Normally the vagina is supported by bands of dense connective tissue something like hammocks. These go from one side of the pelvic bone to the other. There is one that supports the bladder in front of the vagina and another behind the vagina supports the rectum. If the vagina is visualized as a sock, the uterus sits at the very top of the vagina, where the toe of the sock would be. It is held there by several sets of ligaments, the cardinal and uterosacral ligaments. These act like guy wires to hold the uterus and top of the vagina up.

            These supports are frequently damaged by childbirth. The baby’s head passing through the vagina will tear these hammock-like structures off from the pelvic bones or sometimes just weaken them. The damage may be “where the hammock is fastened to the tree”, which is typical of the bladder supports. The tear may be “where the fabric of the hammock would be.” This is most common between the rectum and vagina. The injury is often not apparent at first. After a delivery typically there is some healing that takes place, but with time and lifting, and the weakening and thinning of the tissues in menopause the problem gets worse and worse until at some point, it causes problems.

            When the problem is in the bladder the symptoms may be stress incontinence (wetting your pants with a cough or laugh). There may be a feeling that the bladder is falling out of the vagina or that you are sitting on your bladder. Some people say this feels like there is a tennis ball in their underwear.  Sometimes the bladder exit tube is kinked so that it is impossible to void at all unless the bladder is pushed back into the vagina.

            If the rectum is affected the symptoms are similar except that it may be necessary to push down on the back of the vagina to hold the rectum in place when having a bowel movement. The feeling of “sitting on a tennis ball” is less likely with a rectocele, as this is called but may still occur.

            If the top of the vagina, the cervix or the uterus is protruding, the feeling is “my insides are falling out.” There may be some discomfort in the pelvis or back. There may or may not be any problems with bladder or bowel. This is not uncommon following a hysterectomy when the support ligaments to the uterus have been cut by the surgeon.

Often it is impossible to be sure what area is prolapsed just by symptoms, and a detailed examination is needed.

            The prolapses may occur in only one site or all of them at once and the symptoms may vary according to which are more severe and by the individual. Sometime if one area is fixed surgically it will take the pressure off of another making it worse. If the problem is severe or longstanding the skin over the tissue that is sticking out of the vagina may get eroded and infected.

Treatment

There are several ways of treating vaginal prolapses. In some cases the symptoms are not severe enough to make repair necessary. This is a personal decision. What is a reason for surgery for one person may not bother another. Talk to your doctor about how much your problem bothers you. If the problem doesn’t get any worse and you are careful about straining and lifting you may get by without an operation.

            Some people, either because they do not have a very severe prolapse or because they are not very active, may get by with a pessary. This is a plastic brace that fits into the vagina and supports the bladder, rectum or uterus. They come in various shapes and sizes and can help a lot of people. It is necessary to have a regular appointment with your doctor to check them as urinary tract infections, and vaginal infections may occur. Most people should use some estrogen crème to improve the strength and blood flow in the vaginal skin.

            Most people with significant prolapse, sooner or later will elect to have it repaired. Most of the repairs are done vaginally though occasionally it is necessary operate either laparoscopically or with an open abdominal operation.

The vaginal operations were traditionally called “tacking up the bladder or rectum.” This was done by taking a plication seam in the “hammock” material over the bladder or rectum. This tissue has already failed once and especially in the case of the bladder, it is not the actual site of the defect in more than 75% of cases anyway. Not surprisingly many of the repairs failed over time. Many surgeons now will employ a graft material, either a synthetic nylon mesh or a biologic material such as porcine skin. These materials are a strong framework which encourages your body to grow new support tissue, much like ivy grows over a trellis. The material is sewn into the same place where the tearing occurred in childbirth and has a good but not perfect record. The repairs with patching material have been show to hold up better than those with-out. The best material to use is still controversial however.

Bladder repair

The operations are the Anterior Repair, often called a Paravaginal repair. This involves an incision over the cystocele to push the bladder in place. Then stitches are placed in the fibrous tissue on the sides of the pelvis to hold the patching material under the bladder. Sometimes it is necessary to put in a separate sling under the urethra to improve incontinence.

Rectal repair

The Posterior repair is done in a similar manner. An incision is made over the bulging area and the torn tissues are repaired. A patch is sewn over to support the weak area and the skin is closed. Occasionally it is necessary to repair the rectal sphincter or the supporting muscles of the rectal wall.

Apical (Enterocele) Repair

If the uterus or the top of the vagina is falling down, the remedy is to reconstruct the ligaments that were lost in childbirth or during a hysterectomy. Strong, permanent sutures are placed between the top of the vagina or the cervix to the area of the uterosacral ligaments or to the pelvic sidewall. If this repair is not possible it may be necessary to sew the vagina to the hollow of the sacrum. This is usually done either laparoscopically or by an abdominal operation.

Risks of Operation

            All surgery has risks. Problems can occur with vaginal repairs. Firstly, at the time of surgery the bladder or rectum may be injured. Bleeding or infection are rare but can occur. Any of these may require a return to the operating room or may prolong recovery. The ureter may be obstructed either at the time of surgery or by contraction or compression during healing. This may be found at the time of surgery or may occur later. This is fixed either with an operation to clear the obstruction or by placing a tube in the ureter to allow it to heal. Secondly, the operation may fail and the prolapse may reoccur. This can be because the stitches don’t hold or because a different area is stressed and breaks down when the pressure is transferred to it after the repair. This may require re-operation in the same or a different place. Exercising caution in lifting and resuming activities will help to avoid problems but cannot prevent all complications. The overall risk of problems is about 10 to 20 % overall.

Recovery

Recovery takes about a week to get back to normal activities. I usually recommend that people spend a quiet week at home right after surgery. Light normal activities, driving and light chores around the house can be resumed after a week. Lifting should be limited to about ten pounds for the first six weeks and around twenty-five pounds for six months or more. After a pelvic repair heavy lifting should be avoided permanently. It is also important to avoid straining with constipation, so attention should be paid to keeping the bowels open. Pain is managed by pills and they are usually only needed for the first few days. Most people can return to regular activity after two to four weeks. Intercourse should be avoided for six weeks or until healing is complete. Even in the best of cases the problem may re-occur in up to 25 % of people.