Cystocele - Treating a pelvic organ prolapse

There are several treatment options available for a pelvic organ prolapse, depending on your circumstances.

The treatment most suitable for you will depend on:

the severity of your symptoms
the severity of the prolapse
your age and health
whether you are planning to have children in the future

You may not need any treatment if your prolapse is mild to moderate and not causing any pain or discomfort.

Self-care advice

If your prolapse is mild, there are some steps you can take that may help improve the condition or reduce the risk of it getting worse.

This may include:

doing regular pelvic floor exercises (see below)
losing weight if you are overweight, or maintaining a healthy weight for your build (you can check your body mass index (BMI) using the healthy weight calculator)
eating a high-fibre diet with plenty of fresh fruit, vegetables and wholegrain bread and cereal to avoid constipation and straining when going to the toilet
avoiding heavy lifting and standing up for long periods of time

If you smoke, you should give up because the persistent cough most smokers have can make a prolapse worse. See stopping smoking for more information and advice.

Pelvic floor exercises

Your pelvic floor muscles are muscles that you use to control the flow of urine from your bladder. They surround the bladder and the tube that carries urine from the bladder to outside the body (urethra).

Having weak or damaged pelvic floor muscles can make a prolapse more likely. Recent evidence suggests pelvic floor exercises may help improve a mild prolapse or reduce the risk of it getting worse.

Pelvic floor exercises are also used to treat urinary incontinence (when you leak urine), so may be useful if this is one of your symptoms.

Read more about treating urinary incontinence.

To help strengthen your pelvic floor muscles, sit comfortably and squeeze the muscles 10-15 times in a row. Do not hold your breath or tighten your stomach, buttock, or thigh muscles at the same time.

When you get used to doing this, you can try holding each squeeze for a few seconds. Every week, you can add more squeezes, but be careful not to overdo it and always have a rest inbetween sets of squeezes.

Your doctor may refer you to a physiotherapist, who will be able to teach you how to do pelvic floor exercises. It may take a few months before you notice any improvement.

Hormone replacement therapy (HRT)

While there is little evidence that a treatment called hormone replacement therapy (HRT) can directly treat pelvic organ prolapse, it can help relieve some of the symptoms associated with prolapse, such as dryness of the vagina or discomfort during sex.

HRT involves the use of medication to increase the level of a hormone called oestrogen in women who have been through the menopause.

HRT medication is available as:

a cream you apply to your vagina
a tablet you insert into your vagina
a patch you stick on your skin
an implant inserted under your skin

HRT is widely used for women who have symptoms of a prolapse after menopause. It may be combined with surgery, pelvic floor muscle exercises or vaginal pessaries (see below).

Vaginal pessaries

A vaginal ring pessary is a device inserted into the vagina to hold the prolapse back. It works by holding the vaginal walls in place. Ring pessaries are usually made of latex (rubber) or silicone and come in different shapes and sizes.

Ring pessaries may be an option if your prolapse is more severe but you would prefer not to have surgery. A gynaecologist (a specialist in treating conditions of the female reproductive system) or a specialist nurse usually fits a pessary.

The pessary may need to be removed and replaced every few months, usually by a health professional.

Side effects

Ring pessaries can occasionally cause vaginal discharge, some irritation and possibly bleeding and sores inside your vagina. Other common side effects include:

an imbalance of the usual bacteria found in your vagina (bacterial vaginosis)
passing a small amount of urine when you cough, sneeze or exercise (stress incontinence)
difficulty with bowel movements
interference with having sex, although most women can have intercourse without any problems

These side effects can usually be treated.

Surgery

Surgery may be an option for treating a prolapse if it is felt that the possible benefits outweigh the risks.

In general, surgery for pelvic organ prolapse is relatively common. It is estimated that 1 in 10 women will have had surgery for prolapse by the time they are 80 years old.

Surgery is used to repair the tissue that supports the prolapsed organ or tissue around the vagina.

Surgery to remove the womb (hysterectomy) may also form part of your treatment, but this does not directly treat a prolapse.

These procedures are outlined below.

Surgical repair

One of the main surgical treatments for pelvic organ prolapse involves improving support for the pelvic organs.

This may involve stitching prolapsed organs back into place, as well as stitching existing tissue to make it stronger.

Pelvic organ repair may be done through the vagina or through cuts (incisions). It is usually carried out under general anaesthetic, so you will be asleep during the operation and will not feel any pain.

This type of operation is usually recommended if you want to have children in the future. Your doctors may suggest delaying surgery until you are sure you no longer want to have any more children, however, because pregnancy can cause the prolapse to recur.

Vaginal mesh

Surgery for pelvic organ prolapse may not always be successful and the prolapse can return, meaning another operation may be needed.

For this reason, synthetic (non-absorbable) and biological (absorbable) meshes have been introduced as supporting materials in the surgical treatment of pelvic organ prolapse.

These permanent implants support the vaginal wall and/or internal organs. About 1,500 such operations are carried out in the UK each year.

The majority of women with prolapse who are treated with mesh respond well to this treatment. However, the MHRA has received a number of reports of complications associated with vaginal meshes. The most frequently reported problems have included persistent pain, sexual problems, mesh exposure through vaginal tissues and occasionally injury to nearby organs such as the bladder or bowel.

These reports have not been linked to a single manufacturer’s brand or model and the MHRA has no evidence that the devices themselves have inherent problems that would mean they should be removed from the market. However, as with all devices, the MHRA will continue to keep vaginal meshes for prolapse under careful scrutiny.

If you've recently had vaginal mesh inserted and think there may be complications or you want to find out more about the risks involved, speak to your GP. You can also report an adverse incident on the MHRA website.

If you are thinking about having vaginal mesh inserted, you may want to ask your surgeon some of these questions before you proceed:

What are the alternatives?
What are the chances of success with the use of mesh versus use of other procedures?
What are the pros and cons of using mesh, and what are the pros and cons of alternative procedures?
What experience have you had with implanting mesh?
What have been the outcomes from the people you have treated?
What has been your experience in dealing with any complications that might occur?
What if the mesh does not correct my problems?
If I have a complication related to the mesh, can it be removed and what are the consequences associated with this?

Hysterectomy

If the womb (uterus) is prolapsed, then removing it during an operation called a hysterectomy often helps the surgeon to give better support to the rest of the vagina and reduce the chance of a prolapse returning.

A hysterectomy will usually only be considered in women who have been through the menopause, as you cannot get pregnant after having a hysterectomy.

Methods to elevate and support the uterus without removing it do exist, but they are not always widely available.

Complications from surgery

All types of surgery carry some risks. Your surgeon will explain these in more detail, but possible complications could include:

bleeding, which may require a blood transfusion
damage to the surrounding organs, such as your bladder
an infection – you may be given antibiotics to take during and after surgery to reduce the risk of infection
pain during sex, usually caused by narrowing of the vagina
vaginal discharge and bleeding
experiencing more prolapse symptoms, which may require further surgery
a blood clot forming in one of your veins (for example, in your leg) – you may be given medication to help reduce this risk after surgery (see deep vein thrombosis (DVT) for more information)

Recovering from surgery

Many prolapse operations are done as day surgeries with no overnight stay, although more major operations may require a stay in hospital for one or two days.

If you need to stay in hospital, you may have a drip in your arm to provide fluids and a thin plastic tube called a catheter to drain urine from your bladder. Some gauze will be placed inside your vagina to act as a bandage for the first 24 hours. This may be slightly uncomfortable. Your stitches will usually dissolve on their own after a few weeks.

For the first few days or weeks after your operation you may have some vaginal bleeding similar to a period. You may also have some vaginal discharge. This may last three or four weeks. During this time you should use sanitary towels rather than tampons.

Enhanced recovery

Enhanced recovery is an NHS initiative to improve patient outcomes after surgery and speed up recovery.

This involves careful planning and preparation before surgery, as well as reducing the stress of surgery by:

using pain relief to minimise pain
avoiding unnecessary drips, tubes and drains
enabling you to eat and drink straight after your operation
encouraging early mobilisation

Post-surgery advice

Even with enhanced recovery, there may still be some activities you need to avoid while you recover from surgery. Your care team can advise about activities you may need to avoid, such as heavy lifting and strenuous exercise, and for how long.

Generally, most people are advised to move around as soon as possible, with good rests every few hours.

You can usually shower and bathe as normal after leaving hospital, but you may need to avoid swimming for a few weeks.

You should be able to start having sex again after a short time if your vaginal discharge has stopped.

Your care team will advise about when you can return to work.

Problems with recovery

Vaginal discharge is perfectly normal. However, if the amount of discharge increases over time or becomes smelly, you should contact your GP because you may have an infection. You should also contact your GP if you:

have a high temperature (fever) of 38°C (104°F) or over
experience severe pain low in your tummy
have heavy vaginal bleeding
experience a stinging or burning sensation when you pass urine