Prolapse

What is Prolapse?

We human beings have a fundamental design problem. We were designed as 4 legged animals, but had the temerity to stand up on our hind legs. Consequently the abdominal wall which in a quadruped hangs loosely below a horizontal spine, now becomes a vertical wall on the front of an erect human. Much of our ability to stand upright is due to big muscles running up and down the front and back of the spinal column. However, although it doesn't look like it in many of us, the abdominal wall muscles (tummy muscles) are also important. When the abdominal wall is tensed it increases the pressure within the abdomen and this has the effect of trying to push the contents of the abdomen out of any weak point. Men tend to suffer a hernia or "rupture" in the groin, because the testicle passes down a tube called the inguinal canal in the groin as a youngster. This canal is slightly bigger in the male than in the female. Women however don't bother with little tiny testicles; they have a birth canal through which they pass babies, which are immensely bigger than that. Consequently the commonest kind of hernia in a woman is in the birth canal and these we term as prolapse. 
Another form of hernia is the hiatus hernia, being a weakness where the oesophagus (gullet) enters the abdomen from the chest, allowing acid regurgitation and heart burn.


What leads to hernias?

Anything that increases our intra-abdominal pressure (pressure within the belly) will increase the chance of pushing something out of its normal position. So a lot of lifting or other physical heavy activity and being overweight are the commonest.


Is prolapse different?

Fundamentally prolapse is just a hernia like those mentioned above, however because the birth canal is designed to be open and because it is related to childbirth there are significant differences.


Why does prolapse occur?
  1. "Poor collagen"    It depends upon the tissues which one inherits from one's parents. Some people are described as "double jointed" and they have a particularly stretchy form of collagen, which is present throughout the body.  They may get the pelvic structures stretching more easily than other people.

  2. Pressure in the abdomen    The amount of heavy lifting during one's working lifetime has a bearing. Hopefully labour saving devices have reduced this, but one should have no illusions about how physically demanding it is to bring up a child. Also, a chronic cough or obesity will cause extra pressure on the pelvic floor

  3. Pregnancy      One of the hormones that rises a thousand fold in pregnancy is progesterone and one of its functions is to soften collagen and allow a little movement in the sacro-iliac joints and symphysis pubis, so that the birth canal can be a tiny bit wider at delivery. Some women notice these joints to be too mobile giving low back pain or even instability when walking during their pregnancies. Progesterone will also potentially soften the ligaments that support the womb and these will also be stretched as the womb grows. It has been thought that a caesarean section would protect a women from prolapse in later life, but it seems that this is not entirely so.

  4. The actual birth        Sometimes a quick and easy labour and rapid birth will suggest that the woman's tissues are very easily stretched, alternatively a long and difficult time might suggest that the tissues of the birth canal could be stretched beyond their natural resilience or even tears within could be caused leading to weakness, which shows up as prolapse later. It seems likely that tears of the vesico-vaginal fascia (layer between the bladder and vagina) or recto-vaginal fascia (layer between the rectum or back passage and the vagina) caused by the baby's head are the greatest cause of cystocele and rectocele.

  5. Hormone Depletion        The commonest times for prolapse to be noticed are after childbirth and after the menopause. After childbirth the oestrogen and progesterone hormones of pregnancy plummet back down to normal once the factory of the placenta has been removed from the womb and although at the menopause there is, perhaps, a more gradual reduction it is more profound. Those very feminine tissues of the pelvis need the feminine hormones in order to function properly and consequently a woman is subject to some or all of the factors above may find that the last straw is the loss of her oestrogen.

What are the symptoms of Prolapse?

Prolapse is not a dangerous or life threatening condition, however it can be uncomfortable and very worrying. The commonest description that I hear in the clinic is, "something coming down". Women will talk about feeling a lump or sitting upon an egg. These symptoms generally get worse as the day wears on, a night in bed resolves the problem, allowing the prolapse up into the pelvis and then the next day the symptoms gradually return. Of course in the early stages it might only be noticeable after heavy physical activity and not appear at all on a more restful day.


Are there any related symptoms?

If there is prolapse of the anterior (front) vaginal wall, this may have bladder behind it which is termed a cystocele or it may have urethra behind it which is termed an urethrocele. If there is descent of the bladder neck (where the bladder joins the urethra), this may result in stress incontinence.( See urogynaecology). If there is a large cystocele or a prolapse of the posterior wall of the vagina with rectum (back passage) behind it, it may be that emptying either the bladder or the rectum requires the bulge to be pressed back into place and straining with the abdomen just makes matters worse


What can I do about the prolapse myself?

One can consider the prolapses in two groups.

  1. Prolapse of the vaginal walls, (cystocele, urethrocele, rectocele) may be corrected by pelvic floor exercises, as the pelvic floor muscles are attached to the vagina and will hold it up.
  2. The womb however is supported by ligaments and if they have stretched or torn, no amount of effort and pelvic floor exercises will shorten or repair them

First Aid Measures

100 years ago when anaesthesia was in its infancy, gynaecologists were known for the multiplicity of designs of vaginal pessary that were used to support prolapse. In those days they were made of rubber and some of the chemicals in rubber were promoters of cancer of the vaginal skin. These rings have now been entirely abandoned and we use inert plastic rings. These can look quite intimidating and appear very stiff. They are indeed stiff at room temperature but soften at body temperature and should be unobtrusive in use. They can be very useful if a woman wishes to have further pregnancies or wishes to delay surgery for another reason or if she is too infirm to contemplate surgery at all. Their use requires an adequate perineal body (the tissue between the opening of front and back passage).

However nowadays the correct procedure to cure prolapse is surgical. Traditionally, for the last hundred years or so, Gynaecologists have followed the teaching of Howard Kelly, Professor at Johns Hopkins University in Boston by performing a "Kelly plication".  This, I believe, is not correct and I prefer to repair the actual tissue that has given way, at the site where it has torn. 

This is sometimes called a "Vaginal paravaginal repair".  Sometimes, the paravaginal tissue (fascia) is so weak that a patch is used.  These are made of open weave polypropylene or porcine small intestine. (The patch derived from porcine dermis has, I believe been superceded).  Such a patch is almost invariably used in repair of groin hernias. 


Operations for Vaginal Wall Prolapse
  1. Anterior Colporrhaphy or Anterior Vaginal Repair
  2. Posterior Colporrhaphy or Posterior Vaginal Repair
  3. Vaginal Hysterectomy

Operations for Vaginal Vault Prolapse
  1. Sacro-spinous fixation
  2. Infracoccygeal tension free vaginal tape (eg"Apogee") www.nice.org.uk/IPG125publicinfo
  3. An extension of this is the Gynecare Prolift system which incorporates a mesh to support the bladder in the front, a mesh to hold back the rectum and three tapes (on each side) as a single piece of mesh.
  4. Abdominal Sacro-colpopexy (or laparoscopic)

Links
http://bardmedical.com/PatientCondition.aspx?condition=4
http://bardmedical.com/Resources/Products/Documents/Brochures/Pelvic/Pel...
http://www.pelvichealthsolutions.com/pelvic-organ-prolapse

The Repair of Vaginal Wall Prolapse


Definition

Pelvic organ prolapse (POP) is a protrusion of one or more pelvic organs (bladder, rectum, uterus, vaginal vault, bowel) through vaginal fascia into the vagina and the downward displacement (‘prolapse’) of the associated vaginal wall from its normal location to or outside the vaginal opening.  POP affects a woman’s quality of life by its local physical effects (pressure, bulging, heaviness or discomfort) or its effect on urinary, bowel or sexual function.  POP can be classified according to the compartment affected as: anterior vaginal wall prolapse (urethrocele, cystocele); posterior vaginal wall prolapse (rectocele, enterocele); prolapse of the cervix or uterus; and prolapse of the vaginal vault (which can only occur after prior hysterectomy). A woman can present with prolapse of one or more of these sites.


Causation

In the majority of cases, the pelvic organ (or organs) is permitted to descend through the pelvic fascia because of tears in the fascia often caused by childbirth. In a small proportion, abnormal collagen may allow stretching (Ehlers-Danlos syndrome, Marfan’s syndrome).


Investigations

You might hear the terms “Baden-Walker” or “POP-Q”. These are systems for assessing and recording the severity or extent of your prolapse. Other investigations will be suggested by other symptoms such as urinary incontinence.


What if we do nothing?

Prolapse will generally get worse with time. This tends to be quicker if you are on your feet a lot or if you do a lot of lifting. It may be uncomfortable but is not a threat to life.


Non-Surgical Treatment

Pelvic Floor Exercises (PFE):     The Pelvic Floor muscles are attached to the vaginal wall and so strengthening these muscles with Pelvic Floor Exercises (PFE) can reduce the prolapse. This does not cure the underlying cause of the condition.
Pessaries:    There are many designs of vaginal pessary. In the UK we usually use a “Ring Pessary”. This is circular, made of inert plastic. Pessaries are a form of “first aid” and are used to reduce the discomfort whilst waiting for surgery or in those unfit for surgery. They may fall out. Prolonged use is associated with unpleasant discharge.


Surgical Treatment

Many different operations are employed to correct Prolapse.


For Cystocele and Rectocele

Anterior and/or Posterior Vaginal Repair, also known as Colporrhaphy. This operation is about 120 years old. The tissue between the bladder (anterior) or rectum (back passage) and the vagina is folded over or plicated. There is no attempt to identify or correct the underlying defect. This technique relies upon scar formation to hold the vagina up. So-called “Redundant skin” is trimmed thereby making the vagina tighter. Approximately 30 % of women will need another operation for recurrent prolapse.     (Nice Guidance June 2008, Scottish Intercollegiate Review Body for interventional Procedures (RBIP) October 2007)
Scarring and tightening leads to painful intercourse in a significant number but the true incidence is unknown.
Damage to the bladder occurs in up to 10% of cases but data are too few to give accurate predictions.
This poor success rate has led many Gynaecologists to attempt to improve the operation by searching for and repairing the tears that allow the prolapse to occur.


Site Specific Vaginal repair

In this operation, the pelvic floor fascia is stitched back into place correcting the actual damage suffered by that individual. There is no trimming and no tightening of the vagina.
The success of this is variously reported as 80 to 90% . i.e. 10 to 20 % need a further operation. Painful intercourse should be more rare (as the vagina is not unnecessarily tightened) but information is sparse.


The use of Mesh or Graft

Surgery can be augmented with implantation of mesh or graft materials, with the aim of reducing the risk of failure.
There are numerous types of mesh and graft materials available, which vary according to type of material, structure, and physical properties such as absorbability. There are no existing classification systems for mesh and grafts. We have used the term ‘mesh’ for synthetic material and ‘graft’ for biological material. For the purposes of this review we have defined four classes of mesh/graft: absorbable synthetic mesh; absorbable biological graft; combined absorbable/non-absorbable mesh/graft (termed ‘combined’ hereafter); and non-absorbable synthetic mesh.
Mesh or graft repair is theoretically suitable for any degree of symptomatic anterior and/or posterior vaginal wall prolapse. It was first introduced in response to the high failure rate in both primary and secondary procedures: about 30% of women need an operation for recurrent prolapse. In the UK, it has been most often used for women with recurrent prolapse or with congenital connective tissue disorders (such as Ehlers-Danlos or Marfan’s syndrome). (RBIP 2007)
The technique for implanting mesh or graft varies widely between gynaecologists. It can be positioned and sutured over the fascial defect as an ‘inlay’, or a proprietary “kit” may be used which includes special instruments for placing the mesh and specially shaped mesh with tapes to hold it in place.

Success / failure rates
It is difficult to combine data from studies with differing methodologies, however there is a trend in the crude objective failure rates with procedures not using mesh/graft having the highest failure rate (29%, 95% CI 25 to 32% [184/640]), followed by procedures with absorbable synthetic mesh (23%, 19 to 28% [63/273]), absorbable biological graft (18%, 16 to 20% [186/1041]), and non-absorbable synthetic mesh (9%, 7 to 11% [48/548]) (RBIP 2007)
Fourteen studies involving 1680 women looked at a mixture of anterior, posterior and anterior with posterior repairs, following progress for an average of 13 months. The studies showed that 25% of repairs without mesh failed and 6–8% of repairs with mesh failed. The women’s assessment showed that 41% of repairs without mesh failed compared with 44% for mesh, but in two studies looking at non-absorbable synthetic mesh, none failed. (NICE 2008)


Complications and risks

In five studies, damage to pelvic organs occurred in 6 out of 251 women who had non-absorbable synthetic mesh repair (2.4%). (NICE 2008)
Seven studies involving 1394 women looked at mesh erosion, where the mesh comes through the walls of the vagina or is exposed. The rates varied according to the type of mesh used and happened in 0.7% of procedures using absorbable synthetic mesh, 6% of procedures using absorbable biological mesh and 10% of procedures using non-absorbable synthetic mesh. Women who had non-absorbable synthetic mesh were more likely to need further surgery as a result of erosion. (NICE 2008)
For anterior repair, mesh/graft erosion increased from 0.7% using absorbable synthetic mesh to 6.0% using absorbable biological grafts and to 10.2% using non-absorbable synthetic mesh. The surgical removal rate due to erosion (complete or partial) was 2.9% for absorbable synthetic mesh, 2.6% for absorbable biological graft, and 6.6% for non-absorbable synthetic mesh. (RBIP 2007)
Four studies showed that the risk of developing new-onset urinary incontinence after the procedure ranged from 0–7% and one study using non-absorbable synthetic mesh showed that 4 out of 11 women developed new problems with sexual function after the procedure (NICE 2008)
Other serious complications happened in 1% of patients. One woman developed an abnormal passage between the rectum and vagina (recto-vaginal fistula). (NICE 2008)


Repair of enterocele

During childbirth, the pelvic fascia may become detached from the back of the cervix. This allows some small bowel to be pushed between the edge of the fascia and the cervix at the top of the vagina. This is called an enterocele. The traditional posterior vaginal repair does not correct this and a further technique such as “McCall culdoplasty is necessary. I will be corrected by a site specific posterior repair when the fascia is sewn back onto the cervix or by the use of mesh/graft similarly attached.


Repair of Vault Prolapse

During childbirth, the utero-sacral ligaments may be torn. These ligaments hold the womb (uterus) up in place when you stand up. If they are torn, the womb can descend in the vagina and even pass right out of the vagina. This has many names: utero-vaginal prolapse, uterine prolapse, procidentia (if fully out), It is usually treated by vaginal Hysterectomy coupled with appropriate vaginal repair. The top of the vagina is attached to the utero-sacral ligaments or one of the operations for vault prolapse is employed.
Sacrospinous fixation: The cervix and vaginal vault should be in the middle of the pelvis at the level of the ischial spines and the sacro-spinous ligament. This ligament can be reached vaginally and a non-absorbable stitch used to secure the top of the vagina. Occasionally, the stitch pulls free and further surgery is required. Data are too sparse to make accurate predictions of complications.
Tension free tape support: A polypropylene tape (like the tape used to stop urinary incontinence) can be inserted so that it is positioned horizontally running between the two ischial spines. This involves two tiny holes in the buttocks. The vaginal vault is then stitched to this support. This is a relatively new procedure and long term data are not available.
Mesh Kits: The Gynecare Prolift ® Mesh incorporates the above tape support into its “posterior” and “total” Prolift® designs. The kits from other manufacturers have similar arrangements


 An Anterior pelvic floor repair with Prolift®



Posterior Vaginal Wall Repair with Prolift®

The images have been provided courtesy of ETHICON WOMENS HEALTH & UROLOGY


Summary
  1. Pelvic Organ Prolapse is corrected by surgery. The exact operation is devised to correct the actual prolapse that is present.
  2. Traditional Repair and “Site specific” Repair involve stitches without the addition of extra support. Site specific repair has a much better rate of success (fewer re-operations needed).
  3. The use of vaginal synthetic Mesh or biological Graft may improve the success rate further but may be associated with a higher rate of complications.
  4. Complications associated with the use of Mesh or Graft include damage to other organs (2.4%), painful sexual intercourse (dyspareunia) and exposure of the Mesh leading to re-operation (up to 10%).
  5. The techniques of correction of pelvic organ prolapse with mesh or graft show promise but are, as yet, too new to have any reasonable long term data.
  6. In our unit we audit the use of meshes as recommended by NICE

Links
http://www.pelvichealthsolutions.com/gynecare-prolift

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