Vaginal Prolapse Repair - Cystocele, Rectocele and Enterocele Repair
Organs will prolapse (fall out) when there is a loss of support (damage to the connective tissue) due to gravity or an increase in abdominal pressure with exertion. Prolapse is Typically worse later in the day after being active, and better first thing in the morning after lying down all night. Symptoms can range from pelvic heaviness or pressure, to subtle discomfort with intercourse to tissue actual buldging past the vaginal opening.
Uterine prolapse occurs when the supporting ring at the top of the vagina is damaged. Uterine prolapse often is associated with a cystocele because the upper support of the bladder is the cervix.
A fallen bladder is called a cystocele. There are two basic types. The first is where the supporting connective tissue (fabric) has been stretched out and allows the bladder to push directly against the vaginal mucosa. The second type is where the connective tissue has torn, either along the sides where it attaches to the pelvis called a paravaginal defect, or from the top of the vagina or cervix. Both the bladder and the vagina are made to be stretched so neither one will hold the other in once the supporting tissues have been damaged.
A fallen rectum is called a rectocele. A rectocele occurs when the supporting tissue between the rectum and vagina is compromised. These are a common occurrence as this area takes a beating with childbirth. Difficulties with having a bowel movement can occur with rectoceles. When the rectocele bulges far enough out it acts as a reservoir to collect the stool with a bowel movement. The stool follows the path of least resistance which is into the pouch rather than out of the anus. Women will independently discover that they can help themselves have a bowel movement by pressing on the rectocele while they go. This eliminates the reservoir and facilitates normal function.
An enterocele is a vaginal hernia unique to women. It is a defect in the support tissues between the uterus and rectum, or the bladder and rectum in someone who has had a hysterectomy. This opening allows the small intestine to descend into the vagina. Enteroceles often occur along with rectoceles. They are repaired by closing the opening in the connective tissues at the top of the vagina.
These procedures may be done while you are under general or spinal anesthesia. Under general anesthesia, you will be asleep and unable to feel pain. With spinal anesthesia, you will be awake, but you will be numb from the waist down and you will not feel pain. You will be given medicines to help you relax.
- A surgical cut (incision) is made through your vagina.
- Your bladder is moved back to its normal location and held there by either over sewing the stretched connective tissue (anterior repair) or re-attaching the bladder to the sides of the pelvis (paravaginal repair)
- A rectocele is repaired by sewing the identified tears in the connective tissue between the rectum and vagina much like sewing the pieces of a puzzle together.
- Your doctor may place human-made (synthetic) mesh or biological material between your bladder and vagina to improve support.
Why the Procedure is Performed
This procedure is used to repair the sinking of the vaginal wall (prolapse) or bulging that occurs when the bladder or urethra drop into the vagina.
Symptoms of prolapse that you may have include:
- You may not be able to empty your bladder completely.
- Your bladder may feel full all the time.
- You may feel pressure in your vagina.
- You may have pain when you have sex.
- You may leak urine when you cough, sneeze, or lift something.
- You may get bladder infections.
This surgery by itself does not treat stress incontinence (leaking urine when you cough, sneeze, or lift). It may be performed along with other surgeries.
Before doing this surgery, your doctor may have you learn pelvic floor muscle exercises (Kegel exercises), use estrogen cream in your vagina, or try a device called a pessary in your vagina to hold up the prolapse.
Risks for any surgery are:
- Infection at the site of the surgical cut
- Opening of the surgical cut
- Blood clots in the legs that may travel to the lungs
- Breathing problems
- Other infection
Risks for this surgery are:
- Damage to the urethra, bladder, or vagina
- Irritable bladder
- Changes in the vagina (prolapsed vagina)
- Urine leakage from the vagina or to the skin (fistula)
Before the Procedure
Always tell your doctor or nurse what drugs you are taking, even drugs, supplements, or herbs you bought without a prescription
During the days before the surgery:
- You may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), warfarin (Coumadin), and any other drugs that make it hard for your blood to clot.
- Ask your doctor which drugs you should still take on the day of your surgery.
On the day of your surgery:
- You will usually be asked not to drink or eat anything for 6 to 12 hours before the surgery.
- Take the drugs your doctor told you to take with a small sip of water.
- Your doctor or nurse will tell you when to arrive at the hospital.
You may have a catheter to drain urine for about 5 days after surgery.
You should avoid any activity that increases your abdominal pressure such as heavy lifting, or constipation. You will be given a mild laxative to prevent constipation and generally should not lift anything heavier than a gallon of milk for six weeks until the scar tissue is strong. You should also avoid intercourse for six weeks to allow proper healing.
This surgery will usually repair the prolapse, and most times symptoms of prolapse will go away. This improvement will often last for years.
Vaginal Vault Suspension
This procedure is intended to correct pelvic prolapse that results from inadequate support of the vaginal apex.
Uterosacral ligaments. These fibro-connective tissues are part of the natural support of the vaginal apex (uterus). They are named for their points of origin and insertion (sacrum and uterus). These are shortened and re-attached to the bladder and rectal support with sutures to re-establish support and eliminate the potential for an enterocele (hernia).
Sacrospinous Ligaments. These are very tough fibrous ligaments that extend between the sacrum and the sides of the boney pelvis at points called the ischial spines.
Iliococcygeous Muscle These muscles run parallel to the sacrospinous ligaments and are useful as points of fixation in cases where the vagina is not long enough to reach the sacrospinous ligaments.
Sacrum A Sacro-colpopexy is a procedure in which the vagina (colpos) is tethered (pexed) to the sacrum. A piece of synthetic mesh or a biological graft is used to attach the vagina to the sacrum. These are traditionally done through an abdominal incision, but can also be done using the robot or laparoscope.
Which approach is right for you and whether or not to use a mesh or graft will be discussed in detail.