Surgery for pelvic organ prolapse

All of the surgical approaches aim to lift the organs that have slipped down, as well as to restore support and hold them in place. The most common procedures are listed below:

• Anterior (front) vaginal wall repair: Also known as anterior colporrhaphy, this is a treatment option for women whose bladder has slipped down and is pushing against the front wall of the vagina (a cystocele). It involves strengthening and tightening the connective tissue between the bladder and vagina in order to lift and support the bladder.
• Posterior (back) vaginal wall repair: Also known as posterior colporrhaphy, this treatment is considered for women who have a rectocele. This is a prolapse that causes the lower part of the bowel (the rectum) to push against the back wall of the vagina. The surgery involves strengthening and tightening the connective tissue between the vagina and rectum in order to lift and support this part of the bowel.
• Sacrocolpopexy and sacrohysteropexy: These procedures aim to correct prolapse in the middle of the pelvic floor – for instance, if the uterus (womb) has dropped down. Sacrocolpopexy involves attaching the top of the vagina to the sacrum or coccyx (tailbone) using synthetic mesh. In sacrohysteropexy, the cervix is attached instead. The womb doesn’t have to be removed.
• Sacrospinous fixation: In order to lift the vagina back to a higher position, it is attached to ligaments in the pelvis. This procedure is an alternative to sacrocolpopexy and sacrohysteropexy for correcting prolapse in the middle of the pelvic floor.

Other types of prolapse surgery are available, but there is less research on them and they aren’t as common.

If the prolapse causes urine leakage (stress incontinence), the urethra (urine tube) can be stabilized using a synthetic sling. This can also be done during prolapse surgery.

The pelvic floor is usually stabilized using muscle and connective tissue in the woman’s own pelvic floor. But the various procedures can also be done using a synthetic mesh between the vagina and bladder – a bit like a taut hammock supporting the organs. Each of these approaches has its pros and cons.

The most suitable approach will mainly depend on which organs are affected. If several pelvic organs or areas have slipped down, various procedures are combined. The affected area can also be accessed in different ways: It is usually possible to do the surgery through small cuts in the abdominal wall (laparoscopy) or through the vagina. These approaches are less invasive than larger cuts across the abdominal wall – which are rarely needed. Factors that play a role when deciding whether to operate through the vagina or through the abdominal wall include age, weight and any other medical conditions.

Vaginal wall repair surgery (colporrhaphy) can stabilize the affected organs. This can reduce bladder and bowel problems, pain and feelings of pressure. After the procedure, about 80 to 90 out of 100 women no longer have problems such as urine leakage or pain during sex – at least for a while. There is a lack of research on how well this surgery works compared to pelvic floor exercises and pessaries.

The previously prolapsed organs may slip down again following initially successful vaginal wall repair surgery. Studies on anterior (front) vaginal wall repair have shown that this happens within three years in about 38 out of 100 women who have operations using their own tissue. Using a synthetic mesh reduces this risk.

In studies on posterior (back) vaginal wall repair, the pelvic organs slipped down again in about 10 to 40 out of 100 women. It is not clear whether using a synthetic mesh can lower this risk.

In less than 1 out of 100 women who have anterior (front) vaginal wall repair surgery, the bladder or bowel are injured. Wound infections are possible too. Like after all forms of abdominal surgery, scar tissue may form and cause different parts of abdominal tissue to stick to each other. Known as an adhesion, this can lead to pain or digestive problems. Using synthetic mesh carries certain risks (see below).

After sacrocolpopexy to correct uterine (womb) prolapse, about 90 out of 100 women no longer have problems such as urine leakage and pain during sex – at least for some time.

But there is a risk of the uterus dropping down again (a recurrence): In about 23 out of 100 women, it either drops down again or bulges out of the vagina within two years of the procedure.

Sacrocolpopexy and sacrohysteropexy surgery is performed through the abdominal wall, and a synthetic mesh is always used. Various other procedures are performed through the vagina – for instance, sacrospinous fixation. In these procedures it is probably possible to operate without using synthetic mesh because – compared to operations using the woman’s own tissue – the use of mesh isn’t more likely to prevent a prolapse recurrence. But recurrences are more likely after surgery that is performed through the vagina than after sacrocolpopexy and sacrohysteropexy.

Bladder or bowel injuries occur in about 2 out of 100 women who have sacrocolpopexy or sacrohysteropexy surgery. Like in all forms of abdominal surgery, scar tissue may lead to adhesions that cause pain or digestive problems. The risks of using a synthetic mesh also need to be considered here.

In some types of surgery, synthetic meshes can be sewn into the abdomen. These meshes are thought to stabilize the organs better than the woman's own tissue can. But they are associated with certain complications. For instance, they may become detached, making further surgery necessary. In the past, meshes also often led to bladder injuries and loss of bladder control. But there's no evidence that synthetic meshes are more likely to cause pain in the vagina and during sex. Some meshes were taken off the market because they caused problems so frequently.

There are now newer synthetic meshes that are said to cause fewer complications. But there hasn’t been much good research on them. Because of this, it's not yet possible to say which advantages and disadvantages they may have compared with using the woman’s own tissue in surgery. Medical societies currently recommend being cautious with synthetic meshes and only offering them to women who have a high risk of prolapse recurrence or who have already had a recurrence.

A lot of women would like to keep their womb, even if they don’t wish to have any (more) children. This is usually possible. There is no evidence that removing the womb has any advantages in the treatment of uterine prolapse. The risk of one or more organs slipping down again remains the same – regardless of whether the womb is removed during the procedure or not. Womb-preserving procedures are also gentler on the body overall. Complications from synthetic meshes are probably less common as well.

It may sometimes be more difficult to avoid removing the womb during surgery, though. This may be the case, for instance, if there are adhesions or if the woman has an enlarged womb.

Although women can still have children after womb-preserving surgery, those who wish to have (more) children are advised to have the surgery afterwards, if possible. This is because pregnancy can increase the risk of a prolapse recurrence.

If a doctor recommends surgery for the treatment of a prolapse, it can be a good idea to find out about the other treatment options as well – particularly if they recommend a hysterectomy. It is important to understand why they have suggested removing the womb: Is it because of the prolapse, or are there other reasons? What advantages and disadvantages would a hysterectomy have? And how important is it to you that you keep your womb?

If you are feeling unsure, it's a good idea to seek a second medical opinion – in other words, to talk with a doctor in a different practice or hospital. Our decision aid may be helpful, too. It provides a brief summary of the main pros and cons of the different treatment options.