Surgery for pelvic organ prolapse

Surgery for vaginal prolapse aims to strengthen the connective tissue and lift the organs that have slipped down. There are two types of procedures here:

• Anterior (front) vaginal wall repair: Also known as anterior colporrhaphy, this is a treatment option if the front wall of the vagina has slipped down, along with the bladder. The aim of this surgery is to lift the bladder back up to its original position and strengthen the wall of the vagina. This involves tightening the connective tissue between the bladder and vagina by making a surgical cut in the front wall of the vagina.
• Posterior (back) vaginal wall repair: Also known as posterior colporrhaphy, this treatment is an option if the back wall of the vagina has slipped down, along with the last part of the bowel ( rectum). The surgery involves lifting this part of the bowel back up by tightening the connective tissue between the vagina and rectum. It is done through a surgical cut in the back wall of the vagina.

The surgery options here all involve lifting up the womb and fixing it in place. There are four main types of procedures:

• Sacrohysteropexy (sacrocolpopexy): This approach aims to correct prolapse in the upper area of the pelvic floor – for instance, if the womb has dropped down. The end of the cervix (neck of the womb) or the top end of the vagina is attached to the sacrum or coccyx (tailbone) using synthetic mesh. The womb doesn’t have to be removed. The operation is usually done through small cuts in the abdominal wall (laparoscopy).
• Sacrospinous fixation: An alternative to sacrohysteropexy, this procedure can also be used to correct prolapse in the upper area of the pelvic floor. It involves lifting the womb or vagina up and attaching it to ligaments in the pelvis. The womb is not removed. The operation is done through a cut in the vagina.
• Pectopexy: This newer surgical approach can be used to correct prolapse in the middle area of the pelvic floor. The aim is to support the vagina or womb by stretching synthetic mesh or surgical thread across the pelvis. The womb is not removed. The operation is done through small cuts in the abdominal wall (laparoscopy).
• Surgery to remove the womb (hysterectomy): The womb is removed – either partially or completely. In a partial hysterectomy, only the main body of the womb is removed. The cervix remains in place. If the whole womb is removed (a total hysterectomy), it can be done through the vagina or through the abdominal wall (belly). A partial hysterectomy can only be done through the abdominal wall.

These operations are usually done under general anesthesia. Most women stay in the hospital for three to five days.

There are other types of prolapse surgery too, but there is less scientific 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 be done during prolapse surgery.

In some procedures, the pelvic floor can be stabilized too – either using muscle and connective tissue from the woman’s own pelvic floor, or using synthetic mesh. The synthetic mesh is stretched between the vagina and bladder, a bit like a taut hammock supporting the organs. Whether it makes sense to use mesh will greatly depend on the woman's individual situation.

The choice of procedure will mainly depend on which organs are affected. If several pelvic organs or several areas of the pelvis have slipped down, various procedures are combined. Personal wishes and preferences play an important role too – for example, whether you would like to keep your womb or how you feel about having synthetic mesh inside your body.

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 a larger cut across the abdominal wall, which is rarely needed. Factors that play a role when deciding whether to operate through the vagina or through the abdominal wall include the type of procedure and the woman's preferences.

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.

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 sacrohysteropexy to correct uterine (womb) prolapse, about 90 out of 100 women no longer have problems such as urine leakage or pain during sex – at least for some time. But there's a risk of recurrence (the prolapse might come back): In about 20 out of 100 women, the womb either drops down again or bulges out of the vagina within two years of the procedure.

In sacrospinous fixation, it is probably possible to operate without using synthetic mesh because – compared to operations using the woman’s own tissue – using mesh isn’t more likely to prevent a prolapse recurrence. But recurrences are generally more likely after surgery that is performed through the vagina than after sacrohysteropexy: The womb drops down again in about 30 out of 100 women. Problems such as a leaky bladder and pain during sex are then more likely to come back, too.

Pectopexy can also correct the prolapse and reduce related problems. Research has shown that the treatment outcomes of pectopexy and sacrohysteropexy are similar.

Women can still have children after womb-preserving surgery. But 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.

About 5 out of 100 women have complications such as wound infections, bladder injuries or bowel injuries. There are also the usual risks associated with surgery, for example due to the anesthesia. Like after many kinds of abdominal surgery, adhesions may form. This can lead to pain or digestive problems. It is also important to consider the risks associated with synthetic mesh.

In some types of procedures (like sacrocolpopexy and pectopexy), the organs are almost always supported with synthetic mesh. In other procedures, the organs can be supported using either your own tissue or synthetic mesh. Medical societies currently recommend being cautious with synthetic mesh, saying that it should preferably be offered to women who have a high risk of prolapse recurrence or who have already had a recurrence.

Synthetic mesh is a little better at stabilizing the organs than women's own tissue is – at least in vaginal wall repair surgery. But mesh is associated with certain complications. For instance, it becomes detached in 5 out of 100 women. Then they may need to have more surgery. Bladder injuries and bladder weakness are also more common. But there's no evidence to back up previous claims that synthetic mesh is more likely to cause pain in the vagina and during sex. Some types of mesh were taken off the market because they caused problems so frequently.

There are now newer kinds of synthetic mesh that are said to cause fewer complications. But there's a lack of good research on them. Because of this, it's not yet possible to say which pros and cons they may have compared with using the woman’s own tissue in surgery.

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 scientific 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 was removed during surgery or not. Womb-preserving procedures are also gentler on the body overall. What's more, synthetic mesh is more likely to become detached after a hysterectomy than after other procedures.

If your doctor recommends that you have a hysterectomy, it's a good idea to find out about the other treatment options too. It is important to understand why they have suggested removing your womb: Is it because of the prolapse, or are there other reasons? What pros and cons would a hysterectomy have? And how important is it to you that you keep your womb?

In Germany, doctors who recommend a hysterectomy must inform you of your right to a second medical opinion. In other words, you can have an appointment with a different specialist to help you decide whether or not to have this operation. You will not have to pay for the appointment.

To allow the wounds to heal and ensure the best possible outcome, experts recommend the following:

• For the first 6 to 8 weeks after surgery, avoid strenuous physical activities such as lifting heavy objects or doing sports that involve running or jumping. You can walk or lift light objects (up to 5 kilograms). You should avoid doing hard physical work or carrying heavy loads in the long term, too.
• For the first 6 to 8 weeks, avoid swimming, taking a bath, saunas, tampons and sex.
• Make sure you have soft bowel movements (poop) so you don't need to strain. You can do this by eating plenty of fiber and drinking enough fluids, for example.

After 6 weeks, you can start doing pelvic floor exercises.