What Types of Prolapse Surgeries Are There?

A prolapse means “falling down”.

There are four types of prolapses we will discuss here:

• Bladder Prolapse (cystocele) – most common
• Uterine Prolapse
• Rectal Prolapse (rectocele)
• Vaginal Vault Prolapse (falling down of the upper part of the vagina most commonly after a hysterectomy)

What is Bladder Prolapse (Cystocele) Surgery?

Bladder prolapse (cystocele) surgery is for people who have severe prolapse (stage III – bladder protruding out of the vagina or IV – all the pelvic organs protruding out of the vagina) or bothersome symptoms with moderate prolapse (stage II – bladder slides down to the entrance of the vagina) that have not responded to kegels, pessary, and pelvic floor therapy.

In general, after bladder prolapse (AKA anterior wall) surgery 38% of women will have their bladder fall down again within three years.

There are two categories of bladder prolapse (cystocele) surgery

• Obliterative Surgery
  • Obliterative Surgery involves closing the vagina enough to hold in the pelvic organs.
    • After this surgery you will not be able to have vaginal sex
• Reconstructive Surgery
  • Anterior Colporrhaphy (Anterior Wall Repair) is the most common surgery for bladder prolapse
    • General anaesthesia or spinal block is used for this surgery
    • The surgeon will cut a line in the front wall of the vagina
    • The bladder will be lifted up out of the vagina and the urethra also will be lifted out of the vagina
    • Stitches will be put in the tissue between your vagina and bladder to strengthen the anterior wall and hold up the bladder
    • Sometimes a patch will be positioned between your bladder and vagina to give more support. The patch is made out of a cadaver.
    • The sides of the vagina will be sewn to the walls of the pelvis
    • It is difficult to determine the long term success of this procedure since many of the studies are comparing variants of this study, including different stages of prolapse, including surgeries for multiple types of prolapse. Many studies only report subjective improvement several months out rather than long term.
    • In a meta-analysis, the quality of these studies was determined to be low to moderate, so it is difficult to draw solid conclusions about long term effectiveness.
  • Colposuspension
    • Colposuspension can be done in addition to anterior colporrhapy, or instead of colporrhapy
    • A cut is made in the lower tummy and the neck of the bladder is lifted and the vagina is also lifted up and sewn around the pubic bone to stabilize the bladder
    • This surgery can be open or laproscopic. Both require general anaesthesia
    • The surgery has about 50-70% success
    • The downside is women may have difficulty emptying the bladder, be more prone to infection, and experience discomfort with sex

What is Uterus Prolapse Surgery?

For women who do not want a hysterectomy, there are several surgical options for uterine prolapse.

However, in general after uterine prolapse surgery 23% of women will have their uterus fall down again within two years.

• Sacrohysteropexy is the most common surgery for uterine prolapse
• This laproscopic surgery is done under general anaesthesia.
• Small incisions are cut in your abdomen and air is blown into the abdomen (as with all laproscopic surgeries) so organs and tissues can be visualized with a small camera and surgical instruments are inserted inside you
• Surgical mesh is sewn into the front and back of the cervix and the uterus is lifted up out of the vagina.
• The mesh is sutured into a ligament on the sacrum
• Fibers from the ligament will grow into the mesh and continue to support the uterus
• This surgery can also be used if you had a hysterectomy and the cervix is left and begins to drop down into the vagina

What is Rectal Prolapse (Rectocele) Surgery?

There are two types of rectal prolapse (rectocele) surgery.

In general, 38% of women will have their rectum fall down again within three years of having posterior wall surgery.

• Obliterative Surgery
  • Obliterative Surgery involves closing the vagina enough to hold in the pelvic organs.
    • After this surgery you will not be able to have vaginal sex
• Reconstructive Surgery
  • Posterior colporrhapy is the most common reconstructive surgery for the rectocele (rectal prolapse).
  • An incision is made in the posterior wall of the vagina and weak muscle fibers are identified that are responsible for allowing the rectum to move forward into the vagina.
  • Stitches are placed to support those weak muscles
  • Usually a surgery is done on the perineal body (between the vagina and the anus) at the same time to offer more support to the posterior vaginal wall. This surgery is called perineorrhaphy.
  • A meta-analysis of the  posterior colporrhaphy is reported published studies are of low to moderate quality and difficult to draw conclusions from.

What is Vaginal Vault Prolapse Surgery?

Sacrocolpopexy is the name of the prolapse surgery for vaginal vault prolapse.

If the upper part of the vagina falls into the vagina and the vagina begins turning inside out, you are experiencing vaginal vault prolapse.

Commonly this starts with the removal of the uterus, then the vagina and the other pelvic organs will destabilize and prolapse. These organs depend on each other for proper relationship.

Most sacrocolpopexy is done laproscopically under general anesthesia as an outpatient surgery

• Four or five incisions will be cut in your abdomen through which the camera and instruments will be introduced
• Air will be blown into your abdomen to inflate it
• Surgical mesh will be attached to the top and bottom of the vagina and then fixed to the sacrum on the back wall of the pelvis
• This will suspend your vagina back into place
• If you have any organ that has prolapsed, your surgeon will place support for them also
• If you have incontinence, the surgeon will place mesh under the urethra
• Your surgeon will check to be sure no holes were accidentally made in the organs, then take out the instruments and close your incisions.

You will need about eight weeks to heal from this surgery

Who is a Good Candidate for Natural Medicine, Manual Hands-On Therapy, and Exercise Instead of Prolapse Surgery?

Non-Surgical management of prolapse requires a lot of involvement and determination from the patient.

You will need approximately 20 hours of manual hands-on therapy to attempt to normalize the relationship between your pelvic organs and the support structures of your body. This will include pelvic floor therapy, visceral & vascular manipulation, lymph drainage, and chiropractic.

You will also need to devote approximately 90 minutes to daily exercise for the rest of your life.

We will spend approximately 2-3 hours teaching and practicing exercises, then you will need to practice them at home for about 20-30 minutes daily

You will need to walk 1-2 hours daily to strengthen the muscles of the core and pelvic girdle.

We will spend 1-2 hours discussing diet, ergonomic movement patterns, and other lifestyle components that contribute to strengthening a pelvic bowl.

If you are interested in investing in your body in this way, conservative management is a great to try before surgery.