A Team Approach to Care

Pelvic Organ Prolapse

Pelvic organ prolapse, commonly referred to as pelvic prolapse or vaginal prolapse, is common in women. Although most often patients have no symptoms, it can be quite distressing.

Symptomatic patients frequently complain of a bulge at the opening of the vagina, generalized discomfort or irritation, or a full sensation in the vagina. It can also negatively affect the ability to evacuate the bowel or bladder. This can lead to secondary issues such as urinary urgency, frequency, inability to empty the bladder, incontinence as well as urinary tract infections.

Common causes of prolapse include pregnancy and childbirth, age (postmenopausal), genetic predisposition, prior hysterectomy or pelvic surgery, and obesity. Correction of these issues can be achieved through non-surgical and surgical options.

Symptoms of
Pelvic Organ Prolapse

Individuals who experience one or more of the following symptoms may be dealing with pelvic organ prolapse:
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  • Pressure from the pelvic organs against the vaginal wall
  • “Full” feeling in the lower belly
  • Pulling or stretching sensation in the vagina
  • Lower back pain
  • Pain in the vagina during sex
  • Constipation or other bowel problems
Risk Factors

here are many risk factors associated with pelvic prolapse, and these include:

  • Obesity: Excess weight increases pressure in the abdomen.
  • Constipation: Chronic constipation puts additional pressure from the bowel on the abdominal wall.
  • Smoking: Lung conditions caused by smoking may lead to chronic coughing that increases pressure in the pelvis and abdomen.
  • Pelvic Surgery: The removal of the uterus or other pelvic surgeries may cause one or more of the pelvic organs to change position and cause pelvic organ damage.
  • Nervous System Diseases: Research indicates pelvic prolapse occurs more frequently in women who experience multiple sclerosis, muscular dystrophy, spinal cord injuries, or other nervous system diseases.
  • Genetic Factors: A weakness in the supportive tissue of the pelvis may be inherited; thus, if your sister, mother, or other family members experience pelvic prolapse, you may be more susceptible than others to this condition.
  • Pregnancy: Childbirth puts a significant amount of stress on the pelvic muscles and tissues that can be damaged and lead to pelvic prolapse, particularly in women who have had more than one vaginal birth.
  • Hysterectomy: Some women, particularly women who have given birth, experience vaginal prolapse following a hysterectomy because the pelvic floor muscles are weaker from the birth process.

Comprehensive Urology makes it easy for patients to address pelvic prolapse. Our team learns about a patient’s pelvic prolapse risk factors and performs in-depth patient examinations. We also review a patient’s medical history to determine how to effectively treat pelvic prolapse.

Reasons to consider surgery

Common reasons why an individual may seek out pelvic prolapse treatment include:

  • Bulge of tissue inside or outside the vagina
  • Pulling sensation and/or increased pelvic pressure when you lift or strain
  • Sensation that something is falling out of the vagina
  • Lower back pain or pain in the pelvic area that interferes your ability to perform everyday activities
  • Sex becomes difficult or painful
  • Irregular spotting or bleeding from the vagina occurs
  • Bowel movements become exceedingly difficult
  • Incontinence, frequent urination, and/or constant urges to urinate occur
  • Post-pregnancy incontinence

Pelvic organ prolapse is a serious problem, and failure to address this issue may cause pelvic prolapse symptoms to worsen over time. By scheduling a consultation with Comprehensive Urology, an individual can meet with an expert urologist and take the first step to address pelvic prolapse.

What are my treatment options ?

Surgical approaches for prolapse repair and correction can be done through the vagina using various techniques and materials to recreate the support for the bladder, rectum, uterus, or vaginal vault. On occasion, a hysterectomy is needed to facilitate repair. Repair of the prolapse can also be achieved by using and abdominal approach with the da Vinci robotic system. This procedure allows the surgeon to recreate support for the entire pelvic floor with a low rate of prolapse recurrence, minimal blood loss and faster recovery as compared to a traditional open abdominal approach.

This type of repair is sometimes referred to as a bladder sling or rectal sling. Although the term helps to create a visual picture and understanding of the repair, it has often also created confusion when evaluating patients with previous pelvic surgeries and trying to deduce exactly what surgery was completed in the past. It also has led to alarm in patients who have undergone successful and complication free mid-urethral slings when seeing and hearing advertisements regarding FDA warnings regarding mesh and “bladder slings.”

Types of Vaginal Prolapse

The term vaginal prolapse is very general and encompasses all types of issues in the pelvis. To help patients distinguish what exactly is occurring in the body, it is frequently helpful to use diagrams and also specific terminology to improve understanding of the issue.

Rectocele – As suggested by the name, rectocele specifically deals with the rectum. This occurs when the back wall of the vagina weakens, causing the rectal wall to push against the vaginal wall, creating a bulge. Rectocele is characterized by difficulty moving the bowels, and has been associated with chronic constipation and straining. Again, patients will complain of a vaginal bulge. Some find that their bowel movements are facilitated by pushing the bulge back into the vagina.

Procidentia – When the uterus is the part of the vagina that is “dropping,” it is referred to as procidentia. Many times it can lead to symptoms similar to a cystocele or rectocele because of the pressure exerted on these areas by the descending uterus.

Vaginal Vault Prolapse – Occurs following a hysterectomy or a uterine prolapse.

Prolapsed Uterus (Womb) – Occurs when the uterosacral ligaments located at the top of the vagina are weakened, causing the uterus to fall.

Urethral Diverticulum – Occurs when a pocket or pouch forms along the urethra and can cause vaginal discomfort or pain.

Pelvic Fistula Treatment – Occurs when there is an abnormal connection between the skin and a hollow organ, including the bladder, bowel, uterus, or vagina.


NON-SURGICAL TREATMENTS

Cystocele

Cystocele, also known as anterior prolapse or prolapsed bladder, is a pelvic organ condition that occurs when the wall between a woman’s bladder and her vagina is weakened, which results in the bladder dropping into the vagina. Due to the compromise, the bladder may bulge through the vaginal opening and cause women discomfort and problems emptying the bladder.

Cystocele Levels

There are different levels of cystocele depending on the severity of the condition. These levels are separated into three grades:
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  • Grade 1 – A mild form of cystocele characterized by the bladder dropping only a short way into the vagina.
  • Grade 2 – A more severe form, as the bladder sinks farther down the vagina, reaching the opening.
  • Grade 3 – The most advanced type of cystocele, which occurs when the bladder actually protrudes out of the vaginal opening.
Symptoms of Cystocele
  • Vaginal bulging
  • Heaviness, fullness or pressure in the pelvis
  • Difficulty and incomplete urination
  • Frequent or urgent urination
  • Tissue protruding from the vagina
  • Stress incontinence
  • Frequent bladder infections
  • Painful intercourse
  • Low back pain

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What Causes a Cystocele?

The straining of muscles during vaginal birth delivery is the most common cause of a cystocele. However, other kinds of straining, such as heavy lifting or repeated straining during bowel movements, may also cause the bladder to weaken and fall. Cystocele has also been linked to women who are experiencing menopause.

This is due to the fact that the hormone estrogen helps keep the muscles in and around the vagina firm and strong. When women stop having menstrual cycles, formation of estrogen also stops, causing the muscles that support the vagina and bladder to weaken.

Cystocele Treatment

Depending on the severity of the condition, treatment options may vary from no treatment at all for grade 1 (mild) cystocele to surgery for more serious and advanced cases – grade 2 or 3 cystocele. If symptoms are not too bothersome, you may be advised to avoid heavy lifting or straining activity that may cause a mild cystocele to worsen. If symptoms are noticeably bothersome, a vaginal pessary may be used to hold the bladder in place, which is a device that comes in a variety of shapes and sizes.

For more advanced cystocele symptoms, surgery may be performed to move and keep the bladder in a more normal position. The most common surgical procedure involves making an incision in the wall of the vagina to repair the area that needs tightening. Women who undergo surgery for cystocele repair normally stay in the hospital for several days and may take up to four to six weeks to recover fully.

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NON-SURGICAL TREATMENTS

Rectocele Prolapse

The skilled and compassionate urologists at Comprehensive Urology understand how embarrassing and troubling rectocele can be and strongly believe in providing only the most advanced and effective care possible. We focus on preserving quality of life and sexual function just as much as we strive the achieve the best possible outcomes.

Also known as a posterior prolapse, a rectocele occurs when the fascia or thin wall of fibrous tissue between the vagina and rectum breaks down, causing the rectum to press against the front wall of the vaginal canal. In severe cases, the fascia tears and the rectal tissue bulges into the vagina as a hernia.

Fortunately, most women who have developed rectocele may not even notice the condition or may not suffer any uncomfortable symptoms. Unless the fallen rectum causes pain or discomfort, many women do not need to undergo any treatment.

However, it is important to have the condition examined by an experienced urologist to determine the severity of the prolapse as well as whether treatment is recommended.

What Causes Tears between the Rectum and Vaginal Wall?

The most common cause of rectoceles is childbirth. During the natural childbirth process. The tissue between the vagina and rectum, the rectovaginal septum, can become stretched and weak, allowing the rectum to press against the vaginal wall. Additional causes or risk factors include:

  • Thinning or weakening of the vaginal tissues due to menopause
  • Decreased estrogen
  • Advanced age
  • Multiple vaginal deliveries
  • Trauma during deliver, such as forceps or vacuum injuries
  • Chronic constipation
  • Previous gynecological or rectal surgery
Posterior Prolapse Symptoms

In the majority of cases, most women are not even aware that they have developed rectocele simply because they do not experience any symptoms. However, particularly in severe cases of posterior prolapse, the following symptoms may occur:

  • Feeling pressure within the vagina
  • Pain or discomfort during evacuation
  • Pain or discomfort during intercourse
  • Feeling that something is falling out within the pelvis
  • Constipation
  • Incomplete defecation
  • Vaginal bleeding
  • Tissue bulging out of the vagina

A rectal prolapse can be diagnosed through a pelvic exam, which may include a speculum or bimanual examination. The strength of the vaginal and rectum walls may be evaluated with a digital exam and the patient may be asked to defecate after a contrasting colored material is inserted in the rectum, bladder, and vagina to determine whether a rectocele is present.

Repairing Rectocele

Depending on the severity of the condition as well as the patient’s health and symptoms, treatment may be as minimal as increasing water intake as well as eating a high fiber diet. A rectocele does not necessarily need to be treated if the patient does not experience negative symptoms. The most common non-surgical treatments include:

Pelvic floor strengthening exercises – Also known as Kegel exercises, pelvic floor strengthening exercises can prevent a posterior prolapse from worsening, and are often recommended in addition to more involved treatments.

Stool softeners – Increasing water intake, eating a high fiber diet, and adding stool softeners can improve stool consistency and enable the stool to travel more efficiently through the colon.

Pessary – A silicone rubber device can be worn inside the vagina to help support the vagina and rectum, preventing the prolapse from worsening. There are a variety of shapes and sizes that can be adjusted to meet the patient’s needs and comfort. A pessary is a convenient and comfortable option for many women who only suffer mild to moderate symptoms of rectocele.

When non-surgical treatments fail, surgery may be necessary.

Rectocele Surgery – Surgical repairs of a posterior prolapse can be performed in a number of ways, such as through the vagina, through the anus, or through the space between the vagina and anus (perineum). The rectovaginal septum is reinforced by stitching the tissue together or incorporating a prosthetic mesh.

Laparoscopic Rectocele Repair – A laparoscope is inserted through a small incision in the abdomen, allowing the surgeon to have a magnified, high resolution view of the prolapse and surrounding tissue. The rectocele can be repaired with permanent sutures.

Recovering from Repair of a Rectocele

The success of any surgery depends on a number of factors, such as the severity of the condition, the length of time the patient has been living with the symptoms, as well as the approach of the surgery and the surgeon’s familiarity and skill with the procedure. The recovery process typically requires only pain management with anti-over-the-counter inflammatory drugs or oral narcotics. Following vaginal procedures, most women can return home during the same day as the operation, while abdominal procedures will require stronger anesthesia and therefore, will need hospitalization of up to two or three days.

As with any surgical operations there is a degree of risk, but it is crucial to work with an experienced and dedicated urologist to minimize the chances of painful side effects or life-altering trauma. The team at Comprehensive Urology have extensive training and experience performing rectocele surgery and have a strong track record of successful outcomes, particularly with regards to preservation of sexual function and quality of life.


NON-SURGICAL TREATMENTS

Vaginal Vault

Prolapse is a common problem for women of all ages. Muscles, ligaments and skin that act as a complex support structure holding pelvic organs and tissues in place surround a woman’s vagina. The vagina is also surrounded by the uterus, rectum, bladder, urethra, and small bowel.

Vaginal prolapse occurs when these structures begin to fall out of their normal positions. This is a serious condition and without proper medical treatment, or surgery, these structures may eventually prolapse farther and farther into the vagina. If the support is weakened enough, these structures may fall through the vaginal opening.

Vaginal vault prolapse is a common condition that affects women typically after a hysterectomy, which is the removal of the uterus, or womb. Usually after a hysterectomy, the pelvic and vaginal tissues and muscles are weakened, causing the upper portion of the vagina to lose its normal structure.

The upper portion of the vagina then drops in to the vaginal canal or outside the vagina. Vaginal vault prolapse may also occur in conjunction with a uterine prolapse, vaginal delivery of a baby, previous surgeries, obesity, and menopause.

Symptoms of Vaginal Vault Prolapse
  • Back aches
  • Heaviness or pressure in the pelvis
  • Recurrent bladder infections
  • Enlarged vaginal opening
  • Protrusion of tissue from the vaginal opening
  • Abnormal or excessive discharge from the vagina
  • Urinary incontinence (involuntary release of urine)
  • Frequent and urgent urination
  • Difficulty emptying the bladder
  • Constipation
  • Vaginal bleeding
Treatment options

Vaginal vault prolapse can be treated non-surgically or surgically. It is best to consult with your medical health professional to understand all your options and decide which method is best for you.

Non-surgical treatment options for vaginal vault prolapse include:

  • Exercise – Performing pelvic floor exercises may help keep muscles and ligaments fit and firm.
  • Vaginal Pessary – A removable device that is placed into the vagina to hold the pelvic organs in position.
  • Estrogen Replacement Therapy – May be used to help the body strengthen the muscles in and around the vagina and attempts to reverse vaginal weakening and incontinence.

During a surgical treatment for vault prolapse, the top portion of the vagina is attached to the lower abdominal wall, the lower back spine, or the ligaments of the pelvis. General anesthesia is administered for this type of procedure and most women are required to stay in the hospital from one to two days after surgery. After six weeks, most women are able to return to normal activities, including sexual intercourse.

Robotic Vault Suspension

Vaginal vault prolapse is a common condition that can cause a variety of uncomfortable and in advanced cases, even painful symptoms. The condition occurs when the muscles and ligaments that support the upper portion of the vagina (vaginal apex) are weakened, causing the apex of the vagina to drop (prolapse), potentially falling as far as the vaginal canal or even outside the body through the vaginal opening.

In most cases, vaginal vault prolapse is so mild that women do not experience symptoms; however, those who suffer moderate to severe prolapse, particularly women who’ve had a hysterectomy or uterine prolapse, may need robotic surgery to repair and secure the vaginal vault. At Comprehensive Urology, our skilled urologists are proud to offer the most minimally-invasive surgical treatment for vaginal prolapse using the state-of-the-art da Vinci Surgical System.

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Types of Robotic Vaginal Vault Suspension Procedures

In order to surgically repair vaginal prolapse, the urological surgeons at Comprehensive Urology may perform one of the following types of robotic vaginal vault suspension:

Robotic Sacrocolpopexy: This procedure involves surgically securing the vagina with mesh. The term sacrocolpopexy means ‘to lift the vagina to the pelvic bone’ as the mesh is positioned along the front and back of the vagina and secured to the sacral promontory, also known as the base of the lumbar spine (lower back) and sacrum.

Traditional sacrocolpopexy was performed as an open surgery, which required a six to 12 inch incision across the abdomen. However, robotic sacrocolpopexy uses only five small incisions around the abdomen. The small arms of the da Vinci robot and miniature equipment reach through at specific points to allow the surgeon to perform the procedure with as few incisions as possible.

Robotic Uterosacral Ligament Suspension: Similar to the sacrocolpopexy, the uterosacral ligament suspension involves the use of the patient’s own ligament tissue, rather than a synthetic mesh, to secure the apex of the vagina in its natural position. The procedure is performed in much the same way as the robotic sacrocolpopexy, in which the da Vinci robot will be positioned at the patient’s abdomen and only five small incisions will need to be made.

At Comprehensive Urology, our patients can expect to have dedicated, personalized treatment. Using the da Vinci Surgical System for vaginal vault suspension is safe, but it is not recommended for every patient. To learn more about the device and the procedures, please do not hesitate to contact us.

What are the benefits of Robotic Vaginal Vault Suspension

The da Vinci robot offers the following benefits compared to traditional open surgery:

  • Reduced blood loss and less need for transfusions
  • Less pain
  • Less risk of infections
  • Reduced scarring
  • Shorter hospital stay
  • Quicker recovery

The da Vinci surgical robot offers surgeons a three dimensional view of the surgical site with greater freedom of instrumentation movement and improved surgical ergonomics. In many cases, robotic vaginal prolapse surgery outcomes are similar to purely 


NON-SURGICAL TREATMENTS

Enterocele Small Bowel Prolapse

Enterocele is a type of rectal prolapse in which a defect in the supporting tissue between the rectum and the uterus causes the small bowel to protrude through the posterior (back side) or anterior (front side) of the rectum wall. The small bowel descends into the lower pelvic cavity, pressing on the top part of the vaginal canal and creating a bulge.

In mild cases of enterocele, patients may not even be aware of the condition, however, in cases of significant prolapse, patients may suffer from vaginal pain and discomfort. It is not uncommon for enterocele to contribute to other issues, as well, such as ulcers, fibrosis, and edema of the vaginal walls, or complications with bowel movements. In many cases, women who suffer from enteroceles also suffer from rectoceles (rectum prolapse).

Fortunately, there are numerous treatments available to repair enterocele, from simple pelvic floor muscle strengthening exercises to comprehensive vaginal and abdominal surgical operations. In order to achieve the best possible outcome, it is important to receive care and treatment from a board-certified urologist at Comprehensive Urology.

What are the symptoms?

Depending on the extent of the prolapse, some patients may not experience any symptoms, but in cases of moderate to significant prolapse, patients might experience the following:

  • Pulling sensation in the pelvis that relaxes when sitting or lying down
  • Lower back pain that is alleviated by lying down
  • Vaginal and/or pelvic discomfort
  • Pain during intercourse (dyspareunia)
  • A soft bulge in the vaginal wall
  • Sensation of pressure, pain, or fullness in the pelvis

Women who experience symptoms of enterocele are encouraged to seek a thorough exam in order to not only treat the condition, but to also diagnose or prevent additional bowel, bladder, or uterine conditions from occurring.

Causes?

Nearly half of all women who have given birth experience some degree of prolapse, which often becomes even more likely as women grow older. Other risk factors of enterocele include:

  • Weakened tissue and lower levels of estrogen due to menopause
  • Obesity
  • Giving birth to a large baby or multiple babies
  • Long or difficult labor
  • Previous surgery, such as bladder repair or hysterectomy
  • Long-term constipation
  • Long-term coughing
  • Manual work or heavy lifting

If you experience any of the symptoms of pelvic organ prolapse, particularly if you can feel something from within the vaginal canal, it is important to have an exam with an experienced urologist. If you have a mild or moderate case of prolapse that does not currently cause any pain or discomfort, you will likely not need any treatment, but it is crucial that your doctor is aware of the condition and can monitor it.

What are the treatments?

There are numerous treatment options available for small bowel prolapse depending on the stage of the prolapse, the severity of the symptoms, the age and overall health of the patient, as well as whether the patient is planning on having children in the future. At Comprehensive Urology, we are proud to offer the most advanced and effective medical and surgical treatment options available for enterocele.

Medical or conservative treatment options include:

Pelvic floor strengthening exercises – Strengthening the muscles surrounding the prolapse can help prevent the condition from worsening and is often recommended in addition to other conservative methods.

Pessary – A silicone rubber device that is worn inside the vagina to help support the uterus, rectum, or bladder. The shape and size of the device will depend on the patient, but can be adjusted to suit the patient’s needs and comfort. A pessary can be worn without removal for up to a week and must be removed periodically for cleaning. Many women find a pessary to be a comfortable and convenient option for managing the symptoms of vaginal rectal prolapse.

Hormone Replacement Therapy – Postmenopausal women often experience some degree of vaginal atrophy as a result of less estrogen in their system. By replacing the hormone, the vaginal tissue can regain strength and elasticity to help relieve the symptoms of prolapse. In the event that non-surgical options fail to relieve the symptoms or reduce the prolapse, surgery methods are often more successful.

Enterocele Repair – The prolapsed portion of the vagina is repaired by surgically attaching a synthetic mesh from within the vagina, which is also attached to a ligament called sacrospinous ligament to help support the mesh.

Laparoscopic Prolapse Repair – Using a laparoscope device inserted into the abdominal cavity through a small incision, typically no longer than 1/2-inch, the surgeon has a high resolution, magnified view of the pelvic structures that need to be repaired. The prolapsed tissue can then be repaired with the precise placement of permanent sutures through the laparoscope as well. The minimal incisions allow the patient to recover faster than with tradition surgery.

Prior to any treatment, it is important to consult with the skilled urologist at Comprehensive Urology in Beverly Hills. Our team place preservation of quality of life, sexual function, and overall health as highly as simply treating the condition. If you or a loved one is suffering, we can provide the care and treatment necessary to get back on track.

What is a A urethral diverticulum treatment?

A urethral diverticulum is an uncommon but problematic female urological condition. Most develop from the small glands surrounding the urethra leading to a cyst that connects to the urethra and can sometimes surround the urethra. It is almost never seen in pre-pubertal girls and does not seem to be related to trauma or childbirth.

The most common symptoms of urethral diverticulum include vaginal discomfort or pain, especially with intercourse, a bulge in the vaginal area, and urethral discharge. Not all patients with diverticulum are symptomatic. Diagnosis includes a thorough history, physical exam, imaging with MRI and cystoscopy. Other diagnostic imaging studies may also be used. Diverticulum correction can only be achieved through surgical intervention from a specialist in female urology. On rare occasions, cancerous tissue is found within the diverticulum.

What is a Fistula Treatment?

A fistula refers to an abnormal connection between two hollow organs or a hollow organ and the skin. These may include the bladder, bowel, uterus and vaginal. These are rare occurrences. Fistulae may be caused by a complication from pelvic surgery, radiation therapy, pelvic trauma, vaginal childbirth, bowel diverticulum, or cancer of the bowel, bladder, uterus, or other organs.

When treating pelvic fistulas (as well as other female urology conditions), our women’s health specialists utilize physical exams, pelvic imaging, cystoscopy, colonoscopy, and vaginoscopy. Patients are frequently managed initially with conservative therapy such as a urinary catheter. If this approach fails, then surgical correction is needed. Many times, several different physicians or surgeons will be involved in the care of a fistula. 

What are the risks?

Risk factors for the condition are many. Increased risk is associated with older age, vaginal delivery, obesity, chronic constipations, post-menopausal status, prior pelvic surgery and hysterectomy. Interestingly, when looking at epidemiological data, African Americans have the lowest rates of vaginal prolapse as compared to Caucasians, Hispanics and Asians. Frequently people feel that a history of heavy lifting or manual labor increases the risk for prolapse, but there are no conclusive studies to prove or disprove this theory. The last risk factor for this issue is genetics, mainly that if your mother, sister, grandmother, etc., has a history of prolapse, your risk is higher.

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