Vaginal prolapse is a condition that occurs when the vagina loses its support and cannot maintain its shape. The support system of the uterus, urethra, bladder and, to some degree, the rectum, make up the vagina. Common causes of vaginal prolapse include child birth, menopause, hysterectomy or previous pelvic surgery. It is easier to understand uterine and vaginal wall relaxation (prolapse) if one has a working knowledge of normal anatomy.
The vagina is a fibromuscular tube (fascia) covered with vaginal epithelium (skin). It is this fascia which is responsible for the integrity and vaginal wall strength. The fascia is the support system of the vagina. This fascia is elevated and suspended and attached to muscles and ligaments of the pelvis. A simple analogy to the vaginal wall, skin and peripheral attachment is the floor you may be standing upon. The integrity, strength or support (fascia) of the floor is the concrete or wood and the carpet (skin or epithelium) on the support is the vaginal epithelium (vagina skin). The vaginal epithelium (skin) provides very little support and primarily acts as a covering.
The floor you are standing, like the fascia, is a complete piece of material which supports anything that sits or stands upon it. The floor, as does the fascia, must be attached to something to give it a point of attachment and further strength. Peripherally the floor is attached to the walls and foundation of the house. Likewise the vagina is attached to certain ligaments and muscles so it remains supportive. Vaginal prolapse occurs when vagina loses its support and cannot maintain its shape.
Note the upper pubocervical fascia supports the bladder and urethra, the lower rectovaginal fascia supports the rectum. Specifically the rectovaginal fascia keeps the rectum from protruding into the vagina. Both of the pubocervical and rectovaginal fascia attach to the uterus which in turn attaches to the uterosacral ligaments. There is a continuous supportive structure (fascia) from the opening of the vagina to the uterosacral ligaments. In the situation of a vaginal prolapse, the fascia does not provide the support necessary for the vagina to maintain its natural shape.
Types of Vaginal Prolapse
Surgical Options for Prolapse
Surgical options for patients with uterine and/or vaginal prolapse is dependent upon:
- Degree or severity of prolapse
- Areas specific for prolapse
- Desire to maintain fertility (maintain uterus)
- Desire to maintain sexual function
- Patient's age
- Patient's overall general health
- Patient's desire and opinion
Prolapse surgery is used to repair and reconstruct the support of the vagina and its neighboring organs when there is a prolapsed uterus. The surgeon's goal is to restore normal anatomy, sexual function and human physiologic function (urinating and defecating). Since uterine prolapse is not life threatening, surgery is indicated only if the patient feels that her condition is severe enough that it warrants correction. Mild prolapse need not be surgically corrected for it is rarely symptomatic.
Uterine prolapse is the indication for hysterectomy in approximately 15% of cases in the United States . It is rare for a patient to have a prolapse of the uterus without at least one other type of vaginal prolapse (i.e. Cystocele, rectocele, enterocele, and urethrocele). Therefore it is very important that the physician carefully inspect the vagina for other prolapses. All forms of vaginal relaxation should be treated at the same time as the hysterectomy or uterine suspension. It is possible to have vaginal prolapse surgery without the need for hysterectomy or uterine suspension if there is no prolapsed uterus. Surgery to correct uterine prolapse requires great experience and expertise. Meticulous attention to preoperative evaluation as well as intraoperative technique is essential in repairing all defects present. Failure to do so may result in a second or third surgery for the patient.