Surgical Treatment Options for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) occurs when the pelvic floor muscles and tissues become weakened or stretched, allowing pelvic organs to drop or press into the vagina or lower pelvic cavity. This condition can involve the bladder (cystocele), uterus (uterine prolapse), rectum (rectocele), intestines (enterocele), or the vaginal vault (after hysterectomy). Symptoms can include vaginal bulging, discomfort, bladder or bowel problems, and can impact quality of life.

While conservative treatments such as lifestyle changes, pelvic floor physiotherapy and pessaries may help, surgical options are recommended when symptoms persist or significantly affect wellbeing.

When is Surgical Treatment Necessary?

Surgical intervention is typically considered if:

• Non-surgical treatments have failed or are unsuitable
• Prolapse severity is high (stage 2+)
• Symptoms disrupt daily activities, intimacy, or health
• There are recurring urinary tract infections or continence problems

Importantly, the choice of surgery depends on the type of prolapse, overall health, age, preferences, and future family plans.

Surgical Options for Bladder Prolapse (Cystocele)

Bladder prolapse happens when the bladder descends into the vaginal canal, often causing urinary leakage or difficulty emptying the bladder.

• Anterior Vaginal Repair (Colporrhaphy): The most common procedure involves tightening vaginal tissues supporting the bladder, sometimes with dissolvable stitches. This approach may be combined with repairs for other prolapses.
• Mesh-Augmented Repair: Synthetic or biological mesh can reinforce weakened areas. However, use of mesh inside the vagina has raised safety concerns, and it is now used in select cases where other repairs have failed or aren’t possible. Mesh repairs typically happen via an abdominal route.

Bladder repairs focus on restoring bladder function, improving comfort, and reducing the risk of recurrent prolapse. Recovery usually takes around 6 to 8 weeks.

Surgical Approaches for Uterine Prolapse

Uterine prolapse involves the descent of the uterus into the vaginal canal. Surgical options include uterine-sparing and non-sparing procedures.

• Vaginal Hysterectomy: Removing the uterus via the vagina is a traditional method for severe prolapse, particularly when there are no plans for future pregnancy.
• Uterine Suspension (Hysteropexy): This technique supports the uterus using the body’s ligaments (native tissue repair) or synthetic mesh, without removing the uterus. It can be performed vaginally, laparoscopically, or with robotic assistance.
• Sacrohysteropexy: A mesh is used to attach the uterus to the sacrum (lower spine), usually via minimally invasive laparoscopic surgery. This method is suitable for younger individuals wishing to retain their uterus.

Both approaches aim for durable support and symptom relief. Choice depends on individual preferences, age, and health profile.

Treatment for Rectocele (Rectal Prolapse Into Vagina)

When the rectum bulges forward into the vagina, a rectocele occurs, sometimes causing bowel movement difficulties.

• Posterior Vaginal Repair: An incision inside the vagina enables the surgeon to sew stretched muscles and tissues back together, restoring support to both the rectum and vaginal wall.
• Perineorrhaphy: In some cases, the perineum (area between the vagina and anus) is tightened to further improve muscle support—offering additional protection against recurrence.

Strict attention is given to avoiding injury to the bowel and nerves, and most people experience relief from bowel-related symptoms.

Management of Enterocele (Intestinal Prolapse)

Enterocele involves the small intestine pushing into the area between the rectum and vagina.

• Surgical Repair: Tissues between the vagina and rectum are closed using either a vaginal or abdominal approach. The chosen method depends on the size, location, and whether other types of prolapse exist.
• Laparoscopic Options: Minimally invasive techniques allow for quicker recovery, reduced bleeding, and lower infection risks.

Enterocele repairs are often combined with procedures for cystocele or rectocele, achieving comprehensive pelvic floor restoration.

Vaginal Vault Prolapse: Restoring Support After Hysterectomy

After a hysterectomy, the vaginal vault may lack support and cause it to descend or bulge.

• Sacrocolpopexy: This procedure uses mesh to attach the vaginal vault to the sacrum via the abdomen (often laparoscopically). It provides strong, lasting support and is highly effective, especially in combination with repairs of other prolapsed organs.
• Sacrospinous Fixation: The top of the vagina is anchored to a strong ligament near the tailbone via a vaginal approach. This technique offers a less invasive alternative and can be suitable for those with significant medical conditions.
• Uterosacral Ligament Suspension: Ligaments around the top of the vagina are used for support, preserving vaginal length and function.

Your surgeon will discuss which approach best fits your anatomy, health status and preferences.

Recovery and Risks of Pelvic Organ Prolapse Surgery

Most procedures are performed under general or spinal anaesthesia, with hospital stays ranging from several hours to a couple of days. Recovery periods vary (typically 4 to 8 weeks), during which lifting, strenuous exercise, and sexual activity are restricted.

Potential risks include:

• Bleeding or infection
• Injury to bladder, bowel, or blood vessels
• Recurrence of prolapse
• Mesh complications (if used)
• Urinary or bowel problems
• Pain or discomfort

Choosing the Right Surgical Option

Selecting the best surgical treatment is a shared decision between you and your specialist. Pre-surgery discussions help ensure realistic expectations and tailored care. Key factors whcih are considered include:

• Severity and location of prolapse
• General health and anaesthetic risk
• Age, sexual activity, and plans for children
• Preference for retaining or removing pelvic organs
• Previous pelvic surgeries

Surgical options for pelvic organ prolapse offer hope for lasting symptom relief and restored quality of life. A personalised approach, guided by expert advice, ensures the best possible outcome. If you’re considering surgery, speak with your healthcare provider about the most suitable choices for your needs. In consultation with healthcare professionals, a personalised plan can restore comfort and confidence.

References

• NHS: Pelvic organ prolapse surgery
  https://www.nhs.uk/conditions/pelvic-organ-prolapse/treatment/
• Royal College of Obstetricians & Gynaecologists: Information for you – Pelvic organ prolapse
  https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/pelvic-organ-prolapse/
• NICE: Pelvic organ prolapse overview
  https://cks.nice.org.uk/topics/pelvic-organ-prolapse/
• British Society of Urogynaecology: Patient Information
  https://www.bsug.org.uk/pages/patient-information/2
• Continence Foundation UK: Pelvic organ prolapse
  https://www.continence.org.uk/pages/pelvic-organ-prolapse