VAGINAL DESCENT

Vaginal descent or prolapse is a term that describes the weakness in one or more sides of the wall of your vagina. Because of this, one or more pelvic organs fall into the vagina. However, vaginal descent is a very broad term that can be used for describing the following:

Cystocele - Weakness in the vagina’s front wall that allows the bladder to fall inside the vagina.
Rectocele - Weakness in the vagina’s back wall that allows the rectum to fall inside the vagina.
Enterocele - Weakness in the vagina’s top or roof that allows small bowel to fall inside the vagina.
Uterine prolapse - A condition when the uterus, as well as cervix, descend from their normal position in the pelvis to the top of the vagina. They might also end up at the vaginal opening or even outside it. Vaginal cuff or vaginal vault prolapse occurs when the top of the vagina, which is deep inside the pelvis, descends into the bottom or completely outside the vagina’s opening.

In most cases, women have multiple types of prolapse. The treatment will depend on how severe it is, how much the organs have descended inside the vagina.

Symptoms

Women who are suffering from vaginal descent will complain of pressure or bulging inside the vagina. In some cases, women are even able to feel or see the bulge from their vagina. Women who have rectocele might have to push the prolapse inside the vagina in order to have a proper bowel movement. They might also not be able to completely empty their rectum and leak stool even after having the bowel movement. Women who have cystocele might have to push the prolapse inside for emptying their bladder. Women who have enterocele often complain of back or low abdominal pain.

Causes

Vaginal descent can be caused by anything that increases pressure in the abdomen. Here are some of the common causes:
Pregnancy, labour, or childbirth
Obesity
Constipation
Respiratory problems that cause chronic, long-term cough
Hysterectomy (removing the uterus surgically)
Pelvic organ cancers

Genetics might also play a role in developing vaginal descent. In some women, connective tissues are weaker which places them at more risk.

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Diagnosis

Vaginal descent can be diagnosed by a physician, a primary care physician, or a gynaecologist during a vaginal exam. There are some physicians who are specialized in treating urologic conditions and vaginal prolapses such as a urogynaecologist or a urologist. In order to determine whether there are any associated bowel or bladder conditions that must be addressed while treating the prolapse include a urodynamic test (evaluating bladder function) or defecography (evaluating lower bowel conditions).

Preventing

There are several risk factors for vaginal descent that are out of control including the following:
Advancing age
Difficult vaginal delivery
Family history
Having had a hysterectomy
A cervical cap is a smaller version of this.

However, it is possible to reduce the possibility that you will have problems:
Perform Kegel exercises every day to ensure that you have good muscle strength in the pelvic area
Avoid constipation
Maintain a healthy weight
Don’t smoke as smoking can negatively affect the tissues and chronic cough, common among smokers, increases the risk of problems.

Treatment

Non-surgical treatments

Kegel exercises

Kegel exercises can be used for strengthening the muscles of the pelvic floor. When these muscles grow stronger, they are able to better support the pelvic organs slowing the progression of descent. Also, these exercises are known to help control urinary incontinence, stress urinary incontinence, fecal incontinence, and overactive bladder. However, in order to achieve the full benefits, it is crucial that these exercises are performed regularly and correctly. This treatment option is for mild cases of vaginal descent. In case of severe prolapse, the benefits will be limited.

Pelvic floor therapy

This consists of visiting a physical therapist who specializes in providing therapy for pelvic floor disorders. They will utilize different techniques, depending on the condition of the patient and the disorder they are treating, to help the patient with the vaginal descent. The main aim of this therapy is strengthening the pelvic floor so that it is strong enough to support the pelvic organs and the vagina. There are four main treatment options that are used for vaginal descent in pelvic floor therapy:

Biofeedback - In this, an intravaginal device is used for training pelvic floor muscle so that it can properly contract and relax.
Functional electrical stimulation - In this treatment, an external or intravaginal device is used to deliver a gentle electric current. This relaxes or activates the muscles and nerves in the pelvis.
Manual therapy - In this, the therapist uses pressure that is released from and applied to the muscles in spasm so that they can get relaxed. It also increases the blood flow to the area to improve healing. Women with vaginal descent often contract their pelvic floor muscles subconsciously to the point where they get muscle spasms which can cause pelvic floor dysfunction, a painful condition. This is followed by difficulties with defecation and urination, painful sex, and pelvic pain.
Tissue and joint mobilization - In this therapy, gentle manipulation is used for calming the nerves and muscles of the pelvis.

Vaginal pessary

This is a removal, diaphragm-like device that is worn within the vagina to provide support to organs that are descending through the vagina. It can also be used for decreasing the stress of urinary incontinence. They are available in a variety of sizes and types and fitting them might require multiple visits to find the right one.

Surgical treatments

Native-tissue prolapse repair

Colporrhaphy

Also known as Cystocele Repair, this surgery repairs the defect in the vaginal wall including the rectocele (rectum protruding into the vagina) and cystocele (bladder protruding into the vagina).

Before the procedure, it is important that you tell your doctor about the medications, herbs, or supplements you are taking. This includes prescribed as well as over-the-counter medications. During the week following the surgery, you will have to stop taking ibuprofen, warfarin, aspirin, and other drugs that might make blood clotting difficult. Talk to your doctor about the medicines you take on the day of your procedure.

You will be administered with local, regional, or general anaesthesia at the start of the surgery. Then, the doctor will insert a speculum inside your vagina to hold it open. An incision is made into your vaginal skin to identify the defect in the underlying fascia. Then, the doctor will separate the vaginal skin from the fascia, fold over the defect, and suture. Lastly, they will remove the excess vaginal skin and close the incision using stitches.

For a few days after surgery, a catheter will be attached to you. Until your normal bowel function returns, you will have to take a liquid diet. You must avoid certain activities for a couple of weeks after the procedure that might strain the surgical site such as lifting, long periods of standing, coughing, sneezing, sexual intercourse, and straining with bowel movements.

Perineorrhaphy

The perineum is the area between the rectum and the vagina. Perineorrhaphy is the procedure where the vaginal opening is reconstructed to repair the damage caused to the vulva or the perineum. The procedure involves excision excess skin, reapproximating the perineal muscles to reduce the vaginal opening, and removing skin tags. In almost all cases, this procedure is accompanied by vaginoplasty.

It is performed under local anaesthesia. The doctor makes an incision of V-shape from the tops of your vaginal floor and cuts through the perineum and the vaginal mucosa. The incisions continue laterally on the vaginal opening and either side of the hymenal ring. It ends above the anal area. Then, the doctor will carefully peel the skin inside the diamond-shaped incision and remove it.

To reconstruct, muscles are put back together carefully along the vaginal floor. To cover the reconstructed muscles, the fascia is moved and any excess tissues are cut. Once you get the desired looseness or tightness, the doctor will suture the site.

Uterine resuspension/Vaginal vault suspension

This surgery is performed for fixing the vaginal wall prolapse. It also repairs the structures that are supporting the vaginal vault in a way that readjusts its anatomical position as much as possible. It is performed by attaching the prolapsed vault to the higher portion of ligaments through a synthetic mesh or permanent stitches.

Once the anaesthesia has been administered for numbing your pelvic region, the doctor will use one of the following approaches to perform the surgery:
Vaginal approach - In this, the instruments used to perform the surgery are inserted by opening or dilating the vagina.
Abdominal approach - There are two subtypes of this approach
Laparotomy - In this, a single large incision of about 6 to 12 inches is made in your lower abdomen right along the bikini line.
Laparoscopy - In this, multiple small cuts are made for performing the surgery. A laparoscope is inserted for visualizing the vagina and other structures. Other instruments are inserted through other incisions.

Hysterectomy

Vaginal, abdominal, or laparoscopic hysterectomies are often performed as a part of the prolapsed vaginal repair as it helps get a better suspension of the vagina to the support structures. It is a surgical procedure through which the uterus is removed. During a hysterectomy, the doctor detaches the uterus from the upper vagina, fallopian tubes, and the ovaries, as well as the connective tissue and the blood vessels supporting it and then removes it.

Compared to the abdominal hysterectomy, the vaginal hysterectomy involves faster recovery, shorter stay at the hospital, and lower cost. However, depending on the reason for surgery and the shape and size of your uterus, a vaginal hysterectomy may not be possible. In such cases, your doctor will recommend other surgical options like abdominal hysterectomy.

Hysterectomy might also include removing the cervix along with the uterus. If the doctor has to remove the fallopian tubes and the ovaries, it is known as a total hysterectomy, salpingo-oophorectomy. All these organs are situated in the pelvis and are part of the reproductive system.

Graft-Augmented Prolapse Repairs

If your existing connecting tissues are so weak that there is no possibility of successful prolapse repair, the doctor will recommend graft augmentation using a biologic graft material or synthetic mesh. All the above-mentioned native tissue surgical procedures can be enhanced by using the graft material. Also, there are some surgical approaches where placing the graft is the goal of the surgery:

Laparoscopic Sacrocolpopexy

This is a minimally invasive surgical procedure that involves using a laparoscope for treating vaginal descent. A laparoscope is a long, thin, flexible tube that has a light source and camera at one end. During the Laparoscopic Sacrocolpopexy, the anaesthesiologist will first establish the IV line. Then, you will be administered general anaesthesia so that you sleep during the surgery. The doctor will clean the area that is to be operated on and make 4-5 small incisions on your abdomen. Then, they will use carbon dioxide gas for inflating the abdomen in order to have space and a better view for the surgery. The surgeon will pass a laparoscope through one of these incisions. The remaining incisions will be used for passing other instruments. Then, the surgeon will attach a surgical mesh to the back and front walls of your vagina and to the sacrum which will suspend the top of the cervix or vagina back to its normal position. If needed, the supports of the rectum and bladder will also be strengthened. If you are also suffering from urinary incontinence (inability to control urine), the doctor will place a small mesh underneath your urethra (the tube carrying urine). This will ensure that you have support when you laugh, cough, or sneeze. Lastly, the surgeon will ensure that there aren’t any injuries by examining the inside of your bladder through a small camera at the end of the procedure.

Any woman who has a vaginal descent of a high stage and is still bothering them after trying the non-surgical treatments is a good candidate for any of the above-mentioned surgical procedures.