What is Prolapse?
Prior to childbirth, the pelvic structure is a tightly knit organisation. The ligaments and bands holding the various organs in place are taut, un-stretched and do their job well. The vaginal tract is likewise a compact and firm structure. The lining is corrugated, indicating a high degree of elasticity. The walls are in opposition, and the muscle fibres surrounding the tract are also firm.
In the early days of marriage, this can play an important part in providing a greatly enhanced degree of stimulation during intercourse. This is just another of the little quirks of nature. It is designed primarily to ensure reproduction of the species. The ability of the pelvic structures to alter suddenly is just as amazing. Soon after conception takes place, hormones pour forth into the general system. One of the side effects of this is to give all the pelvic structures a greatly increased ability to move and to stretch in all directions. The organs become more mobile as their supports stretch more.
Finally, the culmination of childbirth puts the greatest test on all these surrounding structures. The womb has increased to astonishing proportions. The cervix finally opens, to allow the newborn infant to escape. The birth canal (into which the vagina is converted) dilates tremendously. It is an amazing phenomenon of nature that a narrow structure that will just accommodate a penis can stretch to such an extent that it allows the passage of a baby’s head, but there is a penalty for this. Invariably the organs are stretched to their fullest capacity. As with a rubber band that is suddenly overstretched, often it fails to come back to its normal, original size. Some of the internal elasticity has gone forever. In a similar manner, a large number of the stretch fibres of the pelvic organs lose their capacity to return to their normal taut state following parturition (childbirth).
The situation may not be very obvious for the first few years, and with younger women. However with the progression of time, it gradually becomes more obvious. Finally, when the “change of life” years approach, the system is suddenly deprived of the normal circulating amounts of female hormone, for these are no longer manufactured by the ovaries.
This represents the final assault on the pelvic organs, structures and supports. No longer do they have any assistance to retain their normal appearance and function. It is much like a machine or a car that is suddenly deprived of its normal supply of oil. Rust sets in, parts become worn, and areas that had suffered in years past, but maintained some semblance of normality from the lubrication present, now suddenly fold up, and suffer the full impact of this deprivation.
The vaginal canal becomes atrophic. The lining thins out. What elasticity remains tends to reduce in capacity to stretch. The entry sags, the vulva becomes thin and shrinks. Deeper in, the uterine supports similarly continue to lose their suppleness. The full after-effects of the trauma of childbirth many years ago are now being fully appreciated by the tissues, devoid of the regular “oiling up” that the female hormone provided during the intervening years.
This means that the pelvic structures do not have the same degree of support as in former years. Also, with continual stress for any reason being exerted on them from above, there is a continual downward force acting upon them. As this increases, the only direction in which they can go is down. The only exit of any size is the vaginal outlet. So, the bladder, located in front of the vagina, tends to push inwards and downwards. This can gradually become quite marked, until it forms a pathological condition in itself, clinically referred to as a cystocele.
As this presses in, a bulging sensation is often felt by the woman. Also, urinary symptoms frequently develop, as it becomes more difficult to empty the bladder completely. A small reservoir develops in the bladder, and infections rapidly become established here. Apart from this, there may be stretching and irritation on the urethra, the little tube conveying urine from the bladder to the exterior. So there is often an intense desire to pass urine frequently, even though the amount passed is small. It often gives little satisfaction. Also, as the bladder valve becomes weakened by all this, urinary incontinence may occur. Or there is loss of total control over the bladder valve. So with a simple forceful action such as a sudden cough or sneeze, urine will suddenly be released quite out of control.
In a similar fashion, the back wall of the vagina can become so weakened that the rectum gradually presses in, and similarly bulges inwards and downwards to form what is referred to as a rectocele. This may gradually worsen, so that constipation may occur. In some cases, it is necessary to manually press the prolapsing parts back in order to achieve normal bowel actions; this causes much distress and inconvenience.
As these conditions occur, they often gradually become more accentuated. With the persistence of the pressures from above, and the mechanical pulling of the cystocele and rectocele, the uterus itself may finally start to be forced down the vaginal passageway. A first-degree prolapse occurs when this is only a slight progression. This becomes second degree when the cervix actually protrudes from the vaginal outlet.
A third-degree prolapse (also known as a procidentia) is said to occur when the cervix and inverted walls of the vagina permanently lie outside of the vaginal canal. If this is allowed to remain this way the protruding part becomes roughened, dry, atrophic, often ulcerated, foul smelling and infected. It is a pitiful sight to see, and any woman is foolish to allow mechanical problems to reach this stage before seeking medical guidance.
However, many do, and large numbers are still seen by gynaecologists. Diagnosis is usually quite obvious. Smaller degrees may not be so apparent, but symptoms are often minimal. Often the woman feels as though “something is giving way,” or “it feels as if something is coming down my front passage.” These apt descriptions are entirely correct, for this is exactly what is taking place.
Treatment of these conditions is essentially surgical. Vaginal repair operations are excellent when carried out by a surgeon skilled in these various procedures. Basically, the loose tissues in the front and back walls of the vagina are removed, and the basic wall is reconstructed.
If there is prolapse, the elongated cervix is partially amputated, and with the remaking of the walls of the vagina and repair of the supports, the uterus is replaced into its correct position. Sometimes it is justified to remove the uterus surgically, for by this time it has totally served its useful function and is of no further use.
All sorts of variations of this theme are carried out. The operations go by various complex-sounding names, which relate to the actual extent of the surgery. These are the names the surgeons talk about, and which you will hear bandied about by women when describing “their” particular repair operation.
- Anterior Colporrhaphy: this means the cystocele has been repaired. The front wall of the vagina is reduced in width, and the bladder stitched hack and a new wall created.
- Posterior Colporrhaphy: this means the rectocele. or back wall of the vagina, is narrowed, the rectum stitched back and the wall repaired.
- Manchester Operation: this is a combination of the foregoing two operations. It is the cure for complete prolapse (procidentia), and in addition the cervix is partially shortened in length (for by now it has mechanically elongated). The uterus is stitched back by reinforcing various of its supports. The vaginal canal is now made more like it was many years before.
- Vaginal Hysterectomy: sometimes the uterus is removed via the vaginal route as part of the entire operation of repair, if the surgeon feels it has outlived its function and the patient would be better with this additional procedure.
Following these surgical endeavours, the wounds soon heal. Often oestrogen therapy is given (hormonal replacement therapy) in the form of tablets taken orally. This will help prevent a recurrence, and will also assist the parts to heal normally. Treatment may be given for a short period of time, or longer term.
Some women are fearful that their sex life comes to an end following operations of this nature. On the contrary, many experience a marked improvement. With the entire pelvic anatomy (including the vagina) brought back to a situation as near as possible to what it was prior to the birth of their first baby, some women claim they have actually experienced a second honeymoon. Many husbands have made the same ecstatic discovery.
Provided the husband is attuned to the need to be careful and gentle for the first several weeks or months, the majority of women rapidly swing back to a very enjoyable, fulfilling and satisfying sexual relationship. Gone completely is the fear of pregnancy (if the uterus is removed), gone is the laxity, the urgent desire to pass urine unexpectedly at any moment, gone are the recurring urinary infections. Indeed, surgery at this time of life can be a very rewarding affair, as countless women have discovered to their immense joy and satisfaction.
Sometimes in women who are unable to undergo surgery, various medical techniques are used. These rely on mechanical support of the pelvic contents, and polythene rings are used for this purpose. But these are only a second- best routine, to be used only if surgery is not possible or practical.