About 15 years after I gave birth to my second and last child, I noticed something bulging down into my lower vagina. It turned out to be my uterus, which was clearly supposed to be sitting a lot higher in my pelvis. It was my first, painless symptom of pelvic organ prolapse. Over the next 15-odd years, the prolapse slowly got worse despite persistent pelvic floor muscle exercises.
Finally, I decided to do something about it. When I talked to a urogynecologist, who does hundreds of prolapse repairs a year, I mentioned that I didn’t know anyone else who’d had the surgery. “Yes, you do,” she said. “But people are embarrassed to talk about it.”
She was probably right. About 200,000 prolapse surgeries are performed each year in the United States—comparable to the number of heart bypass surgeries. I have come to think of prolapse as the most common female ailment no one has ever heard of. In spite of being a medical writer and editor, I certainly hadn’t before I developed it myself.
The lower female pelvis is less than 5 inches in diameter, and into this constricted space must fit the uterus and vagina, roughly in the middle; the bladder and urethra in front of the vagina; and the bowel and rectum behind it. These organs are separated and supported by a complex web of tissues, muscles, fascia, and ligaments. The whole assembly sits top of the relatively tough pelvic floor muscles.
Uterine prolapse, the kind I had, happens when the ligaments holding up the uterus stretch or break, allowing it to telescope down into the vagina. The vaginal walls can also weaken—possibly after the extreme stretching they endure during childbirth—and allow the bladder to herniate into the vagina from the front (cystocele) and/or the rectum from the back (rectocele). And if the prolapse gets bad enough, one or more of those organs can actually protrude beyond the vaginal opening.
Cause and symptoms
The biggest risk factor for pelvic organ prolapse by far is vaginal childbirth, and it gets worse with each delivery. Repeated heavy lifting or chronic constipation, both of which increase intra-abdominal pressure, may also contribute. White and Hispanic women seem to be at greater risk than African-American women.
“Most women who do develop prolapse notice symptoms 15 to 20 years after having a baby,” says Rebecca G. Rogers, M.D., a urogynecologic surgeon and professor of obstetrics and gynecology at the University of New Mexico. “It’s happening slowly but you usually don’t notice it until the prolapse reaches the hymen.”
Nearly half of all women ages 50 to 79 have pelvic organ prolapse to some mild degree, according to estimates from the American Urogynecologic Society. Most probably have no idea it’s there. But a minority of women have symptomatic uterine prolapse. The bulge, though unnerving (as I can attest), isn’t usually painful or even harmful unless the cervix protrudes so far that it rubs against clothing and becomes irritated or even ulcerated.
More troublesome symptoms have to do with the bladder or bowel. Women with prolapse may have an increased risk of urge incontinence (inability to hold urine when the bladder is full) or [stress incontinence (leakage of urine when a person coughs or sneezes).]
Advanced uterine prolapse can also kink or compress the bladder so women suffer the opposite problem: they can’t get a good stream of urine flowing or completely empty their bladder. That’s what happened to me, and it was a major reason I opted for surgery. Prolapse of the rectum can cause either constipation or fecal incontinence. But I had a rectocele and experienced neither of those symptoms.
Surprisingly, unless prolapse is severe it doesn't usually affect sexual function. And even if it does, "regardless of the degree of prolapse, sexual activity is safe for women," Rogers says.
Treatments for pelvic organ prolapse
For women who aren’t having any symptoms or discomfort, the best treatment is none at all.
For symptomatic prolapse, non-surgical fixes come first. Pelvic floor muscle exercises—[the Kegel exercises] familiar to anyone who has ever been pregnant—may halt or slow the progression of prolapse and improve bladder symptoms.
Another option is a pessary, a stout silicone disc or ring that sits in the vagina and mechanically supports the uterus.
In my case, though, neither of those interventions worked. I Kegeled my pelvic floor muscles into excellent shape, but the uterine prolapse kept worsening anyway. And although my ob-gyn fitted a pessary that was comfortable and lifted my sagging uterus, every time I wore it for more than a week or so I developed a [urinary tract infection]. So, on to surgery.
Pelvic organ prolapse surgery
There is no such thing as “standard” pelvic organ prolapse surgery. “There are a number of ways of correcting it, depending on the degree of prolapse, whether it’s in the bladder, uterus, or rectal wall,” says Edward Wallach, M.D., emeritus professor and former chair of the department of gynecology and obstetrics at Johns Hopkins University. “The good surgeon will understand which are the weak spots in the whole complex that keep the structures intact.”
Unfortunately, prolapse surgery is not always successful. Up to 30 percent of operations may fail, either because the prolapse recurs or because new symptoms show up after the surgery—typically, urinary problems are unmasked when the bladder is decompressed.
So it’s critical to select an experienced person to perform the operation, ideally a credentialed female pelvic medicine and reconstructive surgeon or other specialist who does this type of work on a near-daily basis (not your regular ob-gyn).
The surgeon is likely to do a hysterectomy (though prolapse can be corrected without hysterectomy if the patient desires), followed by an exacting and critical procedure to hitch the top of the vagina, called the vaginal vault, to internal structures high in the pelvis. “The top part of the vagina is the key to successful repair,” Rogers says. If the vault descends, the whole repair will fail.
Surgeons may also need to reinforce the back wall of the vagina to fix a rectocele, or the front wall for a cystocele. They may need to raise the bladder back up to its proper position.
Surgeons can do all of this transvaginally (incisions made entirely through the vagina), through the abdomen (using laparoscopes or a surgical robot), or can perform open surgery.
Regardless of the technique used, “this is major surgery,” Rogers warns. I was under the knife for three hours for my transvaginal hysterectomy, vault suspension, and rectocele repair, and it took about three months to make a full recovery—about par for the course.
Mesh or no mesh?
You may have seen TV or online ads from law firms soliciting clients injured by transvaginal mesh. Here is the back story.
Starting in the early 2000s, device manufacturers started repurposing surgical mesh—used for years in hernia repairs—for prolapse surgery. Most of the mesh was made of woven polypropylene plastic filaments, and it came in “kits” designed to be inserted transvaginally—and positioned behind and around the vaginal wall to bolster weak spots or hold up the bladder or vaginal vault. By 2009 about 40 percent of prolapse surgeries used mesh.
It worked, to the extent that the repairs held. But at a terrible cost: a significant minority of women who received transvaginal mesh ended up with painful complications, such as the mesh slicing through vaginal walls, shrinking and folding as scar tissue developed around it, or becoming infected. Sexually active patients reported that intercourse had become painful.
As the popularity of the kits grew, mesh complications reported to the Food and Drug Administration from 2008 to 2010 quintupled compared with reports made during the previous three years. In 2011 [the FDA sent out an alert about these problems,] and in January 2016 announced that manufacturers could no longer sell transvaginal mesh kits without conducting studies proving they’re safe and effective—in effect, taking them off the market.
But the FDA says it’s still OK to use transvaginal mesh “slings” to hitch up fallen bladders. Also still allowed: Using mesh to attach the vaginal vault to the upper pelvis, so long as this mesh is inserted through the abdomen.
Prolapse surgeons’ specialty societies continue to strongly endorse the use of mesh for these two purposes, pointing to the FDA’s stamp of approval and other studies establishing safety.
But some surgeons dissent from this position. Shlomo Raz, M.D., chief of the division of pelvic medicine and reconstructive surgery at UCLA Medical Center, says that he no longer uses mesh for any purpose after doing more than 1,500 surgeries to remove mesh for complications.
He points out that more than three-quarters of the patients his center has treated for mesh complications had bladder slings. Instead, he creates “native tissue” bladder sling lifts using a piece of tendon harvested from the patient’s leg.
Thankfully, my doctor did not use a mesh sling, and I had no complications. Now, months later, I’m happy with the results—especially being able to empty my bladder.