Vaginal Prolapse

What is Vaginal Prolapse?

Vaginal prolapse occurs when the internal tissue of the vagina protrudes outside. While only the vaginal tissue may sag, the bladder, intestines, uterus, or, if the uterus has been removed, the entire vaginal apex (cuff prolapse) may descend.

What Does Prolapse Mean?

The uterus, bladder, and rectum are held in place within the pelvic bone by supportive ligaments and muscles that counteract gravity. Prolapse refers to the downward displacement of the uterus and other structures due to the weakening of these ligaments caused by factors like childbirth or excess weight, resulting in their descent and protrusion through the vagina.

In prolapse, the uterus, bladder, and rectum may sag individually, but often all these organs descend together outside the vaginal opening.

What Causes Vaginal Prolapse?

The pelvic floor in women connects the vaginal cavity to the exterior. In men, this area is closed. Factors such as natural vaginal childbirth, delivering large babies, prolonged labor, smoking, and being overweight cause tears and weakening in the ligaments supporting the uterus and vagina in the pelvic bone. As a result, the uterus and other structures may protrude through the vaginal opening.

If the prolapse extends outside the vagina, surgical intervention is typically performed to suspend the uterus and vagina upward to prevent them from protruding again.

What are the Symptoms of Vaginal Prolapse?

Since the top of the vagina is near the uterus, bladder, and rectum, the symptoms of vaginal prolapse are often intense. These symptoms include:

• A mass felt in the vaginal area
• Lower abdominal pain, which worsens when standing, due to stretched ligaments
• Frequent vaginal infections
• Recurrent severe uterine infections (endometritis)
• Frequent urinary tract infections
• Incontinence or difficulty urinating
• Unpleasant sounds from the vagina during sexual intercourse
• Reduced sexual desire and significant loss of self-confidence
• Difficulty achieving orgasm
• Gas incontinence or difficulty passing stools
• Needing to manually push the vaginal mass back inside to pass stool
• Persistent constipation even with the use of stool softeners

These symptoms significantly reduce quality of life.

Stages of Prolapse

After evaluating patients in the clinic, treatment decisions are made based on the stage of the prolapse. The stage is determined by measuring how many centimeters the vaginal structure protrudes beyond the hymen.

When deciding on surgical treatment, the POP-Q staging system accurately determines the degree of prolapse for the bladder, bowel, and vaginal apex (cuff if the uterus has been removed or the uterus if it remains). According to the POP-Q staging system, prolapse is categorized from Stage 1 (mildest) to Stage 4 (most severe).

How is Vaginal Prolapse Diagnosed?

Vaginal prolapse is identified by the presence of a mass protruding from the vagina and difficulties with urination or bowel movements. If a patient complains of vaginal gas discharge when walking or lower abdominal pain worsening when standing, vaginal prolapse is likely.

During vaginal tightening or vaginoplasty, gynecologists should carefully check for prolapse. If prolapse is present, the suspensory ligaments must be repaired in conjunction with vaginal tightening. Otherwise, vaginal widening will recur, and existing complaints may worsen.

How Can Vaginal Prolapse Be Prevented?

To prevent vaginal prolapse, pelvic floor ligaments and muscles should be protected from trauma during childbirth by performing childbirth exercises and Kegel exercises.

Avoiding large-birth-weight deliveries, correct pushing during childbirth, maintaining a healthy weight, refraining from heavy lifting, and not smoking can help prevent prolapse. However, the most critical factor is the individual variation in collagen and connective tissue, making complete prevention impossible.

Treatment for Vaginal Prolapse

Treatment for vaginal prolapse depends on the organ involved:

• If the uterus has prolapsed: vaginal hysterectomy
• If cuff prolapse has occurred (vaginal apex prolapse after uterine removal): sacrospinous fixation, preferably vaginally
• If the bladder has prolapsed: cystocele repair
• If the vaginal side walls have prolapsed: paravaginal defect repair
• If uterine prolapse occurs in a woman planning childbirth: uterine suspension through the abdomen in selected cases
• If bowel prolapse occurs: rectocele repair

Pelvic floor function is a whole, so surgical planning must follow the POP-Q staging system. Often, these surgeries are combined to eliminate vaginal prolapse and associated symptoms. The goal of vaginal prolapse treatment is to resolve both the prolapse and the associated complaints. Comprehensive preoperative evaluation is essential.

Does Vaginal Prolapse Recur After Treatment?

The purpose of POP-Q staging in vaginal prolapse patients is to identify weak points in the pelvic floor and determine areas where prolapse has started but is not yet complete. By addressing these points during surgery, recurrence from other weak areas can be prevented.

If surgical treatment does not address the pelvic floor as a whole, recurrence may occur in the future. Therefore, a comprehensive approach to the pelvic floor is essential when planning treatment. Properly treated patients have a low risk of recurrence.