Bethany S. Divell, CRNP

The choice of treatment for pelvic organ prolapse depends on the severity of the condition. Mild to moderate prolapse may be managed by doing pelvic floor strengthening exercises, taking hormone replacement therapy, or using pessaries. Pessaries are small devices inserted into the vagina to help support the pelvic organs. Pessary fitting is a quick procedure done in a doctor's office. For severe prolapse, surgical treatment may be necessary. Pelvic organ prolapse surgery repairs the following:

• Cystocele or bladder prolapse, where the bladder sags into the vagina. The surgeon repairs a cystocele by strengthening the front wall of the vagina using stitches so that the bladder will no longer sag.
• Enterocele or small bowel prolapse, which occurs when the small bowel descends towards the vagina. To correct an enterocele, the tissues between the small bowel and the vagina are sewn together, allowing them to provide more support.
• Rectocele or posterior prolapse, which is the bulging of the front wall of the rectum into the back wall of the vagina. Surgery to repair a rectocele removes the excess stretched tissue between the rectum and vagina.
• Uterine prolapse, which occurs when the uterus slips down to the vagina. To treat a uterine prolapse, the surgeon may secure the neck of the uterus (called cervix) to a ligament in the pelvis using stitches. Another option for this type of prolapse is a vaginal hysterectomy, which is the removal of the uterus.

Each of these procedures is performed through a vaginal incision, but an enterocele repair may use the abdominal approach as an alternative. If two or more pelvic organs have prolapsed, a combination of any of these procedures may be performed during the same surgical session.

For women who no longer wish to have intercourse, an operation called colpocleisis

may be a surgical option as well. By closing the vaginal canal, colpocleisis treats pelvic organ prolapse and eliminates any risk of its recurrence.

In most instances, pelvic organ prolapse surgery only requires a hospital stay of one day. Patients may experience vaginal bleeding for the first few weeks following surgery. If this happens, patients should use sanitary pads rather than tampons, as a higher risk of infection is associated with the use of tampons. To further help with recovery, patients should begin doing gentle pelvic floor strengthening exercises a few days after surgery. Doing these exercises at least three times a day as a routine tightens the pelvic floor muscles and prevents the recurrence of prolapse.

The device should be kept clean to avoid issues like vaginal odor, discharge, or irritation. To clean a pessary, it must be taken out and washed with soap and water. Healthcare providers will instruct patients on how to remove and reinsert the device. If patients are unable to do this on their own, they will need to get it done at the doctor's office at least once every two months.

Treatments vary based on the severity of the incontinence. Mild to moderate leakage may be controlled by doing pelvic floor exercises, avoiding foods that can irritate the bladder, or taking medication. For severe incontinence, however, surgery may be necessary. The most common procedures for stress urinary incontinence are bladder suspension, artificial urinary sphincter surgery, and sling surgery.

Each of these procedures takes about an hour to an hour and a half. Patients will likely wake up with a catheter, a tube that drains urine, as swelling after surgery makes it difficult to urinate. Taking slow, short walks to keep the blood flow moving is usually encouraged within hours of the surgery. Although patients may return to work within seven to ten days after certain procedures, strenuous activities such as running and working out are not recommended for at least four to six weeks. In addition, patients should avoid lifting objects over 15 pounds for three months after any of these operations.