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Dr Christopher Hardwick, Consultant Gynaecologist, answers questions about prolapse

HeraldScotland:

What is a prolapse?

A prolapse is really a type of hernia. This is where an organ is pressing away from where it should be and a prolapse is a hernia into the vagina. The bladder, rectum (part of the bowel) or womb and cervix can prolapse into the vagina. This causes a bulge in the vaginal wall and can cause symptoms. Because these organs are supposed to be held in place by the muscles of the pelvic floor prolapses happen when the pelvic floor muscles are no longer supporting these organs as they should. The vaginal skin is stretchy and cannot support any organ on its own so it bulges downwards or outwards. Often this may be worse as the day goes on and be less of a problem at night or first thing in the morning.

Why does prolapse happen?

The womb, bladder and bowel are all supported by the muscles of the pelvic floor and this holds them in place when you are, for example,  walking round with these organs sat on the pelvic floor muscles. The usual starting point of a prolapse is injury to these muscles with childbirth where the muscles tear or ligaments that fix the muscles to bone become torn. This usually does not cause symptoms right away but over years the space between the pelvic floor muscles gets larger and a prolapse appears. This means that older women are more prone to prolapse. It is likely that a lack of oestrogen after the menopause can effect the quality of the pelvic floor muscles and make a prolapse more likely.

Other things that put pressure on the pelvic floor muscles can make prolapse more likely over time. These include being overweight, being constipated or having conditions such as fibroids. Anything that causes a cough like smoking or lung disease can make a prolapse more likely.

I had a prolapse diagnosed at a smear do i have to have treatment for it?

No, prolapses are very common. Up to 50% of women who have had a baby will have a prolapse when examined. Most of these are smaller prolapses that cause no symptoms and perhaps never will. We grade prolapses depending on how far any bulge of the bladder, bowel or womb comes down towards the entrance to the vagina. Grade 1 prolapses which are prolapses only within the vagina are very common, they will often resolve with no treatment and usually cause no symptoms. 

READ MORE: Smear tests and fibroids Q&A

What symptoms do a prolapsed cause?

Prolapses tend to cause symptoms when they become bulges near to, or beyond, the entrance to the vagina. It is likely that a prolapse will have been present for a long time and only when it has become more prominent then symptoms start. Typically a prolapse will cause a feeling of a bulge or pressure within the vagina. They may cause a feeling of incomplete bladder emptying if the bladder is prolapsing into the vagina. A bulge may interfere with intercourse or bowel function. More severe prolapse may lead to skin soreness.

Do I need treatment for my prolapse?

We only manage prolapses that are causing symptoms as the objective of any treatment is to help those symptoms. It is important to balance any effect that the prolapse is having on a woman’s quality of life against the risks and recovery of any treatment. It is important to realise that a prolapse will usually progress in time but this can be unpredictable.

Do I have to have surgery for a prolapse?

No, there are many treatments available that can manage the symptoms of prolapse successfully. If a prolapse has been made worse by weight gain or problems with constipation or a cough then managing these things can cure the symptoms with no need for any gynaecological treatment at all. Stopping smoking can reduce the symptoms of prolapse.

Pelvic floor exercises taught by a pelvic floor specialist physiotherapist have been proven to reduce the symptoms of prolapse. These involve being taught which muscles of the pelvic floor to strengthen and then making these muscles stronger with exercise or stimulation to support the prolapse. There are no risks to pelvic floor exercises and they can be repeated as often as needed if a prolapse recurs. There is however no evidence that self taught exercises can help prolapse.

Pessaries to help with the symptoms of prolapse are very popular and over 80% of women who start to use pessaries will continue with them. These are plastic rings that are placed in the vagina to hold the prolapse inside. They are left in place but need to be replaced regularly every 6 months or so. They can cause some discharge and sometimes bleeding from the vaginal skin but these risks are minimalised if they are changed regularly. Many other types of pessaries exist and cube pessaries are popular with women who want to be able to insert a pessary themselves only when they need it.

What operations can help with prolapses?

The type of operation that may help a prolapse depends on the type of prolapse and the extent of it also. For example the repair of a bladder prolapse (called a cystocoele) would be an anterior pelvic floor repair. So deciding what needs to be repaired depends on a discussion ands examination with your gynaecologist. If the womb and cervix are prolapsing significantly then a hysterectomy performed as part of the prolapse repair may be needed. Sometimes the vagina will need extra support with stitches called sacrospinous fixation stitches that can elevate the top of the vagina or the womb and cervix. It is frequently the case that the exact operation cannot be decided until an examination takes place at the start of the operation and depends on the experience of the gynaecologist. The recovery from this major surgery may be over six weeks. The chance of recurrence of prolapses is high even after operation and so the decision to go for surgery should not be taken lightly.

Will I be told I need a mesh repair for my prolapse?

No, no vaginal mesh repairs are currently being performed in Scotland.

I have had surgery for a prolapse before and it has returned can I have further treatment?

Some women have prolapses that require specialist treatment and this includes women who have an operation to treat prolapse in the past. Women who have had a hysterectomy before also require careful assessment to decide what surgery, if any, would be most likely to be of benefit. Frequently this would mean discussion with specialist colleagues and a joint decision regarding what may be the best options to offer. Operations for these problems may require  abdominal or keyhole operations for prolapse repair.

Cost

There’s nothing worse than unexpected charges that you don’t find out about until after the event, and that’s why we make sure you know the full cost of your surgery before you make the decision to proceed. Our inclusive packages cover all the hospital charges for your stay, your consultant’s fees for the operation and one-follow-up consultation.

BMI Ross Hall Hospital also offers Flexible Finance. The BMI card allows you to spread the cost of treatment interest free (0% APR Representative).

How can I find out more?

Email enquiries.rosshall@bmihealthcare.co.uk or call 0141 303 1405.