When part of the vagina or the uterus is felt at or near the vaginal opening, it is referred to as a prolapse. Some women say it feels like ‘something coming down’ or ‘sitting on a lump’. The awareness of a lump can be quite alarming, but prolapse is not generally a dangerous condition, although can be very uncomfortable.
Prolapse is very uncommon in women who have not had children, but can occur when there is an inherited weakness of the vaginal supports (weak collagen). Obesity, heavy straining and previous pelvic surgery can all make prolapse more likely. It was thought that prolapse could be the cause of backache or painful intercourse, but this is now not considered to be the case. Vaginal dryness found in the menopausal years is a more common cause of discomfort with intercourse. It can be easily treated with the use of vaginal oestrogen cream or tablets. These are not ‘HRT’ and are very safe. Backache is usually due to problems with the bones, nerves and muscles of the lower back.
When a prolapse is diagnosed, it can be managed by ‘reassurance, rings or repair’. No treatment is required if the symptoms do not interfere with daily life, and do not prevent participation in the woman‘s social or sporting activities. In the elderly, and also in those who have not necessarily completed their families, vaginal rings or pessaries can be very useful.
There is now a much better understanding of the normal support to the vagina and uterus, and this has led to more anatomical vaginal prolapse surgery, when thought to be the best option. Most procedures only require a few days in hospital, and recovery is much more rapid. Repairs were often too tight in the past, and could also lead to discomfort with intercourse. Nowadays maintenance of physiological function is the goal, whilst repairing the anatomical problems.
Generally the surgical repairs use just stitches, like a darn of weakened tissue. On occasions a patch of either pigskin or plastic mesh is thought sensible to prevent recurrence of the prolapse. The benefits and drawbacks of these new procedures are being evaluated now, and they are available in Bristol if thought appropriate. Sometimes abdominal or laparoscopic approaches are needed to repair prolapse if it involves the top of the vagina and uterus. The best surgical approach, however, needs to be tailor made for every patient, so the surgeon needs to be able to offer vaginal, abdominal and laparoscopic surgery where appropriate.
Mr. Phillip Smith is recognised as having a special interest in the management or prolapse, having trained in England and in the USA.