Pelvic prolapse or pelvic relaxation is very common in women over the age of 50 but is sometimes seen at an earlier age. It commonly results in a so-called "dropped bladder." In addition to sagging of the bladder into the vagina (cystocele), pelvic prolapse can result in bulging of the rectum into the vagina (rectocele), collapse of the sides of the vaginal walls (paravaginal defect), and/or bulging of the intestine into the top of the vagina (enterocele). A urethrocele or decreased support of the tube leading out of the bladder is commonly seen with a cystocele. If you have not had a hysterectomy, the uterus (womb) may drop to varying degrees (uterine prolapse). Mild pelvic prolapse requires no treatment. If treatment is necessary, it is best to treat all of the support problems simultaneously to get the best long-term results. Pelvic prolapse is caused by tears in a tissue called fascia. Fascia is a strong canvas-like tissue that supports the bladder, vagina, and rectum. It is also found in many other areas of the body.

The following drawing illustrates normal female anatomy as viewed from the side with no prolapse:

The following drawings demonstrate the main types of pelvic prolapse:

     
Factors that increase the likelihood of pelvic prolapse include:

• pregnancy with vaginal delivery
• obesity
• chronic coughing (such as with smoking or chronic bronchitis)
• heavy lifting
• frequent straining
• estrogen deficiency - recent data show this may not be a factor as previously thought

"Just a note to say thank you for your patience, reassurance, and confidence which you gave me before and since my recent surgery. I had suffered many years with a dropped bladder before I found you. Your taking the time to provide detailed information of what to expect relieved my anxieties. I thank God for providing such a skilled and caring physician as you." B.B.

Lifestyle changes may reduce the risk of pelvic prolapse or decrease the symptoms. Symptoms resulting from pelvic prolapse can include:

• pelvic pressure
• pelvic and low back pain
• pain with intercourse
• urinary incontinence or loss of urine when laughing, coughing, sneezing, lifting, etc.
• urinary retention and/or symptoms of recurrent bladder infection
• vaginal irritation
• difficulty having a bowel movement so you have to push on your bottom
• the feeling that something is coming out of the vagina

If the prolapse is not severe, some patients respond to medical or non-surgical treatment of pelvic prolapse. Alternatives to surgery can include:

• lifestyle modification such as quitting smoking, losing weight, and getting allergy treatments
• Kegel’s exercises which are regular contraction of the muscles that allow you to stop urine in mid-stream - this may reduce or eliminate incontinence
• pessary use which is usually a donut-shaped rubber or plastic device inserted into the vagina to provide support
• hormonal (estrogen) replacement therapy – this is controversial
• treatment with medication that helps certain types of incontinence.

If pelvic prolapse surgery is necessary, a number of different procedures may be performed. The choice of procedure(s) depends on the specific problem(s), any associated problems, and the preference and skill of your physician.

• hysterectomy is frequently performed if there is uterine prolapse and if the patient does not desire future fertility (does not want to have more children) – otherwise uterine suspension may be done to preserve the uterus
• vaginal repair of pelvic prolapse  
• paravaginal repair provides support for vaginal side walls  
• Burch procedure provides bladder support
• suburethral sling is used to treat urinary incontinence  
• enterocele repair
• sacral colpopexy

Pelvic prolapse can be severe and debilitating. Many advances have been made in recent years in the surgical treatment of pelvic prolapse. The surgeries are performed by an abdominal or vaginal approach or a combination of the two. Abdominal repair can be completed through a large incision (laparotomy) or laparoscopically through several small incisions. Depending on the particular type of prolapse, a vaginal approach may be used alone or in combination with an abdominal approach. To give the best chance for long-term success of the treatment, the physician should have the ability to perform a number of different repairs – and if the repairs need to be performed abdominally, it is preferable these be done laparoscopically to hasten recovery.

Several laparoscopic procedures for treatment of pelvic prolapse require special expertise to perform the procedures. These include the Burch procedure, paravaginal repair, and sacral colpopexy. With these procedures, the physician must have the ability to suture laparoscopically, which is quite different from suturing through a large incision. Dr. Biggerstaff is one of a limited number of physicians in the region currently performing all of these procedures.

Other advances in the surgical treatment of pelvic prolapse include the use of synthetic mesh and grafts. The use of these new materials and techniques is designed to give better long-term results.