Prolapse (i.e lack of support) of the pelvic organs occurs commonly among women. The pelvic organs are the womb, the vagina, the bowel, and the bladder; either or can herniate into or out of the vagina as a result of weakened muscles, ligaments and fascia (the strong supporting tissue). Risk factors include pregnancy, childbirth, aging and menopause, conditions which are associated with chronic increased pressure in your abdomen (chronic cough, constipation, heavy lifting etc.) or genetic predisposition affecting the strength of the connective tissues.
Although prolapse is not a life-threatening or dangerous condition, it can have a significant negative impact on your quality of life and body image with associated symptoms of sensation of a vaginal bulge, pelvic pressure or discomfort, urinary, bowel or sexual problems.

Many women with prolapse are reluctant to talk about it or may find it too embarrassing to acknowledge having a covert condition. With proper assessment and treatment, prolapse can be managed or treated.

I will be able to discuss and offer the full range of management options that are available by empowering your decision making and supporting you through the process in order to achieve the best outcomes to you.

Conservative measures are an option for the management of pelvic organ prolapse. Although prolapse has common occurrence in up to 50% of women, only 11% require surgical intervention.
A proportion of women would choose not to have any treatment if they have no symptoms or discomfort.

Alternatively, other non-surgical approaches include pelvic floor muscle exercises (PFE) or the use of a vaginal pessary.

Pelvic floor exercises are suitable for early stages or mild prolapse. PFE are unlikely to alleviate symptoms of moderate or advanced prolapse, but can be beneficial as a preventive measure against recurrence following prolapse surgery.

The muscles of the pelvic floor help to support the organs in the abdomen, protect and hold the pelvic organs in the correct position, help in the control of passing of urine, gas, and bowel motions and play a role in sexual function during intercourse.

Like all muscles, the pelvic floor muscles need be exercised regularly in order to work well.

In addition to pelvic floor exercises, a vaginal pessary is an alternative to surgery. Vaginal pessaries are usually made from silicone and provide support to the pelvic organs by gently pushing the tissues back in the vagina and reducing the sensation of a vaginal bulge.
There are different types of pessaries (Ring, Falk, Shelf, Gelhorn etc.) depending on their shape and if the occlude or not the vaginal opening.

If you choose to try a vaginal pessary, you can be fitted with the pessary in the consulting room. Pessary fitting typically takes just a few minutes. A pessary can be used as a short or long term solution for prolapse and require regular changes every 4 – 6 months.

External links:

https://www.yourpelvicfloor.org/conditions/pelvic-floor-exercises/

https://www.yourpelvicfloor.org/conditions/vaginal-pessary-for-pelvic-organ-prolapse/

Repair of the anterior (front) wall of the vagina is the most commonly performed procedure in urogynaecology. It strengthens the support fascial layer between the bladder and the vagina. It utilises your own, native tissues and does not involve the use of mesh.
It aims to remove the sensation of a vaginal bulge and/or laxity without compromising sexual function.
The procedure can be performed under general or regional (spinal) anaesthesia and usually requires an overnight stay in hospital.

During the operation, an incision is performed on the anterior wall of the vagina and stitches are applied to strengthen the weakened tissues. These sutures have delayed absorption to allow complete healing and support of the pelvic organs. The vaginal incision is then closed with stitches that usually take 4 to 6 weeks to absorb.

A cystoscopy (camera test to the bladder) is performed at the end of the operation to ensure that the structure of the bladder is normal and the tubes, connecting the kidneys to the bladder (ureters) , are functioning normally.

Commonly additional procedures such as repair of the back wall of the vagina (posterior vaginal repair), vaginal hysterectomy or suspension of the cervix or vaginal vault may be required as part of the pelvic floor repair.

At the end of the operation, a urinary catheter to drain the bladder and a vaginal gauze pack to reduce bleeding or bruising are sited overnight. On removal of the urinary catheter, we will ensure that you empty your bladder completely before discharge. 10% of women, after pelvic floor surgery, may require a short period of catheterisation to allow return of bladder function.

External links:

https://www.yourpelvicfloor.org/conditions/anterior-vaginal-repair/

Vaginal wall prolapse has common occurrence though symptomatic prolapse requiring surgical intervention is much lower, at a rate of 1 in 10 women. A prolapse of the posterior (back ) wall of the vagina usually occurs due to weakness of the fascial support layer between the vagina and the lower part of the bowel. This may be associated with difficulties passing a bowel movement, feeling of a vaginal bulge or of fulness in the vagina.
Posterior vaginal repair (posterior colporrhaphy) utilises your own, native tissues and does not involve the use of mesh.

It aims to remove the sensation of a vaginal bulge and/or laxity without compromising sexual function.

The operation can be performed under general or regional (spinal) anaesthesia.
During the operation, an incision is performed on the back wall of the vagina and stitches are applied to strengthen the weakened tissues. These sutures have delayed absorption to allow complete healing and support of the pelvic organs. The vaginal incision is then closed with stitches that usually take 4 to 6 weeks to absorb.

In addition, a perineal body repair (the area between the vaginal and anal opening) is usually performed to reconstruct the perineal body, to provide additional support to the back wall of the vagina and sometimes reduce the vaginal opening.

Commonly, posterior repair may be combined with other surgeries such as anterior repair, vaginal hysterectomy or suspension of the cervix or vaginal vault to a strong ligament in the pelvis called the sacrospinous ligament.

Further Resources:

https://www.yourpelvicfloor.org/conditions/posterior-vaginal-wall-perineal-body-repair/

Prolapse of the womb occurs as a result of weakness of the supporting structures of the uterus. There are various options to address this surgically, including removal or conservation of the womb (hysteropexy).
Some women require removing of their womb in cases of marked uterine prolapse and this can be done through the vagina. Described benefits to this approach over abdominal or laparoscopic routes, include easier access via the vagina, overall fewer complications, shorter healing time, less pain, less scarring, a lower chance of infection, less risk of hernias, and faster return to activities.

The procedure can be performed under general or spinal anesthesia (with or without sedation). A cut is performed around the cervix and the bladder and bowel carefully pushed away from the womb. The blood supply to the uterus is secured, allowing removing of the womb and the top of the vagina, known as the vaginal vault, is closed with absorbable stitches.

Commonly, vaginal hysterectomy may be combined with other surgeries such as anterior or posterior vaginal repair, or may require application of additional support stitches to
the vaginal vault (this is called a sacrospinous ligament suspension).

These additional stitches help to reduce the risk of the vaginal vault prolapsing in the future.

The ovaries and uterine tubes are not routinely removed during prolapse surgery.

Recovery following your operation usually takes up to 6 weeks. You would be able to perform light activities such as short walks within a few weeks of surgery. You would be advised to avoid heavy lifting for at least 6 weeks to allow the wounds to heal. Sexual activity can usually be safely resumed after 6 weeks.

External link:

https://www.yourpelvicfloor.org/conditions/vaginal-hysterectomy-for-prolapse/

Vaginal vault prolapse is prolapse (i.e. lack of support) of the top of the vagina. This area of support is one of the most crucial area for the overall support of the vagina. Vaginal vault prolapse is very similar to uterine prolapse however the uterus is no longer present as the patient has had a previous operation to remove the womb (a hysterectomy).
Usually vaginal vault prolapse occurs with other forms of prolapse such as a cystocele, urethrocele, enterocele or rectocele. Patients often report the feeling of a bulge in the vagina, pressure, and vaginal discomfort.

Sacral colpopexy is a procedure that allows correction of the vault prolapse. This is usually done by the use of key-hole techniques(laparoscopically) or can be done via open approach (cut in the lower abdomen) if required.

The operation is performed under general anaesthesia and involves the suspension of the top of the vagina to the ligament overlying the sacrum (tail bone) with the help of permanent, synthetic mesh (lightweight polypropylene).

The mesh is then completely covered with a layer of tissue called peritoneum, which overlays the cavity of the abdomen from within. This prevents the bowel getting stuck to the mesh.
Please note that the abdominal mesh is not included in the recent controversies involving vaginal or incontinence meshes.

The sacrocolpopexy provides robust support to the top of the vagina. Further, concomitant surgical repair of the vagina may be required depending on the extent of the prolapse.
A cystoscopy (camera test to the bladder) is also performed to ensure that no damage has occurred to the bladder or ureters (the tubes connecting the kidneys to the bladder).

At the end of the operation, a urinary catheter is inserted into the bladder to drain urine overnight.

Recovery following your operation usually takes up to 6 weeks. You would be able to perform light activities such as short walks within a few weeks of surgery. You would be advised to avoid heavy lifting for at least 6 weeks to allow the wounds to heal. Sexual activity can usually be safely resumed after 6 weeks.

External link:

https://www.yourpelvicfloor.org/conditions/sacrocolpopexy/

Uterine prolapse, meaning lack of support to the womb, occurs as a result of weakness of the supporting structures of the uterus.
Sacral hysteropexy is a procedure helping to correct prolapse of the uterus in women who wish to preserve their womb. It allows lifting of the womb up to its original position and also restoring the vaginal walls.

This is usually done with the use of key-hole techniques (laparoscopically) or can be done via open approach (cut in the abdomen) if required.

The operation is performed under general anaesthesia and involves the suspension of the womb to the ligament overlying the sacrum (tail bone) with the help of permanent, synthetic mesh (lightweight polypropylene).

The mesh is then completely covered under the lining of the abdomen called peritoneum, to prevent the bowel getting stuck to the mesh.

Please note that the abdominal mesh is not included in the recent controversies involving vaginal or incontinence meshes.

The sacrohysteropexy provides robust support to the womb. Further, a repair inside the vagina may be required at the same time to address concomitant weaknes of the front or back wall of the vagina.

A cystoscopy (camera test to the bladder) is also performed to ensure that no damage has occurred to the bladder or ureters (the tubes connecting the kidneys to the bladder).
At the end of the operation, a urinary catheter is inserted into the bladder to drain urine overnight.

Recovery following your operation usually takes up to 6 weeks. You would be able to perform light activities such as short walks within a few weeks of surgery. You would be advised to avoid heavy lifting for at least 6 weeks to allow the wounds to heal. Sexual activity can usually be safely resumed after 6 weeks.

External link:

https://www.yourpelvicfloor.org/conditions/uterine-preservation-surgery-for-prolapse/

The sacrospinous fixation is a non-mesh procedure that allows restoring the support
to the uterus or the top of the vagina (vaginal vault), in women who have undergone a previous hysterectomy.
The operation can be performed under general or spinal anaesthesia and involves suspension of the vaginal vault or the cervix (in the presence of a womb) to a strong ligament in the pelvis called the sacrospinous ligament. This is performed through a cut in the vagina allowing access to the strong ligament.

The stitches that are used are slowly absorbed over time. This allows overtime for the stitches to be replaced by scar tissue that then supports the vagina or uterus.

Commonly, sacrospinous fixation may be combined with other surgeries such as vaginal hysterectomy, anterior repair, posterior vaginal repair or concomitant incontinence procedure.

At the end of the operation, a urinary catheter to drain the bladder and a vaginal gauze pack to reduce bleeding or bruising are sited overnight. On removal of the urinary catheter, we will ensure that you empty your bladder completely before discharge. 10% of women, after pelvic floor surgery, may require a short period of catheterisation to allow return of bladder function.

External link:

https://www.yourpelvicfloor.org/conditions/sacrospinous-fixation/

Colposleisis (i.e.vaginal closure) is a procedure that allows to partially close the vagina and treat symptoms of uterine or vaginal wall prolapse.
Colpocleisis is only suitable for women who are not sexually active (and not intending to be at any point
in the future) as the vagina opening is closed off, not allowing vaginal intercourse.

This operation is mainly reserved for frail women, with medical problems that make them unsuitable for longer operations; women who haven’t been able to use a vaginal pessary successfully or have failed previous prolapse procedures.

It can be performed under local anaesthesia and sedation, a regional (spinal) or general anaesthetic.

It involves removing a portion of the front and back walls of the vagina, which are then sutured together resulting in a partial closure of the central part of the vagina cavity.

A cystoscopy (camera test to the bladder) is also performed to ensure that no damage has occurred to the bladder or ureters (the tubes connecting the kidneys to the bladder).
At the end of the operation, a urinary catheter is inserted into the bladder to drain urine overnight.
External link:

https://www.yourpelvicfloor.org/conditions/colpocleisis/

Urinary incontinence refers to the accidental leakage of urine from the bladder.

It is estimated that a third of women at the age of 40 or over, in the UK, have significant urinary symptoms, with 12% experiencing incontinence weekly.

This can be a cause of anxiety, social embarrassment and may limit your social and daily activities. Many women feel embarrassed to talk about it or reluctant to look for management options due to beliefs that this condition is ‘normal’, especially as they get older.

I would like to reassure you that fortunately most conditions of urinary incontinence can be successfully managed through gaining understanding of your condition and access to the full range of non- surgical and surgical options available.

There are two main types of urinary incontinence:

 

1) Urgency Urinary Incontinence (Overactive Bladder)

It occurs when you cannot hold urine long enough to reach the toilet in time. It is usually associated with a urgent or strong sensation to pass urine, frequently, as well as night.

External link:

https://www.yourpelvicfloor.org/conditions/overactive-bladder/

2) Stress Urinary Incontinence (cough or activity related)

Is most often described as loss of urine during coughing, sneezing, laughing or with other physical activities such as running, jumping, exercise etc.

External link:

https://www.yourpelvicfloor.org/conditions/stress-urinary-incontinence/

If you suffer from a combination of stress and urge incontinence, then you have ‘mixed urinary incontinence’.

Bladder investigations:

In order to gain more understanding of the function of your bladder, I may ask you to fill in a 2-3 days bladder diary. This is a simple bladder chart , which allows you to record the amount of fluids you drink and the urine you pass throughout the day or night, but also any episode of urgency or urinary leakage.

The bladder diary is incredibly useful in providing information on fluid intake, voiding habits and inform on management strategies.

External link: https://www.yourpelvicfloor.org/conditions/bladder-diary-2/

If the cause of your urinary incontinence is not clear from clinical assessment and the bladder diary alone, then urodynamics test will usually be recommended.

The urodynamics test is performed in office setting, usually lasts around 30 minutes and aims to re-creates your symptoms. It provides information on the function and ability of the bladder to fill, empty and hold normal amount of fluid.

The test involves the placement of a thin plastic tube (catheter) in the bladder, and another small tube in the vagina or the back passage. Sterile fluid is then used to fill the bladder and determine how it behaves as it is fills up.

During the test you would be asked questions about the sensations in your bladder to help the diagnosis.

The results of urodynamic testing will provide us with additional information in order to decide together on the best treatment available to you.

External link: https://www.yourpelvicfloor.org/conditions/urodynamics/

Bladder problems can cause you to leak urine during activities, rush to the toilet many times during the day and night, and sometimes leak urine before you reach the toilet.

Pelvic floor exercises can strengthen the group of muscles and ligaments that support the urethra, bladder, uterus and lower bowel. Regular exercises can help you gain back the control of your bladder function by allowing you to ‘hold on’ until an appropriate time and place.

Like all muscles, the pelvic floor muscles need be exercised regularly in order to work well. Many women experience an improvement in stress incontinence (leakage with cough, sneeze, exercise) with pelvic floor muscle training. Pelvic floor muscle training can be used in conjunction with bladder retraining in the management of women with urgency incontinence (overactive bladder).

Women with urge incontinence (overactive bladder) often benefit from lifestyle changes such as reducing caffeine and alcohol intake, stopping cigarettes, weight reduction and avoiding constipation. In addition, bladder training and a range of medications that can relax the bladder muscle can be offered to treat overactive bladder symptoms.

External links:

https://www.yourpelvicfloor.org/conditions/bladder-training/

https://www.yourpelvicfloor.org/conditions/pelvic-floor-exercises//

The Burch colposuspension is one of the original procedures for the treatment of stress urinary incontinence, described in the early 1960s.This operation avoids the use of mesh and has seen a comeback as an alternative to the sling ‘mesh’ incontinence procedures (TVT,TOT, mini-slings) , following their restriction for use and pause in the UK.

The Burch operation is performed under general anaesthetic and can be performed by laparoscopic (key-hole) or open (cut in the abdomen) approach.

The key-hole Burch colposuspension, is performed through small incisions on the abdomen. Once inside the abdomen, the area behind the pubic bone and above the top of the vagina is explored. Synthetic, permanent stitches are placed on each side of the urethra, through the vaginal wall and into strong ligaments on either side of the pubic bone (Copper’s ligaments).

This provides support to the urethra and prevents urine leakage with activity.

At the end of the operation, a cystoscopy (camera test to the bladder) is also performed to ensure that no damage has occurred to the bladder or ureters (the tubes connecting the kidneys to the bladder). A catheter is then inserted into the bladder to drain urine and remains in place over night.

On removal of the urinary catheter, we will ensure that you empty your bladder completely before discharge.

External links: https://www.nice.org.uk/guidance/ng123/resources/patient-decision-aids-and-user-guides-6725286109

This procedure uses a sling that is made using your own body tissue from your abdomen.

It is usually performed under general anaesthesia. It involves a cut in the lower abdominal wall and a small incision in the vagina. The sling is taken from the rectus sheath in the lower abdominal wall and placed under and around the water – pipe (urethra) through the small vaginal incision. The ends of the sling are tied over the rectus sheath. This supports the urethra and prevents stress incontinence from occurring.

At the end of the operation, a cystoscopy (camera test to the bladder) is also performed to ensure that no damage has occurred to the bladder or ureters (the tubes connecting the kidneys to the bladder). A catheter is then inserted into the bladder to drain urine and remains in place over night.

On removal of the urinary catheter, we will ensure that you empty your bladder completely before discharge.

External link: https://www.yourpelvicfloor.org/conditions/fascial-slings/

During this procedure a synthetic, permanent substance (Bulkamid@) is injected into the muscular wall of the urethra (water pipe) under direct vision, using a thin camera. The ‘filler’ bulks up the wall of the urethra, resulting in less, or no, urine leakage. Although the cure rate is less compared to the autologous fascial sling or Burch procedures and its benefits wear off with time, it is less invasive, does not require incisions, has a low complication rate and can be performed as a day procedure under local, spinal or general anaesthetic.

If urinary incontinence returns the paraurethral bulking procedure may be repeated (“top-up” injection) or an alternative treatment remains an option.

External link: https://www.yourpelvicfloor.org/conditions/urethral-bulking/

Botulinum Toxin injection is a treatment for urgency urinary incontinence in women with overactive bladder, who have failed to improve with lifestyle modifications and medications.

It works by relaxing the muscle of the bladder wall (the detrusor muscle), reducing the sensation of urgency and urge incontinence episodes.

The procedure is usually performed as a day case under local anesthetic, sedation or general anesthesia.

The Botulinum Toxin is diluted in water solution and injected into the wall of the bladder at 20 different sites under the guidance of a camera (cystoscope) inserted through your water pipe (urethra).

Following the treatment your bladder is emptied and you will be discharged home after ensuring that your bladder is emptying well.

If this is not the case, you will be taught self-catheterisation which involves

passing a tiny tube into the bladder up to 3 to 4 times a day to empty it until your bladder function returns.

Bladder botulinum injections usually wear off over 6 to 9 months, occasionally longer, and repeat treatments can be performed.

External link: https://www.yourpelvicfloor.org/conditions/botulinum-toxin-a-bota-for-overactive-bladder-and-neurogenic-detrusor-overactivity/

This is a camera test to your bladder and water pipe (urethra).

It helps further in the diagnosis of conditions such as loss of bladder control (incontinence) or overactive bladder, frequent bladder infections, blood in the urine (hematuria), pain in the bladder, urethra and also during a surgical procedure such as a hysterectomy, prolapse or incontinence procedure to ensure there has been no damage to the bladder or the ureters. There are two main types of cystoscopes – flexible or rigid. A flexible cystoscope is a thin telescope (camera) which is passed into the bladder via the urethra. Because it is flexible, it usually passes easily along the

curves of the urethra and can also be moved to look at all the inside lining of the bladder.

A rigid cystoscope is a shorter, rigid telescope. It allows a greater variety of devices to pass down side channels for example if it is required to take samples or inject into the bladder. Sometimes, it is necessary to perform a rigid cystoscopy at a later date after a flexible cystoscopy.

It can be performed under local or general anaesthesia in outpatient setting or in operating theatre. It usually takes 15-20 minutes to complete. During the procedure your bladder is filled with a sterile liquid to allow a good view of the bladder wall. You will be able to empty the bladder as soon as the examination is over.

External link: https://www.yourpelvicfloor.org/conditions/cystoscopy/

A hysteroscopy an operation carried out to look inside the uterus using a thin telescope called a hysteroscope. The hysteroscope is inserted through the vagina and cervix.

It is usually performed to investigate heavy or irregular periods, to investigate bleeding after the menopause, to obtain a small sample (biopsy) for further, more detailed examination in the laboratory or remove polyps from inside the womb .

It can be performed either in the outpatient setting or in operating theatre, normally as a day case.

External links: https://www.rcog.org.uk/en/patients/patient-leaflets/outpatient-hysteroscopy/

In gynaecology, diagnostic laparoscopy helps making a diagnosis by looking inside the pelvis. Diagnostic laparoscopy is performed under general anaesthesia where small cuts are done onto the abdomen to allow access into the cavity of the pelvis.

The extent of your operation depends on your personal circumstances and will be discussed in the details at your consultation.

The procedure is usually performed as a day case and you will be able to go home the same day.

External links: https://www.rcog.org.uk/en/patients/patient-leaflets/laparoscopy/

If the cause of your urinary incontinence is not clear from clinical assessment and the bladder diary alone, then urodynamics test will usually be recommended.

The urodynamics test is performed in office setting, usually lasts around 30 minutes and aims to re-creates your symptoms. It provides information on the function and ability of the bladder to fill, empty and hold normal amount of fluid.

The test involves the placement of a thin plastic tube (catheter) in the bladder, and another small tube in the vagina or the back passage. Sterile fluid is then used to fill the bladder and determine how it behaves as it is fills up.

During the test you would be asked questions about the sensations in your bladder to help the diagnosis.

The results of urodynamic testing will provide us with additional information in order to decide together on the best treatment available to you.

External link:

https://www.yourpelvicfloor.org/conditions/urodynamics/

Pelvic floor ultrasound is a specialist investigation that allows imaging of the bladder, water pipe (urethra), vagina, cervix, womb (uterus), perineum, anal canal, and the pelvic floor muscles.

It provides further information on pelvic floor problems such as prolapse of the bladder, uterus, rectum and bowel, previous damage to the pelvic floor muscles and/or anal canal during childbirth or if you have previously had ‘mesh implants’ or a sling inserted, these may also be seen on the scan. Other findings include incomplete emptying of the bladder, function of the pelvic floor during muscle contraction, and complex problems of the back passage including prolapse of the back wall of the vagina.

The scan is performed in clinic setting and involves placement of a hand-held scan probe (transducer) onto the perineum (transperineal). An internal scan may also be required – this involves placing a scan probe into the vaginal introitus (endovaginal scan) and/or into the anal canal (endoanal scan).

The different approaches allow more detailed assessment and provides more insight into complex pelvic floor disorders.

Ultrasound scans are considered to be safe, and there are no known risks of performing pelvic floor scans.

External link: https://www.yourpelvicfloor.org/conditions/transperineal-pelvic-floor-ultrasound-scan/

Pregnancy and childbirth are unique experiences in the life of women. The outcome of a healthy mother and healthy baby are desirable end points, but many factors can influence the outcome of any pregnancy or childbirth.

Approximately 1-3% of women who deliver vaginally experience pelvic floor trauma in the form of obstetric anal sphincter injury (OASI). This may also be called a third or fourth degree tear. Risk factors include forceps or ventouse delivery, having a baby weighing more than 4 kg or having a baby that is “back to back” but often there is no particular reason identified.

Following repair, the majority of women (80%) recover well and have no problems at the 3-year follow up. A small number of women may have problems at follow up such as urgency (being unable to hang on and having to rush to the toiled to open the bowels) or incontinence (being unable to control bowel movements or gas). Most of the time, these problems will settle with measures such as physiotherapy. A small proportion of women will need further treatment for bowel disturbances.

The endoanal ultrasound is a specialist internal scan of the entrance to the anus that allows detailed assessment of the anal muscles. It provides information on muscle healing and/or persistent sphincter defects. It helps informed decision regarding mode of delivery in future pregnancy or management of persistent symptoms.

The scan is performed in clinic setting, may feel slightly uncomfortable but is not painful and takes 10-15 minutes.