From the Guidelines
Vaginal prolapse treatment should prioritize a multidisciplinary approach, focusing on pelvic floor exercises, pessary use, and lifestyle modifications for mild cases, while reserving surgery for more severe cases, as this approach has been shown to improve quality of life and reduce morbidity 1.
Introduction to Vaginal Prolapse
Vaginal prolapse occurs when the pelvic floor muscles weaken, causing the vagina and surrounding organs to descend into or outside the vaginal canal. This condition can result from various factors, including childbirth, aging, menopause, chronic straining, obesity, or genetic factors that weaken connective tissues.
Diagnosis and Evaluation
The initial evaluation of patients with suspected vaginal prolapse is clinical, beginning with a physical examination 1. Imaging tests such as fluoroscopy cystocolpoproctography (CCP) or MR defecography may be obtained when the clinical evaluation is difficult or considered inadequate, or if patients present with persistent or recurrent prolapse symptoms after attempted surgical or nonsurgical treatments 1.
Treatment Options
Treatment depends on the severity and symptoms of the prolapse. For mild cases,
- Pelvic floor exercises (Kegel exercises) performed regularly can strengthen supporting muscles.
- A pessary, a removable device inserted into the vagina, can provide structural support and relieve symptoms. For more severe cases,
- Surgery may be necessary to repair and restore the normal position of the vagina and surrounding organs.
- Hormone replacement therapy may help postmenopausal women by improving tissue elasticity. Lifestyle modifications are also important, including
- Maintaining a healthy weight
- Avoiding heavy lifting
- Treating chronic cough
- Preventing constipation through adequate fiber and fluid intake.
Impact on Quality of Life
Vaginal prolapse can significantly impact quality of life through symptoms like pelvic pressure, urinary or bowel problems, sexual dysfunction, and discomfort 1. Early intervention can prevent worsening of the condition and improve outcomes. The goal of any treatment strategy is to improve the patient’s quality of life, as vaginal prolapse primarily causes morbidity but is not life-threatening 1.
From the Research
Definition and Prevalence of Vaginal Prolapse
- Vaginal prolapse is a prevalent condition, with up to 12% of women requiring surgery in their lifetime 2
- It is common, and some degree of prolapse is seen in 50% of parous women 3, 4
Symptoms of Vaginal Prolapse
- Patients with prolapse may present with a vaginal bulge or pressure, bladder, bowel, or sexual symptoms 5
- Women with prolapse can experience a variety of pelvic floor symptoms 3, 4
Management Options for Vaginal Prolapse
- Management options include conservative measures, pessary use, or surgical intervention 2, 5
- Conservative management approaches, such as giving lifestyle advice and delivering pelvic floor muscle training, are often used in cases of mild to moderate prolapse 3, 4
- Pessaries are the most commonly used conservative management options 2
- Guided pelvic floor muscle training is more beneficial than self-taught Kegel exercises, though may not be effective for high stage or apical prolapse 2
Surgical Treatment Options
- Surgical treatment options include abdominal and vaginal approaches, the latter of which can be performed open, laparoscopically, and robotically 2
- Sacrocolpopexy has better long-term success for treatment of apical prolapse than vaginal techniques, but vaginal surgery can be considered an acceptable alternative 2
- Uterosacral ligament suspension and sacrospinous ligament suspension are considered equally effective procedures and can be combined with a vaginal hysterectomy 2
- Robotic assisted sacrocolpopexy and laparoscopic assisted sacrocolpopexy are equally effective and should be utilized by pelvic floor surgeons based on their skill level and expertise in laparoscopy 2
Conservative Management
- Pelvic floor physical therapy (PFPT) with a physical therapist is the best approach to conservative management of apical prolapse 2
- Pessaries should be managed with regular follow-up care to minimize complications 2
- There is now some evidence available indicating a positive effect of pelvic floor muscle training (PFMT) for prolapse symptoms and severity 4