Category — Uterine Prolapse

(C) Lauri Romanzi, 2010

Pelvic organ prolapse, the medical term for vaginal bulges caused by damage to the connective tissues supporting the organs above and around the vagina (the uterus, bladder, rectum and vaginal opening), is a silent epidemic affecting women worldwide. Common terms include dropped bladder, dropped uterus, rectocele and vaginal laxity. Recent estimates using US Census population projections anticipate a 46 percent increase in pelvic organ prolapse among American women over the next 40 years, from 3.3 million in 2010 to 4.9 million. According to a recent study from Duke University, it is possible that the number of women with prolapse will be even greater than this, up to 9.2 million. Prolapse may occur to varying degrees in up to 50 percent of women who’ve given birth. Prolapse can even cause depression.

Childbirth contributes to most prolapse conditions, however genetics, medical disorders such as connective tissue disease, diabetes and obesity, and lifestyle habits have all been shown to contribute to pelvic organ prolapse risk. I’ve had many young women in their 30’s with prolapse who’ve never been pregnant, or found themselves suffering a dropped bladder after an easy and quick delivery of their first normal (or even low) weight baby. Even cesarean section is no guarantee against pelvic organ prolapse, with 5% of women in one recent study suffering severe, palpable and visible prolapse even though they delivered by cesarean section before going into labor. The role of Kegel fitness and Kegel exercise in the prevention of treatment of pelvic organ prolapse is just recently getting the research attention it deserves, and Kegel exercise may well play a role in prevention and treatment of prolapse. But for certain, if you suffer prolapse that looks like the image below, no amount of pelvic floor Kegel exercise, or any other kind of exercise, will pull your parts back into place.

Prolapse surgery often comes with a recommendation for hysterectomy, but the latest trends highlight new techniques that fix the prolapse just as well without removing the uterus. When the uterus prolapses it can be resuspended by one of several techniques, and the surgery holds up just as well as when a hysterectomy is included in prolapse repair surgery. This uterine resuspension concept is an exciting new option that allows many women to undergo prolapse repair surgery without removing any organs.

While many women with prolapse believe just one single body part is out of postion, most commonly, prolapse involves hernia-type displacement of several organs. When the bladder drops, formally called a cystocele (siss-toe-seal), it is often accompanied by a rectal bulge, called a rectocele (wreck-toe-seal).  Laxity at the vaginal opening, called a perineocele (pear-in-ee-oh-seal) results when the perineum loses connective tissue bulk as a result of childbirth.  Uterine prolapse is called, well, uterine prolapse. But behind a prolapsed uterus, it is common to find an internal small intestine hernia called an enterocele (en-tare-oh-seal).

When you put all these prolapse possibilities together at their absolute worst, it looks like this:

Courtesy WomensVoicesForChange.org

My role as guest blogger gives me the opportunity to demystify this deeply troubling malady.  For more information, check out this first of 2 posts on pelvic organ prolapse done for my friends at Sweet Talk on The Spot:

Dr R covers Prolapse, Part 1 for Sweet Talk on The Spot

To review Dr R’s book on prolapse, see www.plumbingandrenovations.com

If you have any questions, send in your comments on this post or post your own question to Ask Dr R.

(C) Lauri Romanzi, 2010

I urge you all to check out the entire content on Women\’s Voices for Change, an online resource for grown women and the people who love them.

Betty, a woman with uterine prolapse, recently wrote in to this blog, asking advice after her doctor told her she would need a hysterectomy to fix her prolapse. We now understand that the mechanics of prolapse are all about those ligaments, and that the uterus, literally, contributes nothing to prolapse other than it’s change in position from “up there” to “out there”.  Dr. Pat Allen, Gynecologist extraordinaire and founder of Women’s Voices for Change, called me in to pinch hit on this one, and with bases full, Dr. R goes to bat:

Dear Betty,

You’ve done a great job of describing a condition that many women are intimately familiar with and, like you, embarrassed to talk about. I asked WVFC Medical Advisory Board member Lauri Romanzi, M.D., a specialist in reconstructive pelvic surgery and urogynecology, to respond. Which she did, pulling out a drawerful of medical illustrations to help explain what’s going on in your body, and why a hysterectomy isn’t the answer. —Dr. Pat

Betty\’s Prolapse Problem

The uterus comes with dual support, one robust uterosacral ligament on each side, holding it in place at the top of the vagina.

Repeat after me… Resuspend – Do Not Remove.  Hysterectomy is not a cure for prolapse, Hysterectomy is a cure for having a uterus.  There are three basic categories of uterine resuspension:

#1: Suspend the uterus to one or both adjacent sacrospinous ligaments

Sacrohysteropexy: Resuspend with an "artifical uterosacral ligament" graft

  For more details click on the role of Kegel exercises in uterine prolapse, click this interview link:

Dr. R for Sweet Talk on the Spot – Prolapse Part 2

And if you absorb nothing else, retain this: When it comes to prolapse, the uterus is a victim, not a perpetrator. Prolapse occurs because the ligaments supporting the uterus gave way, not because the uterus is heavy.  Uterine resuspension (hysteropexy) works just as well as do prolapse repairs where the uterus is removed (hysterectomy).  Durability is essentially the same. There is zero advantage to removing the uterus to repair prolapse. However, if you have prolapse and also suffer a separate,  good reason to consider hysterectomy, such as severe fibroids or endometriosis or high personal risk for gynecologic cancers, there may be a true benefit to removing the uterus at the time of prolapse repair.  Otherwise, lift that uterus up into normal position with a resuspension procedure and get on with your life! 

To find a surgeon to do your uterine resuspension in your area,  visit http://www.mypelvichealth.org/FindaProvider/tabid/75/Default.aspx and ask your regional specialists if they are comfortable and experienced with uterine resuspension for uterine prolapse.

Dear Dr. Romanzi,
(I bet you don’t get too many men writing you for help!) My dearest sweetheart suffers from a prolapsed uterus/bladder and is considering having a hysterectomy at the advice of her gyno. Being a former pre-med student and having seen what my mother and sister-in-law went through in their hysterectomies (cancer related…) I keep trying to convince her that this a radical surgical approach for a problem that demands far less. She has had 2 children, is 52 years old and is physically active. However, “the bulge” is causing her discomfort in her exercising and she is talking more and more of the hysterectomy. I am ordering your book tonight, but in the meantime had some questions… 1) Since she is past her childbearing years, is reconstructive surgery appropriate, or could a pessary work? 2) We are from Cincinnati, OH. I went to the AUGS website to try and find providers in our area, but I wasn’t sure if these are just gynecologists or OB’s who perform reconstructive surgery, and 3) Is the reconstructive approach treated as “cosmetic” surgery from an insurance perspective, or is it usually a covered procedure. If the former, what does it typically cost? She is a women of limited means and this obviously comes into the equation. Thanks so much for your help. D

Hello D,

Thank you for writing in – I know there are more men out there trying to help the women they love, and your willingness to post your questions will undoubtedly help other men actively advocate for the health of the women in the lives.
1) Since she is past her childbearing years, is reconstructive surgery appropriate, or could a pessary work?
She may do perfectly well with a pessary and I often advise pessary use before any other therapies are considered. But some women cannot be fit with comfortable pessary or a pessary that truly holds it all in due to the severity of prolapse (the worse the prolapse the more difficult to find a well fitting comfortable pessary) or idiosyncracies in the boney pelvis that make pessaries uncomfortable, in which case the next option is reconstructive surgery. Some women may be fitted for a pessary that works perfectly well, but they find it annoying or “unsexy” to use, in which case it may be worn until she has time to undergo reconstructive surgery and it’s recuperation (~4 weeks to return to work, 6-8 week til sex is possible). Pessaries that fit well physically and jive with lifestyle and body image provide an excellent non-surgical therapy for prolapse.
2) We are from Cincinnati, OH. I went to the AUGS website to try and find providers in our area, but I wasn’t sure if these are just gynecologists or OB’s who perform reconstructive surgery,
The major university medical centers all have urogynecology divisions run by fellowship trained specialists – these are a good place to start. You may want to obtain several opinions should you choose reconstructive surgery.
3) Is the reconstructive approach treated as “cosmetic” surgery from an insurance perspective, or is it usually a covered procedure
Prolapse surgery is the same as any other reconstructive surgery, be it a hernia, a knee repair or a rotator cuff repair. While not an emergency, it is a recognized condition that insurance companies do not consider cosmetic.
Finally, hysterectomy does not improve the durability of prolapse surgery, and she DOES NOT need a hysterectomy to benefit from excellent long term (hopefully life-long) results should she choose to undergo reconstructive pelvic surgery. Recurrence is possible with any and all reconstructive operations done anywhere in the body by any technique, and prolapse repair is prone to recurrence in the same way hernias may recur and damaged knee ligaments may not last forever after knee surgery. Reconstructive surgery puts things back together, unlike extirpative surgery that takes things out – appendix out, guaranteed you’ll never have to have it removed again! Hernia surgery – might need another one someday.
In order to help women understand the causes, therapies and surgeries for prolapse, I wrote PLUMBING AND RENOVATIONS as an in-hand resource for women with prolapse and/or incontinence (www.plumbingandrenovations.com). She may find this book a helpful guide as the therapeutic options are considered. Thank you for writing in and please do keep us posted.

Best Regards,
DR R

Plumbing and Renovations was written to demystify prolapse and incontinence. For starters, if you have prolapse, you do NOT need a hysterectomy, even if your uterus (take the kids out of the room) is hitting your knees.
A few reviews from readers:
1 of 1 people found the following review helpful:
5.0 out of 5 stars Informative and a surprisingly easy read!, December 26, 2008
By L. Y (New York, NY) -
This review is from: Plumbing & Renovations (Paperback)
This book truly saved me! After 2 opinions that I should get a hysterectomy, I found an alternative and am now working on my second child! After having my first, I needed help getting my pelvis back in shape. An incontinence issue acquired during my pregnancy also needed addressing. This book spelled it all out for me and with its amazing illustrations and information, I have seen a real improvement all of the way around.
I am hoping to see more of these “Beauty Call” books from this author, as I think they touch on subjects rarely addressed, in a thorough, concise and amusing way. Kudos! <

5.0 out of 5 stars Finally! An intelligent (and hilarious) surgeon, April 7, 2009
By EG “never_enough_books” (Athens, Greece) -

This review is from: Plumbing & Renovations (Paperback)
Ladies, if you have a dropped uterus (you’d be surprised how many women do) read this book first! You probably don’t need a hysterectomy. You also want to read this book if you suffer from a dropped bladder, your vagina is loose, or you want to know what treatments are available to, among other things, improve your sex life. Eminently readable, informative and wise, this book should be issued as a textbook for sex education classes, so thoroughly does it cover the subject of the female anatomy. Dr. Romanzi, I Kegel as I write this. Thanks!

5.0 out of 5 stars A hilarious entree into what your mom forgot to tell you – or never knew, December 30, 2008
By A G (New York) -
This review is from: Plumbing & Renovations (Paperback)
A friend gave me this book and I was SHOCKED by what no one – not your mom, not your doctors tell you. I learned more about my body from this book than I ever could have imagined. Plus, its a riot. It should be recommended reading for women.

I recently read your book, “Plumbing and Renovations” and appreciated the way you talked about topics that are typically viewed as ‘taboo’ in a conversational and optimistic way. My question is: how do you know if you are experiencing uterine prolapse, as opposed to vaginal prolapse? And which one is a more serious condition?

Hello Orange County,

You ask an excellent question. Most commonly, vaginal and uterine prolapse occur together, because pelvic support of the uterus and vaginal walls are interdependent and vulnerable to the same prolapse-inducing forces. Neither would be “more serious” than the other, and each can occur to variable degrees, as, having read the book, you are likely aware. For women with prolapse, sometimes the different areas of prolapse alternate “taking the lead”, making things even more confusing for the woman with the condition. A careful examination in various positions (lying flat, standing and seated) with a prolapse specialist will give you all the answers. Thank you for your commentary!
Best Regards,
Dr. R

www.plumbingandrenovations.com

Hello Doctor,
I am a 48 year old, one vaginal delivery with stress incontinence since. Recently had difficulty with tampon insertion during period….went to PCP and she said I have a cystocele and prolapse of uterus. I am so stressed about it. I am extremely active and lift weights and kickbox..do a lot of cardio with jumping. Now feels like I have a tampon in when I work out after. I have three fibroids…one in fundus meas. 5cm one central meas. 4.8cm and one at lower margin 2.8cm. I am pertrified of mesh support. What do you as a woman who understands uterine preservation emotionally for a woman think about myomectomy with ligament suspension shortening and pessary when exercising and tabel invertion therapy????? Curious as to what you think.

Hello Ms. S,
You bring many important issues to the table. Your fibroids don’t sound big enough to be an issue here, but the necessity of myomectomy or other fibroid specific therapy can only be determined with a live consultation and recent imaging. Assuming your fibroids are present but of no clinical relevance at present, you may not even need surgery. With mild prolapse, pessary use and Kegel exercise may be all you need to hold the prolapse at bay while you continue to kickbox and live a full and active life. I am very strongly biased toward uterine resuspension for women with prolapse, unless there is a very good reason, aside from the prolapse, to consider concomitant hysterectomy, and completely understand and validate your emotional attachment to your uterus. I also understand your reticence regarding mesh – all graft materials must be carefully considered, and there is a growing concern regarding plastic/permanent mesh support grafting for prolapse repair. There is no data on table inversion therapy for prolapse, but it certainly won’t make anything worse. Or as I say in my book, parachute jumping, no, bungie jumping, yes. If you can travel to NYC, you can ask to speak to my patient advocate, Judy, about scheduling a consultation. Or you may find my book on pelvic organ prolapse and vaginal rejuvenation helpful – exercises, pessaries, graft materials and all the current uterine resuspension techniques are described and illustrated – see http://www.plumbingandrenovations.com. For a specialist in your area, see http://www.augs.org.
All the best!
Dr. R

Hi. I’m really scared and worried. I had sex a week ago and don’t really remember it due to an alcohol blackout (which is horrible in and of itself), but apparently it was for an extended period of time so I think I was pretty dry for the duration. I thought the first couple of days that I had a vaginal infection due to a lot of irritation and pain when urinating. I was constantly searching on the internet for an answer. (I couldn’t get in for a doctor’s appointment until this coming week – on 10/26.) Last Wednesday though, I noticed when I felt into my vaginal area, that it feels as though my vaginal walls have collapsed and it’s near my vaginal opening. I’m almost positive it’s a pelvic organ prolapse, but I haven’t read anywhere that it can be caused due to intercourse. Everything seems to mention childbirth and age being the causes. It must be possible through intercourse too because I think it’s happened to me. I’m horrified at how this will affect my life — quality of life, having kids, having sex. I’m only 36 years old and have not had children yet. Also I haven’t had very many partners and the last time I had sex before this was two years ago. If you would please respond back with any insight and advice, I would really appreciate it. Thanks.

Hello Ms. M,
By now you likely have your answer, as the response to your question failed to post and it’s been some time since you wrote in. Now, prolapse is definitely much more common in women who have given birth, but can and does occur in young, fit healthy women who have never been pregnant. Sex is not a known cause of prolapse – if you DO have prolapse, likely it was happening to you gradually with the sex/irritation/self-palpation of prolapse a coincidence. My youngest “never pregnant” patient with prolapse was a 31 year old, very fit, dancer, yoga practitioner who came in with severe enterocele and uterine prolapse. It can happen to anyone is the point, even if you are thin, young, fit and never stressed your pelvis with a pregnancy.

If you do have prolapse, it needs pessary support to keep it from getting worse, or surgical repair done carefully to resuspend the prolapsed parts without using any permanent graft materials that might complicate a pregnancy. Keep me posted – and for more information, you may want to peruse my book on incontinence, prolapse and vaginal rejuvenation – see http://www.plumbingandrenovations.com.

Best Regards,

Dr. R

This is what we have been looking for! The only thing her doctor has offered is a hysterectomy. After reading over 300 sites and personal stories of what other women have gone through after surgery and doing some research on our own we realized that this is NOT what we want. Would it be possible to let us know which Urologist in or near Springfield Oregon would be able to perform this procedure? Or if there are any in Oregon at all? Tanya has a Cystocele, Rectocele, and Uterine prolapse. The uterine prolapse is not severe and the uterus is healthy. Neither one of us wanted her to have a hysterectomy in the fist place but that was the only option given. Since we know (now) that ALL of these CAN be fixed, we really don’t feel that a hysterectomy is the answer. Thank you for reading this and for helping us out.