Prolapse and Pelvic Relaxation

Frederick R. Jelovsek MD

Get the answers to your many questions about vaginal prolapse and pelvic relaxation.

Kegel exercises for prolapse -- are they useful?

Tissue falling out of the vagina

Can hysterectomy cause prolapsed vaginal walls?

What type of surgery for prolapse?

Redundant sigmoid colon after surgery

How long does a uterine suspension last?

Repair of prolapsed uterus and bladder without hysterectomy

Is hysterectomy necessary?

Factors affecting successful repair of prolapse

Effect of pessary on progression of prolapse

Surgical vs. nonsurgical repair of prolapse in elderly woman

Can you go through pregnancy with severe prolapse?

Abdominal vs vaginal prolapse surgery and future vaginal delivery

Cystocoele after delivery but want another pregnancy

Does postpartum prolapse improve over time?

8 Months postpartum, rectocoele and uterine prolapse

Differential Diagnosis of Vaginal Pelvic Relaxation

Patient Instructions

Kegel Exercises
Bladder Retraining

Kegel exercises for prolapse -- are they useful?

Have you found exercise of the pelvic floor muscle to be of any real value with uterine prolapse?

In general, no. But if a woman is very motivated, premenopausal and performs Kegel exercises for 6 months (it takes that long to show a difference), it can help quite a bit if the prolapse is not very severe. By "not severe", I mean if you put your index finger in the vagina and up to the knuckle joint (2nd crease on your finger) before you feel the cervix (feels like the end of your nose), then the grade of uterine prolapse is probably 2 or less the way doctors measure.

If you are post menopausal or the cervix comes almost down to the vaginal opening or more with straining, then in my experience it is unlikely that exercises will significantly improve the discomfort due to prolapse.

Tissue falling out of the vagina

My mom has some type of tissue falling out of her vagina. She thinks it is her bladder. Would this have anything to do with her not taking hormones all of these years? Her hysterectomy was at 45 years old and she also gave birth to 10 children.

It may be the bladder or the entire vagina. This is called vaginal vault prolapse. Ultimately, it will probably need to be surgically repaired. In the meantime a pessary can sometimes be successful in holding up the tissue most of the time so it doesn't get irritated by coming out of the vaginal introitus and rubbing on clothes.

She is the primary caretaker of my 40 year old sister dying of colon cancer and promised me she will take care of this when life is some what normal again. What do you think about this?

This is a common reason for putting off such surgery. Especially if she has to lift your sister, it's better to wait for the surgery. If women have to lift heavy objects, the surgery for this condition is often unsuccessful because the tissue used to repair this hernia may tear itself and the prolapse just returns. We restrict our patients from lifting over 10 pounds for at least 3 months after prolapse surgery and encourage them not to ever lift more than 20 lbs again.

My dad said he has seen tissue with blood. When I asked her, she said no. I'm afraid she wouldn't tell me for worry.

The vaginal skin lining can bleed due to irritation from being outside the body and rubbing on clothes. It can be treated by her doctor with estrogen cream which makes the vaginal skin tougher and more resistant to inflammation.

Can hysterectomy cause prolapsed vaginal walls?

I am a 51 year old woman who has had 2 pregnancies, delivered vaginally with no real complications. I did experience a couple of things in my pregnancies that I think contributed to my current uterine prolapse. I am one of ten kids, my mother has no problems. My oldest sister had a hysterectomy in her early 30's and now has some urinary incontinence which I believe is related to weakened vaginal walls. My youngest sister is 34 and has a seriously prolapsed uterus. We have both been told by our gyn's that hysterectomy to correct prolapse will lead, eventually, to a weakening of the ligature that suspends the bladder and further weakening of the pelvic floor muscles. This will undoubtedly lead to prolapsed vaginal walls. Pessary is not a viable option, it doesn't do the job. I am looking for any help and information I can get.

In one respect, your doctor is correct in that if only a hysterectomy is done without additional support of the end of the vagina and the paravaginal spaces, then you could be at risk for future vaginal prolapse and stress urinary incontinence.

On the other hand, those are standard, known problems that are easily corrected at the time of the hysterectomy. It takes a little longer surgically to take the extra steps to fix existing or prevent future prolapse or incontinence, but your recovery time is the same.

What type of surgery for prolapse?

I plan to have surgery soon to repair the prolapse I have had for 4 years. I have a specialist and go see him for the first time, next week. I am very anxious to know this answer. Thought you would be able to reply before I went so I would have some info. First what type of surgery will it be for a suspension -- the laparoscope, vaginally, or will he want to cut me open?

Usually either abdominal or vaginal. There are some laparoscopists doing suspensions but the best results still seem to be with the more major procedures. An exception would be with the uterus still in place and mild prolapse. Laparoscopy work well for that.

What is the most common procedure?

This depends on the degree of prolapse. Most severe prolapses are treated with abdominal procedures. Less severe with vaginal procedures but it also depends upon what other pelvic defects are present, e.g., cystocele, rectocele, paravaginal defect, urethrovesical neck descensus etc.

Also, I was referred to him by my OB/GYN of 12 years. I do trust him, yet I would like to know how to get more info on the specialist before I let him do my surgery. Any ideas?

The most common method is to ask other patients of even physicians that know him. The medical staff department of the hospital he works at can give you training and licensing information.

Redundant sigmoid colon after surgery

I would like to know if, after having a vaginal hysterectomy for a prolapsed uterus, you could get a redundant sigmoid colon. What is it?

No. A hysterectomy does not cause a redundant sigmoid colon. If you have one, many women do, it was there prior to the hysterectomy. Perhaps are you referring to a rectocele or enterocele or rectal prolapse? These are sometimes present in patients who have had a prolapsed uterus in the past. This condition is when the rectal wall toward the vaginal canal protrudes into the vagina. Defecation is often relieved by digital pressure to the posterior vaginal wall. Could this be what you mean by redundant sigmoid colon?

I have a rectocele but the redundant sigmoid colon was evident on the defecography and the doctor told me the only way to repair it is to do abdominal surgery because he would also need to remove part of the sigmoid colon during the surgery. I don't know if it is called an enterocele or not. I will have to ask him at my next visit. He told me to try Konsyl® every day and see how that works for me. I think that I had these defects in the pelvic floor when my hysterectomy was done but it was not detected. A very complex situation this prolapse thing is. Like my ob/gyn said if you don't fix all the defects the outcome will not be good. I think I am going to wait until I can't stand the discomfort before having anymore surgery because I am only 49 and am worried that the prolapse will happen again and I will need more rework.

A redundant sigmoid colon is like a knee-high sock in the space of an ankle-high sock. It has a lot of excess material. In the case of the sigmoid colon, this is not infrequent and is not a problem unless the rectum is turning inside out (rectal prolapse). Rectal prolapse is very infrequent. Ask your doctor if that is what is going on. If you don't have that, then the sigmoid colon does not need to be operated on. Colon resection will not help either rectocele or enterocele, only rectal prolapse.

How long does a uterine suspension last?

Just in general, without any specific details of the surgery, How long or how many years does a suspension of the uterus last? Or does the suspension last you for a life time? I had an incision in the abdomen above the pubic hair and mesh material was added to give the hold up strength. I just wondered what the average is that you see?

There's no scientific data that I know of for how long a suspension lasts. From urinary incontinence surgery results I would say that only a very few, e.g., 30-40% last a lifetime. At about 10 years, a 50% success rate is not uncommon for both prolapse and incontinence surgery. At the time of menopause, within about 1-5 years, more relaxation takes place and any natural ligaments helping the support tend to loosen at that time. I would expect surgery using mesh to last on the longer side of those numbers.

Repair of prolapsed uterus and bladder without hysterectomy

I'm 38 years old. I have been pregnant 8 times and have had 4 children and 4 miscarriages. I had a tubal ligation about 6 years ago. Now I can feel the uterus dropped into my vagina. My OB-GYN doctor told me that I have a prolapsed uterus and recommends that I have a vaginal hysterectomy. My main concern is the bladder. Will I have a prolapsed bladder in the future?

Prolapse of the bladder often accompanies uterine prolapse either at the same time or later. When a hysterectomy is done for prolapse, the bladder is usually supported at the same time to prevent future bladder prolapse. You should know be informed, however, that prolapse of the uterus and bladder can be treated surgically with suspension of the uterus and bladder without a hysterectomy.

I am pleasantly surprised that you would mention this, not many Doctors do! Do you have any additional information on the suspension surgery, particularly regarding statistics on the success rate and the best techniques?

There are several different surgical techniques to do a uterine suspension with prolapse but many of them depend upon what associated support defects, if any, accompany the uterine descensus. I've included some of the abstracts below.

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Preliminary experience in pelviscopic uterine suspension using Webster-Baldy and Franke's method.

Koh LW, Tang FC, Huang MH
Department of Obstetrics and Gynecology, Show Chwan Memorial Hospital, Changhua, Taiwan, R.O.C.

Acta Obstet Gynecol Scand 1996 Jul;75(6):575-8

OBJECTIVE. To find which method gives the best relief from dyspareunia and pelvic pain caused by a retroverted uterus using the two methods mentioned as compared to other methods reported in the medical literature. SUBJECTS. Twenty-five patients, with ages ranging from 25-55 years old, complaining of mild to severe pelvic pain and dyspareunia seeking treatment in our OPD were evaluated and treated in a span of 3 years' time. METHODS. Pelviscopic retrouterine ligament fixation using Webster-Baldy and Franke's method were done after each patient was evaluated as to the uterine position, degree of misalignment of the uterus and severity of adhesion. Pelvic pain and dyspareunia were reproduced by palpation of the retroverted uterus. Ultrasonographies were performed to confirm initial findings and to rule out any ovarian or uterine abnormalities. Orthopedic and psychological consultations were done to rule out any orthopedic disorders or non-organic causes of their problem. RESULTS. Of the twenty-five patients treated, 20 patients were treated using Webster-Baldy method and five patients were treated using Franke's method, all the patients (100%) experienced great improvement 6 weeks after the operation. After 6 months, 16 patients (80%) with the Webster-Baldy method and four patients (80%) with the Franke's method had complete relief from pelvic pain and dyspareunia. The remaining four patients (20%) with the former method and one patient (20%) with the latter method complained of mild abdominal discomfort. After 6 months to 2 years of follow-up, 17 patients with Webster-Baldy method and five patients with Franke's method (88%) had improved sexual life and the remaining three patients were lost to follow-up. CONCLUSION. When dyspareunia and pelvic pain are caused by a retroverted method, we believe uterine suspension using different procedures will certainly relieve this problem. We have presented and have chosen these two procedures mainly due to their simplicity and the almost nil possibility of bowel intussusception into the anterior cul-de-sac as compared to other methods.

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Surgical support and suspension of genital prolapse, including preservation of the uterus, using the Gore-Tex soft tissue patch (a preliminary report).

van Lindert AC, Groenendijk AG, Scholten PC, Heintz AP
Department of Gynecology, University Hospital Utrecht, The Netherlands.

Eur J Obstet Gynecol Reprod Biol 1993 Jul;50(2):133-9

Abdominal-retroperitoneal sacral genito-colpopexy using the expanded polytetrafluoroethylene (ePTFE) soft tissue patch has been found to be highly effective for repair of genito-vaginal prolapse. We treated 61 patients in this way, including patients who had failed multiple previous attempts at repair. At a mean of 32 months of follow-up, more than 95% of patients were still classified as successfully treated. To preserve the uterus in cases of complete genito-vaginal prolapse, we have developed a new surgical technique, which we describe in this paper.

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A new technique of uterine suspension to pectineal ligaments in the management of uterovaginal prolapse.

Joshi VM
Department of Obstetrics and Gynecology, K. E. M. Hospital, Rasta Peth, Pune, India.

Obstet Gynecol 1993 May;81(5 ( Pt 1)):790-3

The incidence of uterovaginal prolapse in young women is high in developing countries. Preservation of the uterus is of prime importance in the surgical management of these patients. A new technique of uterine suspension to the pectineal ligaments is presented as an alternative to traditional procedures. Through a Cherney incision, the uterus is suspended to the pectineal ligaments on both sides with mersilene tape. A simultaneous Burch colposuspension can be useful in selected cases. The operation has been done in 20 women, who averaged 27.5 years of age. There was no early or late morbidity during the follow-up period of 6-30 months. Of nine women desiring further childbearing, seven conceived within 6 months of surgery and thus far five have had an uneventful vaginal delivery at term; the other two have continuing normal gestations. There was no recurrence of prolapse at 6 weeks postpartum in any of the women.

*****

[Anterolateral hysteropexy via abdominal approach. Results and indications. Apropos of a series of 92 patients].
[Article in French]

Rimailho J, Talbot C, Bernard JD, Hoff J, Becue J
Service de Chirurgie Generale et Gynecologique, Hopital Rangueil, Toulouse.

Ann Chir 1993;47(3):244-9

Of the possible surgical techniques for the treatment of genito-urinary prolapses, abdominal suspension is reserved for young patients in whom retention of sexual function is desirable. Fixation to the sacral promontory is the reference method but has some contraindications. Anterolateral suspension of the uterine isthmus to the anterior superior iliac spines by a strip of non-absorbable mesh, as described by Kapandji, is then a good alternative. We report our results with this technique over an 8-year period in 92 patients. Mean follow-up was 5 years. There was no intraoperative mortality nor major complications. Anatomical results were satisfactory in 87% of cases at 5 years, with however 4 reoperations for total recurrent prolapse, of which one was posterior. Functional results showed two cases of deep dyspareunia and 12% post-operative stress urinary incontinence, of gradual onset. In conclusion, anterolateral hysteropexy associated with removal of the pouch of Douglas is a reliable procedure with no particular danger. It can be a good alternative to fixation to the sacrum promontory when the latter is contraindicated or dangerous.

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Uterine preservation in the surgical management of genuine stress urinary incontinence associated with uterovaginal prolapse.

Nesbitt RE Jr
Department of Obstetrics and Gynecology, State University of New York Health Science Center, Syracuse.

Surg Gynecol Obstet 1989 Feb;168(2):143-7

Retropubic ventral suspension of both the uterine isthmus and the vesical neck is presented as a new operative approach designed to correct uterovaginal prolapse as well as genuine stress urinary incontinence while preserving the uterus. This operation, which has been performed 16 times upon patients whose follow-up study has been five years or longer, is simple, conservative, anatomically sound, effective and safe. It represents a rational alternative in selected patients to the traditional procedure, which calls for vaginal hysterectomy together with an anterior and posterior colporraphy.

Is hysterectomy necessary?

I have a stage 4 cystocele. The surgeon I have consulted recommends paravaginal repair, a Burch procedure and hysterectomy. I am not going to have any more children, but I am concerned about having a hysterectomy. My uterus is in the right position but sags a bit when I push. Is the hysterectomy a necessary part of this repair?

Assuming you are not having other problems, especially bleeding, the hysterectomy is not needed to do the paravaginal repair and Burch retropubic urethropexy. Even though the uterus is not dropping down, it would be best to help suspend it, usually with a uterosacral culdoplasty if the uterus is not removed. Just let your doctor know you would rather not have the hysterectomy if it is not absolutely necessary for other reasons. Bladder repairs are not more or less successful whether or not the uterus is removed.

Factors affecting successful repair of prolapse

I am 35 and have the basic prolapse package of 'celes'. My first delivery was 40 hours, maternal fever of 102, 2 vacuum tries w/2 fundal method attempts (second attempt was successful) and a 4th degree episiotomy. The only problem I noticed then was diminished urine stream which made me take longer to urinate. The birth of my second child 6 months ago was an easy 12 hours, 5 pushes, and the baby was out. (Both deliveries were induced and both babies were over 9 lbs but neither one past due date). About 3 weeks after this delivery, I noticed the prolapse at the entrance of the introitus and perhaps a tad out at the end of the day. There is no history of prolapse in my family either pre or post menopausal. What I'd like to know is are there certain things that may indicate that the surgical repair may be more successful (long lasting) than if the prolapse were possibly inherited? I am contemplating re suspension surgery after my youngest is a bit more mobile and I don't have to lift as much. The surgical approach will be abdominal and I'm not sure if the mesh will be used. I read in one of the other posts (old) that the average lifespann of a surgical repair is roughly 5-10 years. But, it was also stated that an approximate 30-40% of the procedures lasted almost a life time - any idea of why that is and what makes each case different?

Without a family history of connective tissue problems and without diseases such as diabetes, the main determinants of success of surgical repair are:

1) giving it time to heal the first 3 months post surgical without any undue strain intraabdominal.

2) lack of a chronic cough from smoking or allergies.

3) being of normal weight.

4) having the surgery done before menopause (which you would probably do).

Another obvious factor to be mentioned in regards to success is to make sure you have a surgeon who is experienced is such surgery.

Why is it important to have the surgery premenopausal? Will it stand a better chance of withstanding menopause later on? I know that the estrogen/collagen levels in a woman have a lot to do with how the vagina heals etc.

The repair seems to heal stronger in women who have the repair before menopause. It may well have to do with how collagen heals because even though we give estrogens in the postmenopause, the tissues do not seem to heal as strong as they do when surgery is premenopause.

Have you yourself seen any successful re suspension cases that lasted for a long time? If so, what kind of surgery was it and how long have they lasted so far.

Yes definitely - I have seen successful resuspensions lasting 20 -30 years or more. Procedures are all different depending upon the different support defects present. The surgeries having abdominal approaches tend to have a higher long term success rate but vaginal repairs can last long also.

Effect of pessary on progression of prolapse

Does wearing a pessary slow down the progression of uterine prolapse until a woman can schedule surgery? If a woman can keep a pessary in does this suggest that surgery might also be more of a success? The pessary I wear resembles a diaphragm with holes in it. It doesn't stay in like one, but rather it's in a vertical position with the cervix kept up by the upper rim of the pessary (make sense?). At this time I don't have problems with incontinence, but I suspect that the urethra is kinked so it takes longer to empty the bladder.

Success with a pessary is not related at all to the surgical success. They are really two different things because the pessary is just providing bulk to hold up tissues and not relying on pelvic attachments. I think a pessary may slow prolapse progression somewhat if the pessary is a good fit. Mainly pessaries help the current symptoms (relieve pressure etc.).

Surgical vs. nonsurgical repair of prolapse in elderly woman

My grandmother has a prolapsed uterus and bladder and I am trying to help her decide on the best option for an 85 year old woman. She is in fairly good health but I'm concerned about the anesthesia at her age. Are there any non-invasive procedures? What are the benefits/risks to a stitch vs. removal of the uterus?

The only nonsurgical treatment would be a pessary. There is an art to fitting one so you will need to find someone who uses them frequently in treatment.

Surgically, the stitch of sewing the the vagina shut (colpocleisis) is about 85% successful and carries less risk of surgical complications than a hysterectomy. If either a vaginal hysterectomy or colpocleisis is done, it can be performed under spinal or epidural rather than general anesthesia. This is safer for the heart in an elderly woman.

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Prolapse and Pelvic Relaxation

Frederick R. Jelovsek MD

Differential Diagnosis of Vaginal Pelvic Relaxation

Related Educational Articles

Patient Instructions

Have you found exercise of the pelvic floor muscle to be of any real value with uterine prolapse?

My mom has some type of tissue falling out of her vagina. She thinks it is her bladder. Would this have anything to do with her not taking hormones all of these years? Her hysterectomy was at 45 years old and she also gave birth to 10 children.

She is the primary caretaker of my 40 year old sister dying of colon cancer and promised me she will take care of this when life is some what normal again. What do you think about this?

My dad said he has seen tissue with blood. When I asked her, she said no. I'm afraid she wouldn't tell me for worry.

What is the most common procedure?

Also, I was referred to him by my OB/GYN of 12 years. I do trust him, yet I would like to know how to get more info on the specialist before I let him do my surgery. Any ideas?

I would like to know if, after having a vaginal hysterectomy for a prolapsed uterus, you could get a redundant sigmoid colon. What is it?

I am pleasantly surprised that you would mention this, not many Doctors do! Do you have any additional information on the suspension surgery, particularly regarding statistics on the success rate and the best techniques?

Why is it important to have the surgery premenopausal? Will it stand a better chance of withstanding menopause later on? I know that the estrogen/collagen levels in a woman have a lot to do with how the vagina heals etc.

Have you yourself seen any successful re suspension cases that lasted for a long time? If so, what kind of surgery was it and how long have they lasted so far.

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