Pelvic organ prolapse (POP) is a common problem for women. Almost half of all women who have had babies will have some POP but not all have symptoms. About one third of ALL women will have some symptoms of POP.
Risks for POP are genetic, having many pregnancies, being menopausal, increasing age and conditions that increase abdominal pressure such as obesity, constipation, coughing and heavy lifting.
What is it that’s falling down? Most common is the bladder. It pushes down into the anterior or front wall of the vagina. The cervix and uterus can move closer to or beyond the vaginal opening. The rectum can push into the back or posterior wall of the vagina. Occasionally, all of that happens together. If the urethra loses support, incontinence of urine can occur. It sounds bad, but severity of symptoms doesn’t always correlate well with the amount of prolapse.
How can we fix the prolapse for those women who have symptoms such as pressure, feeling a bulge, pelvic heaviness, loss of urine, frequency or urgency of urination or difficulty having a bowel movement?
For surgical options, native tissue repair means using only sutures
(stitches) and the body’s own tissues to repair the prolapse. This could include hysterectomy (removal of the uterus). The tissues that are bulging are put back in place and the area reinforced, similar to hernia repair. Because native tissue has already weakened and allowed POP to occur, other materials have been sought to improve outcomes.
Unfortunately, POP repair does have a fairly high recurrence rate, up to 30-50% in some studies. The use of synthetic mesh for POP started increasing around 2004. Mesh differs from native tissue in that it does not dissolve once in the body, creating a stronger and longer lasting repair less prone to recurrence. A common material for this mesh is polypropylene. By 2011 the FDA voiced concerns about mesh erosion, pelvic pain, buttock and groin pain and discomfort with intercourse related to mesh POP repairs. Erosion means the mesh becomes exposed on the vaginal surface but in more severe cases could erode into bladder or bowel. Small mesh erosions could be managed in the office or outpatient centers without compromise to the repair, others required more extensive revision and removal of the mesh.
So are the risks worth it? Is mesh repair better? Most studies do show that compared to native tissue, mesh results in better restoration of anatomy but similar improvement in symptoms at a higher complication rate. Now it is often recommended that mesh be reserved for recurrent POP failing native tissue repair and only be used by surgeons who have undergone specialized training for its use.
What about those slings for incontinence? Those also use mesh. Yes, but a small piece and there is a longer history with that surgery to know that the complication rates including erosion are much less than with POP surgery where larger pieces are used and in areas with different pressures.
Where are we now with using mesh? We are still using it but mainly in recurrent or more severe POP. We usually don’t use it over the rectum.
We do use mesh for urinary incontinence slings and this is highly successful with minimal complications.
What’s new with mesh? There are developments in the use of biologic mesh which is made of material that dissolves but improves the strength of the native tissue where it is used. The hope is that the repairs will stay stronger without the erosion and pain issues, but more studies need to be done before this is proven.
Do I have to have surgery for POP? No, there are also nonsurgical options such as pessary use and pelvic floor muscle exercises through physical therapy.
There are many options and we try to stay current with all available treatments for your benefit. The bottom line is that there is usually something that will help. Don’t hesitate to ask us!
Written by Dr Patricia Kohls