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Pelvic Prolapse

Pelvic organ prolapse occurs when the muscles or connective tissues that support a woman’s pelvic organs become weakened or damaged. It is a common disorder especially among women over 50. It is essentially a herniation of the affected organ through the path of least resistance. As a result, the organs may move out of place.

Chronic straining, repeated heavy lifting, obesity, chronic constipation, multiple vaginal deliveries, genetics, smoking and aging are factors that can weaken the fascia and cause the organs to reposition. To better understand this condition think of the vaginal canal as an empty chamber. Imagine that the door to this chamber is the vaginal opening. This chamber would have two side walls, a back wall , a roof and also a floor.( insert picture to demonstrate better) When these walls are weakened or damaged the organ(s) that remain behind these walls are the ones that would prolapse and herniate into this hollow room.

The prolapse is then named after the protruding pelvic organ. In a supine ( lying back down) position usually bladder is on top of the roof. Behind the back wall is usually the uterus  or  the intestines in women who have had hysterectomy. This is called enterocele. End portion of the large intestine is called rectum. This is under the flooring of the vagina. Its prolapse is called rectocele.

You have state of the art treatment choices  when it comes to pelvic prolapse treatment at our  practice serving Los Angeles, Orange and San Bernardino Counties . Dr.  Bonni offers a range of specialized solutions that can be customized to your unique needs.

Colpocleisis for Uterine or Vaginal Vault Prolapse
Cystocele Repair
Enterocele Repair
Rectocele Repair (Posterior Repair)
Uterine Suspension
Vaginal Vault Prolapse Treatments

Cystocele Repair

A cystocele is a prolapsed bladder, the intrusion of the bladder into the vagina.  Cystocele may result when the pubocervical fascia breaks away from the pelvic side walls. This tear is known as a paravaginal defect. They could also result from midline defects.There are several options when it comes to treating cystoceles:

Colporrhaphy

Anterior colporrhaphy is performed through the opening of the vagina. The defect in the pubocervical fascia is identified and repaired.

Graft augmented Prolapse Repair Systems

The past decade has seen a huge surge in many  minimally invasive procedures for pelvic floor reconstruction with different graft systems. Sophisticated non absorbable or absorbable synthetic or cadaveric surgical grafts are used to provide a framework of support for the prolapsed organ. The advantage is usualy a decrease in recurrence rate. They can be interposed to support the repair of almost all types of pelvic organ prolapses. They are indicated only in a select group of patients. Their insertion requires expertise in female pelvic medicine and reconstructive pelvic surgery. Graft related erosions and complications may happen. These complications also need a very careful evaluation and proper treatment in expert hands.

Laparoscopic Paravaginal Repair

During this minimally invasive procedure, reconstructive  repairs of the defect is done by using sutures to mend the tears, restoring the bladder to its natural position.

Graft removal or revision

We have seen tremendous increase in usage of synthetic grafts and meshes for female pelvic medicine and reconstructive pelvic surgery in the past ten years. Lack of accurate selection of patients, controlled studies and proper fellowship trained professionals to do these procedures has led to an increase in number of complications attributed to interposition of these materials at the time of pelvic surgery. Often time a poorly selected patient with some type of a prolapse receives a graft augmented repair. This in turn results in complications such as pelvic pain, pain with intercourse, bleeding, erosion of the mesh material through the vagina or into the viscus organ to name a few. Repair, revision or removal of this inserted mesh material is a tedious work that needs excellent understanding of urogynecology and pelvic surgery. Regional anatomy is often times very distorted and chances of injury to neighboring organs is high. Careful protection of these organs as well as a meticulous dissection in expert hands is necessary to remove the mesh completely or partially. At times repair or revision may just be enough.

Enterocele Repair

An enterocele occurs when the small bowel descends and pushes against the vaginal wall. It is also known as  small bowel prolapse.  Enterocele repair involves suturing together the pubocervical and rectovaginal fascia, the supportive layers of the vagina. This should be done after the enterocele sac is carefully identified dissected and removed. The bowels are then pushed back inside and away from the harms way. This could be accomplished laparoscopically, vaginally or rarely through an open procedure with or without usage of synthetic supportive grafts and materials.

Rectocele Repair Surgery (Posterior Repair)

Through various approaches and techniques the  tears and defects in the  supportive layer of tissue (fascia) that separates the vagina from the rectum is identified and the rectal bulge into the vagina is reduced. Layers are repaired.  Grafts could be used in select group of patients to reinforce the repair. Procedure is done vaginally.

Uterine Suspension

Also called a dropped womb, uterine prolapse is a condition in which the uterus slides out of its proper place and descends into the vaginal canal. For women who suffer from uterine prolapse but do not wish to undergo hysterectomy, uterine preservation and suspension may be recommended. Uterine preservation surgery is a procedure by which  the uterus or portion of it is saved. Many different technics have been identified. During uterine preservation surgery, usually a surgical mesh is secured to the sacrum (tailbone) and to the posterior aspect of the uterus to lift the uterus to its normal place within the pelvis and provide lasting support. This procedure is also known as sacral colpohysteropexy, hysteropexy, or uterine suspension.

Vaginal Vault Prolapse Treatments

Vaginal vault prolapse is the collapse of the upper portion of the vagina (the apex) into the vaginal canal. This condition is usually after a patient has had a  hysterectomy. Many different surgical repairs for vaginal vault prolapse have been identified. More common ones  include the following vault suspension procedures:

Colpocleisis for Uterine or Vaginal Vault Prolapse

Colpocleisis is a vaginal procedure used to treat uterine or vaginal vault prolapse. In patients with uterine prolapse, the procedure is known as a LeFort colpocleisis. It is referred to as a total colpocleisis in women who have undergone hysterectomies. It prevents prolapse by closing down the vaginal canal so it  is only appropriate for women who are not sexually active and plan to remain celibate.

Sacral Colpopexy (Laparoscopic)

This is a highly successful treatment for vaginal vault prolapse. Laparoscopic sacral colpopexy restores the vagina to its correct anatomical position. During this minimally invasive procedure, Dr. Bonni creates a supportive bridge of surgical mesh from the vaginal apex to the longitudinal ligament running on top of the periosteum of the sacrum (the thick, triangular bone at the base of the spine). This procedure could also be done using the Da Vinci robotic system.

Sacrospinous Ligament Suspension

Sacrospinous ligament suspension or fixation  is a surgical procedure to correct vaginal vault prolapse. The treatment involves suturing the vaginal vault to one or both sacrospinous ligaments (bilateral ligaments that connect each pelvic bone to the sacrum and coccyx). Although it provides a vaginal approach to the repair but because of its distortion of the anatomy and the change in vaginal vectores it is not very widely used in modern pelvic surgery.

High Uterosacral Ligament Suspension (Laparoscopic)

Laparoscopic uterosacral ligament suspension is a treatment for vaginal vault prolapse that uses the uterosacral ligaments to support the apex of the vagina. Designed to hold the uterus in place, the uterosacral ligaments are fibrous bands that extend from the cervix to the  pelvic wall. During the procedure,  these ligaments are delicately identified as high as possible where they attach to pelvic side walls and are sutured  to the vaginal apex.

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