Pelvic Organ Prolapse
Pelvic organ prolapse occurs when pelvic floor muscles and ligaments weaken, allowing pelvic organs to descend into or through the vaginal canal. Risk factors: childbirth (especially instrumental/multi-parous), obesity, menopause (oestrogen deficiency), and chronic straining.
POP-Q Staging (Pelvic Organ Prolapse Quantification System):
- Stage 0: No prolapse
- Stage I: Leading edge >1 cm above hymen - often asymptomatic
- Stage II: Between 1 cm above and 1 cm below hymen - mild symptoms
- Stage III: >1 cm below hymen but not complete eversion - dragging sensation, incomplete bladder emptying
- Stage IV: Complete vaginal eversion - significant discomfort, difficulty with urinary/bowel emptying, may require digital reduction
Types of prolapse:
- Cystocele (anterior compartment): Bladder descends through the anterior vaginal wall - most common type; causes urinary frequency, incomplete voiding, recurrent UTIs, stress incontinence
- Rectocele (posterior compartment): Rectum bulges through the posterior vaginal wall; causes difficulty defaecating, sensation of incomplete bowel emptying, may require digital support to defaecate
- Uterine prolapse: Uterus descends into the vaginal canal - can be managed with hysterectomy + pelvic floor repair, or uterine suspension if fertility/uterine preservation required
- Vaginal vault prolapse: After hysterectomy, the vaginal apex descends - requires apical support procedure (sacrocolpopexy)
- Enterocele: Small bowel peritoneum herniates between vagina and rectum - requires obliteration at time of vault repair
Symptoms requiring surgical assessment:
- Vaginal bulge (sensation of something coming down)
- Incomplete bladder/bowel emptying
- Pelvic pressure or dragging discomfort (worse after prolonged standing)
- Recurrent UTIs from bladder incomplete emptying
- Difficulty passing urine or needing to reduce prolapse digitally to void
Surgical Options
1. Anterior colporrhaphy (cystocele repair): Native tissue repair of the anterior vaginal wall: excess vaginal epithelium trimmed, pubocervical fascia plicated (tightened) to restore anterior vaginal compartment. Can be combined with sling insertion for concomitant stress incontinence. Success rate 70-80% at 5 years. Day case or 1 night. Local augmentation with mesh not routinely performed following NICE and MHRA guidance restrictions.
2. Posterior colporrhaphy (rectocele repair): Plication of rectovaginal septum/perineal body reconstruction - reduces posterior compartment bulge and improves defaecatory symptoms. Success 80-85% at 5 years. Usually same admission as anterior repair.
3. Laparoscopic sacrocolpopexy (gold standard for apical prolapse): Mesh sutured to the anterior and posterior vaginal apex and the promontory of the sacrum (via retroperitoneum) - permanent, anatomical support of the vaginal vault. The best evidence-based surgical treatment for vault prolapse and uterine prolapse (with laparoscopic hysterectomy). Robotic sacrocolpopexy also available.
- Success rate: 85-95% at 10 years
- Mesh: lightweight polypropylene type I mesh in retroperitoneal space - over 30 years of literature; lower mesh complications than vaginal mesh, now endorsed by major guidelines (NICE, AUGS/SUFU)
- Hospital: 2-3 nights; hotel: 7-14 nights; recovery: 6-8 weeks
4. Native tissue apical procedures (uterosacral ligament suspension): For patients who prefer mesh-free surgery: McCall culdoplasty or uterosacral ligament vaginal vault suspension at time of vaginal repair. Slightly lower long-term success vs. sacrocolpopexy.
5. Midurethral sling for stress urinary incontinence (SUI): Genuine SUI - involuntary urine leakage with raised intra-abdominal pressure (cough, sneeze, exercise) - caused by urethral hypermobility or intrinsic sphincter deficiency.
- Retropubic TVT (tension-free vaginal tape): Polypropylene tape placed beneath the mid-urethra via small vaginal incision and two suprapubic stab incisions - 85-90% cure rate at 10 years
- Trans-obturator TOT: Tape passed through the obturator foramen - similar cure rate; lower bladder injury risk but potentially higher groin discomfort
- Day case or 1-night admission; return to normal activity in 2-3 weeks; heavy lifting restricted for 6 weeks
Recovery and Results
Anterior/posterior repair (native tissue):
- Hospital: 1-2 nights; return to hotel same or next day
- Vaginal packing removed before discharge
- Sexual intercourse: 6-8 weeks post-op
- Driving: 2-3 weeks; return to desk work: 2 weeks; heavy lifting: 6 weeks
Laparoscopic sacrocolpopexy:
- Hospital: 2-3 nights; hotel: 10-14 nights (bowels important - high-fibre diet, laxatives)
- Vaginal oestrogen cream recommended for 3 months post-operatively (improves tissue healing)
- Sexual intercourse: 8-12 weeks; heavy lifting restriction: 3 months
- Constipation prevention critical to protect mesh fixation - dietary and laxative guidance provided
Midurethral sling:
- Most performed as day case
- Mild discomfort at sling entry points for 1-2 weeks
- Urinary voiding trial before discharge - catheter rarely required post-op
- Sexual intercourse: 4-6 weeks; high-impact exercise: 6 weeks; immediate improvement in leakage in most patients
Diet and bladder/bowel care:
- High-fibre diet and adequate hydration from 2 weeks before surgery
- Pelvic floor physiotherapy prescription provided post-operatively
- Long-term: maintain healthy weight; avoid chronic straining; pelvic floor exercises
Cost comparison:
- Anterior/posterior repair Turkey: -3,000-5,000; UK private: -5,000-10,000
- Sacrocolpopexy Turkey: -6,000-10,000; UK private: -12,000-20,000
- TVT/TOT sling Turkey: -3,000-5,000; UK private: -4,000-8,000
- Combined prolapse + sling Turkey: -7,000-12,000; UK private: -14,000-25,000