use this mesh to repair hernias. Since a prolapse is a bit like a hernia, it was thought it would be good in the vagina. It is a long saga, but the mesh is no longer an option.
How to prevent vaginal prolapse?
ExerciseExercise is the fountain of youth that we all desire. It has great health benefits, including helping to maintain strength and tone in the pelvic floor muscles.
Never strain to use your bowels. Fibre in the diet helps.
Using a fibre supplement such as Metamucil is a good and healthy long-term step to ensure you never strain. It is not addictive, and ok to use long term.
Pelvic floor exercises
The pelvic floor muscles are a little obscure and many women have difficulty identifying those muscles. Hence, they are often bad at exercising them.
It is the muscles that you need to contract to stop in the middle of emptying the bladder. Your partner can tell you when you contract the muscles during intercourse. A physiotherapist who specialises in women’s health can be very valuable in helping you to learn how to control them.
Pelvic floor muscle exercises are VERY important. Unfortunately, most women lose motivation to maintain regular pelvic floor exercises over time.
Avoid lifting heavy objects
What is heavy? If you need to think about lifting it, it is heavy. Most activities of daily living are OK.
I do encourage exercise, but weight lifting as a sport is not good for a weak pelvic floor.
Be aware when gardening. Many aspects of gardening involve the need to lift objects. Think about ways around it. The pelvic floor muscles tire, so keep time in the garden short and take breaks.