Prolapse Repair

Also see our prolapse information page.

The International Urogynaecological Associsation (IUGA) has a huge range of patient information leaflets available here. 

The pamphlets that may be of most interest are:

• Pelvic Organ Prolapse (outlines the different types of prolapse, and the options to manage these)

• Anterior Vaginal Repair (surgery to repair prolapse where the bladder is pushing on the front wall of the vagina)

• Posterior Vaginal Repair and Perineal Body Repair (surgery to repair where the bowel is pushing on the back wall of the vagina, or the muscles between the vagina and anus are weakened)

• Sacrospinous Fixation (surgery to suspend the top of the vagina to the sacrospinous ligament at the back of the pelvis)

There are three main areas that contribute to prolapse - the front wall of the vagina (next to the bladder), the top of the vagina (joining the cervix and uterus) and the back wall of the vagina (next to the bowel). The muscles and tissue that support these areas can weaken with childbirth (especially if forceps are used, or there are tears at the birth), with menopause, and with activities such as heavy lifting and chronic coughing. 

In basic terms there are four main surgical procedures that can address these issues, and these each address different parts of what is contributing to the prolapse. Often two or more of these procedures are needed to address the prolapse, and often the exact procedure can't be decided until the time of surgery, as the findings under an anaesthetic may be slightly different to examination in the clinic room. You will be informed of all the possibilities, and only procedures that you have consented to will be performed.

Note in the past mesh was used to repair prolapse; this is no longer available in New Zealand (and most other countries) due to the risks associated with mesh.

There are other more complex procedures that can address prolapse in specific situations (for example with a previous hysterectomy or previous prolapse surgery). These should be done by a gynaecologist or urogynaecologist with specific training and credentialling in these more complex procedures.

The four main procedures are:

1. Anterior vaginal wall repair - This addresses the bladder pushing down onto the front wall of the vagina. This involves a midline incision along the front wall of the vagina, pushing the bladder back and using dissolvable sutures to strengthen the tissue between the vagina and the bladder, and then closing the skin of the vagina. This will reduce a bulge coming from this area, and may affect bladder function (but is not a procedure to address incontinence). There is a small risk that this procedure makes incontinence worse. 

2. Sacrospinous fixation - This addresses the uterus and cervix (or top of the vagina where a previous hysterectomy has been done) prolapsing out of the vagina. A strong dissolvable suture is placed from the top of the vagina (directly near the cervix, or the scar from where the cervix a hysterectomy has been done previously) to the sacrospinous ligament - a big ligament that connects two parts of the pelvic bones. Occasionally the tension on this ligament can lead to pain in the buttock that usually resolves after a few weeks; if it does not resolve there is a small chance of needing a repeat procedure to release the stitch.

3. Posterior vaginal wall repair - This addresses the bowel (or abdominal cavity) pushing down into the back wall of the vagina. This involves a midline incision along the back wall of the vagina, pushing the bowel (or abdominal cavity) back and using dissolvable sutures to strengthen the tissue between the bowel (or abdominal cavity) and the vagina, then closing the skin of the vagina. This is almost always done in conjunction with a perineal body repair, as the two areas are generally linked.

4. Perineal body repair - This addresses weakness in the muscles between the vagina and the anus. These muscles are stretched and often torn during childbirth, and often never completely return to their normal anatomy. Loss of support at this area is a big contributor to prolapse. A small incision is made at the bottom of the vaginal opening, the muscles are brought together with dissolvable sutures, and the overlying skin is closed. 

Detailed informations about each of these procedures, the anatomy, the risks involved and what to expect afterwards is available in the pamphlets above under Resources.

Before surgery it is important to make sure you have a good understanding of what procedures are planned, the risks involved, and what to expect.

It is ideal if you are not constipated at the time of prolapse surgery, so if you need to take some laxatives in the week leading up to surgery please let us know and we can prescribe these as needed.

For general advice around preparing for surgery, see "Preparing for Surgery" in the links above.

After prolapse surgery it is normal to be in hospital for 1-2 nights.

When you wake up from surgery there you will most likely have a catheter (a tube in the bladder) and a vaginal pack (a gauze swab that acts like a tampon to put pressure against the sutures). Both of these will usually be removed early the morning after surgery. 

Local anaesthetic will be used during the surgery as well as strong painkillers with the anaesthetic, so it is not expected for there to be a lot of pain when you wake up from surgery. The local anaesthetic will wear off after several hours, and tablet pain killers are usually able to manage pain well. 

After you leave hospital, it is important to:

• Avoid heavy lifting for at least 3 months

• Avoid sexual intercourse (anything in the vagina) for at least 6 weeks, sometimes longer

• Avoid constipation as much as possible

A follow up visit will be booked at 6 weeks to see how symptoms are improving and check in.