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A prolapse is a medical condition where an organ or tissue falls down or slips from its normal position. This occurs when the pelvic floor muscles and connective tissue that support the pelvic organs are weakened.
A pelvic organ prolapse is a condition that occurs when the structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself falls out from their normal position.

UTERO-VAGINAL PROLAPSE

Utero-vaginal prolapse is a downward movement of the uterus and vagina.

CAUSES OF VAGINAL PROLAPSE

The main cause of vaginal prolapse is the weak muscles, tissues, and ligaments that support the vagina, surrounding tissues and organs.
The factors that can cause vaginal prolapse include
• frequent lifting of heavy objects,
• chronic cough,
• severe constipation,
• menopause,
• childbirth,
• previous surgeries in the pelvic area,
• advanced age,
• hysterectomy and
• obesity.

SYMPTOMS OF UTERO-VAGINAL PROLAPSE

A woman with a mild prolapse may not experience any symptoms. However, women with more severe forms of prolapse may experience:
• Sensation of pulling or pressure in the lower abdomen or pelvis
• An uncomfortable feeling of fullness in the vagina
• Low back pain
• Urinary problems, such as urine leakage or urine retention
• Difficulty in urinating and emptying bowel
• Urinary tract infections
• Vaginal bleeding or discharge
• Discomfort during intercourse

DIAGNOSIS OF UTERO-VAGINAL PROLAPSE

Dr Farag will diagnose the condition by taking a detailed history and performing a physical examination. During the examination, you may be asked to cough or bear down.

COMPLICATIONS WITH UTERO-VAGINAL PROLAPSE

If left untreated, severe cases of utero-vaginal prolapse can cause ulceration and infection of the cervix and vaginal walls, urinary tract infections, lower tract bleeding, thickening of the skin of the cervix, urinary obstruction, and worsening of the prolapse.

PREVENTION OF UTERO-VAGINAL PROLAPSE

Although utero-vaginal prolapse is not always preventable, there are certain measures that can be taken to help reduce the risk of developing utero-vaginal prolapse or prevent it from getting worse. These include:
• Perform Kegel exercises to strengthen your pelvic floor muscles especially during pregnancy and after childbirth
• Avoid constipation and straining with bowel movements,
• Avoid heavy lifting, prolonged standing, and chronic cough

TYPES OF PELVIC PROLAPSE

There are different types of pelvic organ prolapse, such as
• Rectocele - rectum protrudes into vagina
• Cystocele - bladder protrudes into vagina
• Enterocele - small bowel protrudes into vagina
• Uterine prolapse - uterus and cervix protrude into vagina
• Vaginal Vault prolapse - vaginal apex herniates into vagina
Dr Farag will diagnose the condition by performing a physical examination, including pelvic examination, with reference to medical and family history, and may perform other tests such as cystoscopy, ultrasound scan.

TREATMENTS FOR PELVIC PROLAPSE

Treatment options include
• Pelvic floor exercises
• Lifestyle changes - to avoid heavy lifting, constipation
• Local oestrogen treatment
• Pessary, a removable device fitted in the vagina to reduce pain and pressure of pelvic organ prolapse.
If the non-surgical treatment does not reduce the symptoms of pelvic organ prolapse, then surgery is considered. There are several types of surgeries to correct different types of pelvic floor prolapse.
The surgery can be performed laparoscopically or through the vagina, depending on the nature of the prolapse.

SURGICAL TREATMENTS FOR PELVIC FLOOR DISORDERS

There are different types of procedures to address a specific prolapse. The aim of pelvic floor reconstruction is to restore normal anatomy and function of the pelvic organs. The most essential part of the surgery is to restore support to the vaginal apex.
Dr Farag will discuss with you the laparoscopic surgical options such as
• Laparoscopic Pelvic Repair and
• Vaginal Pelvic Floor Repair.
The most essential part of the surgery is to restore support to the vaginal apex.
The most common procedures to restore vaginal apex support are:

LAPAROSCOPIC SACRAL COLPOPEXY

This is a keyhole procedure. A mesh sling is attached to the top of the vagina and anchored to the sacral promontory (a bony landmark in the pelvis). This will elevate the vaginal vault.
This procedure is considered the gold standard in the treatment of pelvic prolapse. It is performed in women who have had a hysterectomy and have a prolapse of the vaginal vault. It takes about 60-90 minutes. You will be in hospital for two days. You will return to normal activities after about 2-3 weeks.

LAPAROSCOPIC SACRAL HYSTEROPEXY

This is a keyhole procedure. A mesh sling is attached to the posterior cervix and posterior vaginal wall to elevate the uterus. The mesh sling is anchored to the sacral promontory (bony landmark in the pelvis).
This procedure will allow the uterus to be conserved. It takes about 60 minutes to perform. You will be in hospital overnight. You will return to normal activities after about 2-3 weeks.

TOTAL LAPAROSCOPIC HYSTERECTOMY AND SACRAL COLPOPEXY

A Total Laparoscopic Hysterectomy is performed. Then the mesh sling is attached to the vaginal apex and anchored to the Sacral Promontory (bony landmark in the pelvis).
This is performed for women with a large uterine prolapse. You will be in hospital for two days. You will return to normal activities after about 2-3 weeks.

SUBTOTAL LAPAROSCOPIC HYSTERECTOMY AND SACRAL COLPOPEXY

A Subtotal Laparoscopic Hysterectomy is performed. The uterus is removed but the cervix is conserved. Then the mesh sling is attached to the cervix and anchored to the sacral promontory (bony landmark in pelvis)
Your will be in hospital for about two days

LAPAROSCOPIC UTERO-SACRAL LIGAMENT HYSTEROPEXY

This is a keyhole procedure. The uterus is elevated by re-attaching the posterior cervix to the utero-sacral ligaments. This is an ideal procedure for women with postpartum prolapse who are planning future pregnancies and for whom pessaries are ineffective.
The procedure avoids mesh. It is considered a temporary procedure- not a long term treatment option. It takes about 30 minutes to perform. You will be in hospital overnight. You will return to normal activities after about 2-3 weeks.

LAPAROSCOPIC PARAVAGINAL REPAIR

This is a keyhole procedure. The anterior wall of the vagina elevated using sutures on either side of the bladder neck. This procedure will treat anterior (bladder) prolapse. It can also address stress incontinence. It is done in conjunction with a Laparoscopic Mesh Sacral Colpopexy to elevate the vaginal apex. You will be in hospital for two days. You will return to normal activities after about 2-3 weeks.

ANTERIOR COLPORRHAPHY

This is a vaginal procedure to address a moderate degree of cystocele. The anterior vaginal wall is opened to reveal the bladder prolapse. The prolapse is reduced and held in place with a ladder of slowly absorbing sutures. The vaginal skin is closed with a rapidly absorbing suture. This procedure takes about 30 minutes to perform. You will be in hospital overnight. You will return to normal activities after about 2-3 weeks.

POSTERIOR COLPORRHAPHY

This is a vaginal procedure to address a moderate degree of rectocele. The posterior vaginal wall is opened to reveal the rectal prolapse. The prolapse is reduced and held in place with a ladder of slowly absorbing sutures. The vaginal skin is closed with a rapidly absorbing suture. This procedure takes about 30 minutes to perform. You will be in hospital overnight. You will return to normal activities after about 2-3 weeks

PERINEORRAPHY

This is a vaginal procedure performed to treat a gaping introitus. A small incision is made at the posterior introitus and minimal dissection performed at the perineum. Sutures are placed to build up the perineal body and treat the gaping introitus.
This procedure takes about 30 minutes to perform. You will be in hospital overnight. You will return to normal activities after about one week.

SACROSPINOUS COLPOPEXY

This is a vaginal procedure to elevate the vaginal apex to the sacrospinous ligaments. It is performed in conjunction with a posterior colporraphy. It is reserved for those women who are medically unfit for a laparoscopic procedure. It takes about 45 minutes to perform. You will be in hospital for two days. You will return to normal activities after about 2-3 weeks.
COMPLICATIONS OF VAGINAL PROLAPSE SURGERY
Every surgical procedure may be associated with certain risks and complications. The possible complications after the surgeries for vaginal prolapse include pain, infection, bleeding, recurrence of symptoms, injury to ureters, and perforation of rectum and bladder.
The complications are usually mild and can be treated accordingly.
The advantages of choosing minimally invasive surgery is that the defects can be clearly identified, incisions are small, postoperative pain and discomfort are reduced, shorter duration in hospital, and quicker recovery.
POST OPERATIVE EXPECTATIONS
Most women will require some form of oral analgesia for about one week. Constipation is very common after pelvic floor repair procedures.