Pelvic organ prolapse is one of those conditions that's quite common for older women, and yet many women don't know much about it.

So first: a quick definition. What exactly is pelvic organ prolapse?

When the tissues and muscles supporting the pelvic organs (the vagina, uterus, bladder, urethra, small intestine, and rectum,) weaken or loosen, these organs can descend or "prolapse." The prolapsed organ usually herniates into the vagina and sometimes pushes the vagina outward causing a visible bulge outside of a woman's body.

According to The American College of Obstetricians and Gynecologists (ACOG), pelvic organ prolapse "affects 1 in 4 women in their 40s and 1 in 3 in their 60s. By the time women reach their 80s, POP affects half of all women."

Childbirth and changes during pregnancy are often the main culprits. But women who've never had children can experience POP as well. Other causes include aging, changes in hormones due to menopause, obesity, chronic cough, chronic constipation, or injury to the pelvic floor.

Symptoms include the following:

• Voiding dysfunction
• Lower backache
• Feeling of pelvic or vulvar fullness
• Seeing or feeling a vaginal bulge
• Pelvic pressure that can get worse with standing or as the day goes on

We asked one of our urogynecologists, Dr. Dima Ezzedine, to discuss surgery for pelvic organ prolapse, including information on native tissue vs. mesh-augmented surgery.

As with all content on our blog, the information provided in this article is meant to be educational in nature, not medical advice. Always consult a physician regarding your specific health needs.

Is surgery always necessary for pelvic organ prolapse? If not, what are the non-surgical treatments for POP?

DR. EZZEDINE: Surgery is not always necessary for pelvic organ prolapse. In fact, many cases of pelvic organ prolapse do not require any medical intervention unless it has caused bothersome symptoms, like urinary, bowel, or sexual dysfunction.

Women affected by bothersome symptomatic POP have a variety of options, including non-surgical ones such as the use of a pessary (a vaginally inserted silicone device that supports the pelvic organs) or pelvic floor physical therapy, which is extremely beneficial for all women with pelvic floor disorders but is most useful for women with early stages POP.

Of note, all women with pelvic organ prolapse, whether symptomatic or not, would certainly benefit from behavioral and lifestyle modifications, such as weight loss, avoiding constipation, and avoiding heavy lifting.

At what point does surgery become necessary? Who is considered a good candidate for surgery?

DR. EZZEDINE: Surgery becomes necessary when a woman with symptomatic prolapse either cannot tolerate or does not respond sufficiently to non-surgical options—or if they desire to expeditiously correct a bothersome prolapse.

What are the different types of surgery for prolapse?

DR. EZZEDINE: There are two main types or concepts of prolapse surgery: reconstructive (or corrective) and obliterative (vaginal closure procedure). There is a fundamental difference between those 2 types:

• Reconstructive surgeries aim at restoring anatomy and maintaining function of all pelvic organs including the vagina.
• Obliterative surgeries aim at reducing the prolapse by closing the vaginal canal, thus making prolapse recurrence much more difficult to occur at the expense of the inability to achieve penetrable sexual intercourse.

What are the different types of reconstructive surgery—and the pros and cons of each?

DR. EZZEDINE:  Below is an overview. 

Native-tissue repairs:

Anterior and Posterior Colporrhaphy are prolapse repair procedures performed through the vagina (no abdominal scars). The woman's own connective tissues are used to recreate the support necessary to reduce the vaginal bulge and replace the bladder or the rectum into their normal anatomic positions.

Sacrospinous ligament fixation is performed when the top of the vagina is descending (apical prolapse) with or without the need to perform a hysterectomy. Many times, it is done in combination with anterior and/or posterior colporrhaphy as it is common to have a prolapse of more than one part of the vagina. This procedure is performed also through the vagina, and it entails suture-anchoring the top of the vagina (or cervix) to a strong ligament in a woman's body called "the sacrospinous ligament."

Uterosacral ligament suspension is another form of apical prolapse surgery that aims at suspending the top of the vagina, using sutures, to a woman's own suspensory ligaments (the uterosacral ligaments), thus restoring normal anatomic position of the vagina. This can be performed either vaginally (at the time of a vaginal hysterectomy) or abdominally via laparoscopy or robotic surgery.

Mesh-Augmented repairs:

Sacrocolpopexy is currently the only mesh-augmented prolapse procedure in urogynecology. It addresses apical prolapse and it has the highest reported success rate of up to 90% among all reconstructive prolapse surgeries. It is performed through the abdomen either using laparoscopy or robotic surgery.

A woman may be offered one or a combination of these procedures depending on the nature of her prolapse. The risks of these surgeries also vary based on a woman's previous medical and surgical history. 

When it comes to native tissue vs. mesh-augmented surgery, what should patients keep in mind?

DR. EZZEDINE: When it comes to deciding which type of surgery to go for, it is important for patients to balance a given procedure's benefits against its risks.

For example, the main reason to opt for the one currently available mesh-augmented surgery is its high success rate and longevity. However, this should be certainly balanced against the increased risk of injury to internal organs in a patient with prior multiple abdominal surgeries (high risk of internal scar tissues) or the increased risk of mesh complications in a patient with current tobacco use or uncontrolled diabetes.

Mesh has come under greater scrutiny in recent years, especially within the media. And yet there's a big difference between mesh that's placed through the abdomen and mesh that's placed through the vagina. Can you elaborate on what women need to know—and questions they should ask their healthcare providers?

DR. EZZEDINE: In April of 2019, the FDA ordered a product withdrawal on all vaginal mesh kits (meshes used for prolapse surgery that are inserted through the vagina). The FDA has made that decision due to the high number of reported vaginal mesh complications with the vaginally inserted mesh for prolapse. This decision does NOT apply to abdominally inserted mesh prolapse surgeries, such as in sacrocolpopexy, which is known to have a low risk of mesh complications.

It is important to note here that women who already have a vaginally inserted mesh do not have to have it removed as the majority of them develop no side effects. However, I do recommend regular follow-up visits with a specialist for anyone with a previous history of mesh prolapse surgery.

What can patients expect after having reconstructive surgery for pelvic organ prolapse?

DR. EZZEDINE: After surgery, most patients should expect a same-day discharge home. They can eat their usual diet at home and stay active on their feet as much as they can tolerate. Walking around the house and climbing stairs are encouraged to lower their risk of blood clots. Avoiding constipation is also important after prolapse surgery.

Generally, core-body exercises, heavy lifting, and sexual intercourse should be postponed for about 6 weeks after surgery. Accordingly, the time needed to be off work will be determined on a case-by-case basis.

Is there anything else you want to make sure patients understand about surgery for pelvic organ prolapse—or about native tissue vs mesh-augmented surgery specifically?

DR. EZZEDINE: Surgery for POP is primarily an elective (non-urgent) surgery, and a woman has to be perfectly confident in her decision to proceed with it. I want to reassure my patients that once they are ready for a prolapse surgery, I will be available to help them make the best decision for them and to guide them through this process, and together, we will come up with a plan that best fits their individual needs, medical history, and treatment goals. 

Are you interested in making an appointment with Dr. Ezzedine?

Dr. Ezzedine is accepting new patients in our Plymouth Care Center. Click here to make an appointment with her.