If I have prolapse, do I definitely need surgery?
In a word, no. Or at least, most likely not. I wanted to get this question out of the way first, because I think prolapse can be a very scary diagnosis when you are first told you have it. Then, your brain (or at least mine!) jumps to the most extreme outcome, which would be surgery. As we discussed in a past article about the best exercises for prolapse, pelvic floor muscle training and core strengthening can be a really effective treatment for prolapse. It can relieve your symptoms, delay/prevent the need for surgery, and potentially even reduce the grade of your prolapse. Plus, pessaries are another great non-surgical option that can prevent or delay the need for surgery too (if the idea of a pessary is new to you, check out my past article on pessaries). So, especially if you are newly-diagnosed with prolapse, don't jump to the thought that you will have to have surgery some day!
Who does need surgery for prolapse?
Indications for prolapse surgery are the following:
Significant "bother" of symptoms (vaginal heaviness/pressure, associated bowel/bladder symptoms, difficulty/pain with intercourse, etc)
"Failed" a good trial of conservative treatment—PT/pelvic floor muscle training, pessaries, etc. that do not satisfactorily resolve symptoms
Completed childbearing
Typically more-advanced prolapse grades (3-4), unless with lesser grades the symptoms are severe and not responding to conservative treatment
If your prolapse is mild (grade 1-2), you are going to have more children, or have other medical conditions that would make surgery difficult, then you can/should avoid it! Typically the biggest differentiator regarding need for surgery is if the prolapse extends beyond the hymen, or external to the vagina. Conservative treatment is less likely to be successful (but not always, of course!) in cases where the prolapse is external to the vaginal opening. More often than not, surgery will eventually be needed to resolve symptoms. But, that doesn’t mean a good trial of conservative treatment isn’t a good idea!
How common is prolapse surgery?
It is pretty common, at least with age. If you have a uterus/vagina, you have a lifetime risk of 11-20% of undergoing a surgery for prolapse or stress incontinence. By age 80 the risk is 20%.
How successful is prolapse surgery?
It is very successful, especially in the short term! Success rates are generally around 80-90%, especially within the first 2 years following surgery. However, it is true generally that the further away you get from surgery, the more likely your prolapse may return. And we don't have a lot of high-quality studies that follow people after prolapse surgeries beyond 2 years (many stop around 6-12 months).
The other caveat here is how we define "success." There is a BIG difference between restoring your anatomy (i.e., reducing the organ back to its original position, and having it stay there) and improving your symptoms. Around 5 years post-op, the majority of repairs will have "failed" in terms of anatomy. Meaning that if someone did a vaginal examination, the prolapse will have returned (although potentially not to the same degree that it was present before). However, even in these cases, the symptoms are still reported to be much better, and happiness with surgery outcomes is still high. So this is further proof that the degree of prolapse isn’t always equal to the severity of symptoms, and that more research is definitely needed.
Why do prolapse surgeries fail?
There are a lot of reasons. The biggest one is that the tissues surgeons are trying to repair are very delicate. There's a really fine line between suspending an organ via it's own ligaments, or using mesh, with just enough tension vs. using too much tension. So it's always a balance between fixing the original problem without causing further complications.
The other is that many times, the original cause of the prolapse has not been corrected. As I discussed at length in my intra-abdominal pressure article, prolapse really is a top-down problem more than a bottom-up problem. In fact, one recent study that looked at outcomes at 5 years after prolapse surgery found no difference between those who did and did not do post-operative pelvic floor muscle training (Jelovsek 2018). Essentially, pelvic floor muscle training did not stop the prolapse from returning. So if you still are doing a lot of heavy lifting, have continued constipation, or are just genetically predisposed to having prolapse, there is a high likelihood it will return because there is still a lot of top-down pressure on your internal organs.
It's important to note though, as I stated above, generally your symptoms still remain improved even if the prolapse itself returns post-operatively. Although of course, some people will need to have a second surgery. This is also why it's best to delay surgery for as long as possible.
Should I have prolapse surgery?
This is obviously a very personal decision, and depends upon a lot of factors! I think the biggest takeaways here are that you should try PT, pelvic floor & core exercises, and/or pessaries first. MommaStrong also fits in well with these exercise recommendations, and has some specific videos for prolapse! All of these things are recommended to be the first-line interventions for prolapse, and can help the majority of people who are living with prolapse. If that doesn't work for you, or for whatever reason your surgeon determines surgery is the best route right away, then definitely consider it. It can be very successful, especially for symptom improvement! As with any surgery though, I would always recommend getting at least 2 opinions before deciding to move forward. And I would highly recommend at least one of those opinions come from a urogynecologist or colorectal surgeon depending upon your needs.
The next article will discuss different options for prolapse surgeries, so be sure to check that one out!
References:
Bureau, M., & Carlson, K. V. (2017). Pelvic organ prolapse: A primer for urologists. Canadian Urological Association journal = Journal de l'Association des urologues du Canada, 11(6Suppl2), S125–S130. https://doi.org/10.5489/cuaj.4634
Dumoulin, C., Hunter, K. F., Moore, K., Bradley, C. S., Burgio, K. L., Hagen, S., Imamura, M., Thakar, R., Williams, K., & Chambers, T. (2016). Conservative management for female urinary incontinence and pelvic organ prolapse review 2013: Summary of the 5th International Consultation on Incontinence. Neurourology and urodynamics, 35(1), 15–20. https://doi.org/10.1002/nau.22677
Jelovsek, J. E., Barber, M. D., Brubaker, L., Norton, P., Gantz, M., Richter, H. E., Weidner, A., Menefee, S., Schaffer, J., Pugh, N., Meikle, S., & NICHD Pelvic Floor Disorders Network (2018). Effect of Uterosacral Ligament Suspension vs Sacrospinous Ligament Fixation With or Without Perioperative Behavioral Therapy for Pelvic Organ Vaginal Prolapse on Surgical Outcomes and Prolapse Symptoms at 5 Years in the OPTIMAL Randomized Clinical Trial. JAMA, 319(15), 1554–1565. https://doi.org/10.1001/jama.2018.2827
Weintraub, A. Y., Glinter, H., & Marcus-Braun, N. (2020). Narrative review of the epidemiology, diagnosis and pathophysiology of pelvic organ prolapse. International braz j urol : official journal of the Brazilian Society of Urology, 46(1), 5–14. https://doi.org/10.1590/S1677-5538.IBJU.2018.0581
Photo by Alexander Grey on Unsplash