Family doctor

What is it?

Genital tract prolapse can be defined as weakness of the supporting structures of the uterus, pelvic floor and vagina. This condition affects up to 30 to 40 percent of all women and is certainly one of the more common reasons why women over the age of 40 present for gynaecological assessment and care.

What does genital tract prolapse involve?

• Weakness in the front (cystocele) and/or back (rectocele) walls of the vagina
• Weakness of the supports to the uterus (prolapse of the uterus)
• Weakness in the upper part of the vagina which can cause a hernia (enterocele)

What causes this condition?

• Childbirth - prolonged labours and in particular, prolonged 2nd stage labour, and big babies.
• Menopause - decreasing oestrogen levels have an impact on the collagen content of the pelvic floor tissues.
• Hereditary genetic predisposition to this condition - many women have large babies with long labours, go through menopause and do not have a prolapse.

What symptoms do women present with?

• Some women are asymptomatic - in other words they have no symptoms at all and the prolapse or weakness in the genital tract is noted on a routine examination.
• More commonly a woman may present with a history of noticing a lump at the entrance to her vagina which may be, either her cervix (which is the bottom part of the uterus) or the front and back walls of the vagina which have prolapsed down through the entrance to the vagina.
• There maybe a dragging sensation in the lower pelvis and/or backache.
• Stress incontinence - which is leakage of urine when coughing, sneezing, laughing or during exercises.
• The need to place a finger in the vagina when having a bowel motion to reduce the prolapse and thus make passing a bowel motion a little easier.

At what age does this problem become more common?

While many women do notice temporary symptoms of prolapse such as a lump to the entrance to the vagina and/or stress incontinence following delivery of a baby, these symptoms often significantly improve with the passage of time and/or physiotherapy.

The most common age group are those women who are experiencing menopause, usually over the age of 50, although all age groups may be affected.

How is the problem treated?

Taking a careful history of the symptoms will give a very good guide to what is going on.

Examination will confirm whether the prolapse is involving the vaginal walls and/or the uterus - in most cases it is unusual to find an isolated defect or weakness in one part of the pelvic floor, but rather a general weakness. It is important that all areas of genital tract prolapse are repaired.

Physiotherapy - pelvic floor exercises can be very useful in those women with mild degrees of prolapse and/or stress incontinence. Perseverance and professional help with these exercises is important.

In selected patients, particularly when older and not wishing to be sexually active, or who cannot have surgery because of heart disease or other medical problems, a vinyl ring pessary can be inserted onto the vagina which will hold the prolapse back. This has the disadvantage of making intercourse very difficult and at times causing ulceration to the vagina due to pressure from the ring on the vagina. However, it is an effective treatment for those groups described above and many patients will be satisfied with the help a ring pessary can give.

Surgery

If conservative measures fail to improve the situation, the options of surgery may be discussed with a gynaecologist. The following operations are available:

• An anterior colporrhaphy or repair - tightens up the front walls of the vagina.
• Prosterior repair or prosterior colporrhaphy - tightens up the back wall of the vagina.
• Hysterectomy (removal of the uterus) is usually performed through the vagina if significant uterine prolapse is present.
• If stress incontinence (leakage of urine with coughing or sneezing) is present, a laparoscopic incontinence procedure called a Laparoscopic Burch colposuspension is favoured.
• Increasingly, laparoscopic surgery is used to tighten up the back wall of the vagina, to repair hernias involving the top of the vagina (enteroceles), and to support the top of the vagina after a hysterectomy if it becomes weakened.

How long will I be in hospital for?

Usually two to four days depending on the type and extent of surgery involved. The only significant restriction postoperatively would be the need to avoid heavy lifting for approximately six weeks.

What are the long term results like?

Results following prolapse surgery are usually very good, whether performed through the vagina or with the aid of the laparoscope, with excellent patient satisfaction.

The tissues in the area that are being operated on are not as strong as they used to be, otherwise the prolapse would not have occurred, therefore there is still a slight risk of occurrence of the prolapse in the future. The risk of recurrence of the prolapse can be reduced by making sure that all pelvic floor defects are treated at the time of the initial surgery and that appropriate surgery is performed based on the clinical findings.

Seeking help

Many women delay seeking help for this condition due to embarrassment; this should not be the case as effective and sympathetic treatment should be available through you gynaecologist or family doctor.