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PROLAPSE

Genital prolapse, also known as pelvic organ prolapse (POP), is a major public health issue in western populations where as many as 38% to 76% of women consulting for routine gynaecological care suffer from the condition. The lifetime risk of these women undergoing genital prolapse surgery is estimated at 11.8%.

Patients referred for surgery frequently complain about bulging and associated urinary, bowel or sexual symptoms, which are responsible for a significant decrease in health-related quality of life.

The decision criteria for surgery are mainly based on anatomical abnormalities and how  anatomical abnormalities  impact on quality of life of patients with genital prolapse.

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A vaginal prolapse is a condition in which structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself may begin to prolapse, or fall out of their normal positions. Without medical treatment or surgery, these structures may eventually prolapse farther and farther into the vagina or even through the vaginal opening if their supports weaken enough

The following are types of vaginal prolapse:

  • Rectocele: This type of vaginal prolapse involves a prolapse of the back wall of the vagina. The rectal wall pushes against the vaginal wall, creating a bulge. This bulge may become especially noticeable during bowel movements.

  • Cystocele:  This can occur when the front wall of the vagina (pubocervical fascia) prolapses. As a result, the bladder may prolapse into the vagina. Urinary incontinence is a common symptom of this condition.

  • Enterocele: The weakening of the upper vaginal supports can cause this type of vaginal prolapse. This condition primarily occurs following a hysterectomy.

  • Uterus prolapse: This involves a weakening of a group of ligaments called the uterosacral ligaments at the top of the vagina. This causes the uterus to fall, which commonly causes both the front and back walls of the vagina to weaken as well.

  • Vaginal vault prolapse:  This condition is common after a hysterectomy, with upwards of 10% of women developing a vaginal vault prolapse after undergoing a hysterectomy.

Approximately 30%-40% of women develop some presentation of vaginal prolapse in their lifetime, usually following menopause, childbirth, or a hysterectomy. Most women who develop this condition are older than 40 years of age.

Causes and risk factors of a vaginal prolapse include the following:

  • Childbirth (especially multiple births)
  • Menopause Hysterectomy
  • Advance age
  • Obesity
  • Dysfunction of the nerves and tissues
  • Abnormalities of the connective tissue
  • Strenuous physical activity
  • Prior pelvic surgery

Vaginal Prolapse Diagnosis

Generally, the most reliable way that a doctor can make a definite diagnosis of any type of vaginal prolapse involves a medical history and physical examination of the woman. This involves the doctor examining each section of the vagina separately to determine the type and extent of the prolapse and what type of treatment is most appropriate.

Evaluation

  • Bladder function test is URODYNAMICS. This is important clinical investigation that may assist the surgeon in selecting the correct type of surgery. For further diagnostic purposes, if indicated: Ultrasound and Cystourethroscopy should be done.

Vaginal Prolapse Treatment

Most vaginal prolapses gradually worsen and can only be fully corrected with surgery. However, the type of treatment that is appropriate to treat a vaginal prolapse depends on factors such as the cause and severity of the prolapse, whether the woman is sexually active, and the woman’s treatment preference.

  • Nonsurgical options may be most appropriate for women who are not sexually active, cannot undergo surgery because of medical reasons, or experience few or no symptoms associated with the condition.
  • Surgrical repair is the treatment option that most sexually active women who develop a vaginal prolapse choose because the procedure is usually effective

Meshes: Many doctors now use mesh as a vaginal prolapse treatment. These mesh repairs may be as effective as traditional surgical procedures, while smaller incisions potentially minimize pain and recovery time.

What to expect during the procedure
Typically, these minimally invasive prolapse treatment procedures take place on an in-patient basis and are performed under anesthesia. Minimally invasive mesh repair procedures generally follow these steps:

  • A vaginal incision and a few small skin incisions are made. You may either have an incision at the crease where your upper thigh meets your buttocks or in the middle of your buttocks on both sides.
  • The mesh is inserted through an incision, placed in the body, secured with stitches, and the incisions are closed.

The use of mesh in surgical procedures is not new, and is commonly used. Mesh used for vaginal prolapse surgery is light, soft, porous, and pliable, allowing your own body’s tissues to grow in and around it. Once placed, you should not feel the mesh inside you.

RECOMMENDATIONS FOR PATIENTS 

The FDA recommends that women considering surgery for pelvic organ prolapse: 

Before surgery: 

                        Be aware of the risks associated with transvaginal POP repair.

                        Know that having a mesh surgery may increase the risk for needing additional surgery due to mesh-related complications. In a small number of patients, repeat surgery may not resolve complications.

                        Ask their surgeons about all POP treatment options, including surgical repair with or without mesh and non-surgical options, and understand why their surgeons may be recommending treatment of POP with mesh.

After surgery: 

                        Continue with annual and other routine check-ups and follow-up care. Patients do not need to take action if they are satisfied with their surgery and are not having complications or symptoms.

                        Notify their health care providers if they develop complications or symptoms, including persistent vaginal bleeding or discharge, pelvic or groin pain or pain with sex, that last after the last follow-up appointment.

                        Let their health care providers know if they have surgical mesh, especially if planning to have another related surgery or other medical procedures.

                        Talk to their health care providers about any questions or concerns.

                        Ask their surgeons at their next routine check-up if they received mesh for their POP surgery if they do not know if mesh was used.

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