Q: I am a 68-year-old female who has suffered with prolapse for the past two years. My gynecologist says that I will probably soon want an operation that will lay me up for several months. I would very much like to avoid an operation but the prolapse is significantly affecting my activities because it bothers me every time I bend over. I have seen a physical therapist and do daily Kegel exercises and take Vagifem. Do you have any other suggestions?
A: Because you don’t mention the specific prolapse experienced, I will generalize. Pelvic organ prolapse accompanies a feeling of pressure or heaviness that commonly occurs with other pelvic floor disorders such as urinary or bowel incontinence and an overactive bladder. Prolapse can affect one or more organs of the pelvis. A weakness of the front of the vaginal wall near the bladder will result in a cystocele, otherwise known as a dropped bladder. A weakness of the vaginal ceiling results in uterine prolapse, otherwise known as an enterocele. A defect of the back vaginal wall near the rectum will result in a rectocele. If the prolapse is mild, it may not require any treatment at all and may even improve on its own with non-surgical options that include Kegels, also known as pelvic floor exercises. Kegels are a series of exercises designed to strengthen the muscles of the uterus, bladder and large intestine. While this column is devoted to pelvic organ prolapse in women, Kegels can assist men and women who have problems with bowel control and urinary leakage.
Another non-surgical option for women is a pessary used to support the pelvic organs. One that fits comfortably and treats symptoms adequately is considered ideal. On the downside, the device requires removal and cleaning on a regular basis. Many individuals may require local vaginal estrogen such as Vagifem in conjunction with the pessary for comfort to reduce the risk of irritation, and to lower the incidence of urinary tract infections. In fact, the medication Vagifem is an estrogen.
While options, these non-surgical approaches to management may have some limited effectiveness in addressing the symptoms of pelvic organ prolapse. Surgical repairs can be performed transvaginally, abdominally, laparoscopically and robotically, yet there is nearly a 30% recurrence rate. This has led pelvic surgeons to look for better methods to approach the problem. Many surgeons today are using vaginal grafts in an attempt to improve long-term success. However, there is limited research to prove these methods improve results without increasing complications. Permanent mesh may improve vaginal support, yet many women have better results with repairs that are performed using their own tissues instead of the synthetic materials offered. Because of better results, surgeons may prefer to use mesh for anterior repairs in the instance of a cystocele or in cases of prior prolapse.
The bottom line is that before reaching a decision and consenting to any surgical procedure, I urge you to speak with your gynecologist regarding all treatment options available, his or her experience with those repairs, and the ability to address every complication that may occur during the surgical procedure and after. If your quality of life is compromised now, you may choose to try a pessary for a period to determine if any success is achieved. If not, make an appointment for an in-depth discussion as to which procedure (if any) is right for you.
