WHAT IS PELVIC ORGAN PROLAPSE (POP)?
Pelvic organ prolapse is the equivalent of a hernia in the tissues that support the pelvic organs. Put simply, there is weakness or damage to some of the tissues supporting the pelvic organs which can allow them to slide out of their natural resting position. In this page, we will attempt to explain the condition and talk about pelvic organ prolapse symptoms, stages and treatment. There are a number of different types of pelvic organ prolapse which we will discuss, however, we will begin by looking at the anatomy and normal positioning of organs in the pelvis.
Before we begin, it is worth noting that although we have the same “parts” and they are in similar places, the shape, size and composition can be quite different. Even the origin and insertion of muscle and connective tissue can vary from person to person. If you stand ten women next to each other and look at the differences in body shape and size, you can begin to understand that what lies beneath the skin is also different in shape and size. These differences are hard to account for when establishing “normal”.
POP IN NUMBERS
WHAT IS “NORMAL” POSITIONING OF PELVIC ORGANS?
The diagram below shows the “normal” anatomical positioning of the organs within the pelvis (bladder, uterus and rectum). If you are female, you will have these organs and bones in similar positions. If you’ve had a hysterectomy, your uterus will be missing.
MY CERVIX FEELS VERY LOW, DOES THIS MEAN I HAVE A POP?
If you happen to feel your cervix is low, this is not necessarily due to POP. Before you panic, you need to understand that your pelvic organs are not rigidly held in the exact same position at all times. The bladder and rectum are changing shape and size based on their contents (urine and poop). The uterus is changing size during the course of the monthly menstrual cycle growing significantly towards the end of the cycle. Even the position of the cervix is changing depending on where you are in your monthly cycle. There is continual movement that goes with the ebb and flow of your body’s natural rhythms.
Those who practice natural family planning methods will be familiar with tracking the position of their cervix throughout the cycle, as well as tracking basal body temperature and cervical mucus. By keeping track of your body’s rhythm, you empower yourself by increasing your understanding of what “normal” is for you. You can use an app like Natural Cycles to track your basal temperature. This app predicts your cycle and lets you know when you are fertile. You can save notes each day, giving you the opportunity to record your cervical mucus and the position of your cervix. After a few months, you should have a clear picture of your cycle. This also helps you to establish a baseline from which to identify any changes, should they occur.
HOW DO I CHECK THE POSITION OF MY CERVIX?
To check the position of your cervix (the opening to the neck of your womb), you should be standing. It might help to prop one leg up on a chair or the side of the toilet bowl. Make sure you wash your hands thoroughly with soap and water before you start. Relax your pelvic floor muscles as you gently insert your middle and index fingers into your vagina to feel your cervix. The cervix feels like a bump that is soft but firm, a bit like the tip of your nose. Depending on the time in your cycle, it may feel soft or hard. You can use the “knuckle rule” to gauge the position.
The cervix is typically low during menstruation (one knuckle) and it can feel hard at this point. During pre and post ovulation, it rises, usually to the two knuckle mark. It rises even higher during the fertile period, where you can put your fingers in to the third knuckle and maybe still not feel it. This varies from woman to woman and you should get to know your own body using your own measuring sticks (fingers!).
Testing for pelvic organ prolapse is typically done by a specialist with the vulsalva movement, where you bear down as though trying to squeeze out a big poop or a baby. Some specialists will have you sit on a straddle chair or stand, although many do the test when you are lying down. It is best to have the check done during your fertile period when your uterus is at its highest. When you see your pelvic health specialist for a checkup, you can let them know at what stage in your menstrual cycle you are.
DO MY PELVIC FLOOR MUSCLES HOLD MY PELVIC ORGANS IN PLACE?
Not exactly. Your pelvic floor provides the platform beneath your pelvic organs on which they rest. It is called your pelvic “floor” because it acts like a floor covering the base of your pelvis. It’s a floor with a number of “doors” down to the outside world (urethral opening, vaginal opening, rectal opening). This floor is made of three different layers of muscle which can contract and relax. Just like the muscles elsewhere in your body, if you don’t use them or you injure them, they can become weak and may not function effectively. A strong pelvic floor typically sits higher and provides more stability for your pelvic organs, while a weak pelvic floor sits lower and provides less stability. In the book, The Flower Empowered, the workings of the different pelvic floor muscles are explained in detail as well as the connection between your pelvic floor and the other supporting structures. For now, lets just imagine that beneath your internal organs is an elastic floor. Thankfully, this elastic floor does not work alone, it has friends in high places!
FRIENDS IN HIGH PLACES?
That’s right! Friends in high places 🙂 The friends to your pelvic floor are a network of tendinous structures that are part of your body’s network of connective tissue (fascia). Fascia is like the glue that holds your body together. It includes connective structures such as ligaments and tendons. Within your pelvis, your fascia acts like a suspension system above your pelvic floor that can provide additional support for your organs. The human fascial system has only gained proper attention in the last few decades. It is still not fully understood but is truly fascianating (excuse the pun!)
It is important to note that fascial tissue is not uniform in its density. Your fascia is designed by your body to distribute load. Tom Myers refers to this as “tensegrity” (tension with integrity). Throughout your body (including your pelvis) the direction of fibres and the strength of fascial tissues will be based on your specific patterns of movement. Fascia has viscoelastic properties – viscous as in having a thick sticky consistency (like honey) and elastic meaning that it can stretch. This combination of viscosity and elasticity allow fascia to stretch slowly then return to the original state slowly over time after the strain is removed (much like the “Stretch Armstrong” toys that you can stretch really far and then when released, they slowly return to their original shape).
Pregnancy and childbirth can stretch these fascial structures and it takes time for them to return following delivery. When you pelvic floor is weak and low, it lowers your pelvic organs causing these tissues to take the strain. If you do not strengthen your pelvic floor, they will remain in the stretched position. This would be the equivalent of pulling Stretch Armstrong’s arms but never letting go to allow him to return to his normal shape. This is why pelvic floor muscle training (PFMT) is so very crucial in preventing and recovering from POP.
If your connective tissues are torn, either through childbirth, injury or surgery, this can result in instability that can contribute to POP. The most important thing to know is that failure to strengthen your pelvic floor using PFMT will result in your organs pulling on these supporting connective tissues. Over time, this can lead to complete prolapse of your organs. The diagram below shows the main fascial ligaments that support the uterus.
DOES HAVING A HYSTERECTOMY IMPACT THIS SUPPORT SYSTEM?
Yes, removal of the uterus impacts on the stability of these suspension structures. Hysterectomies have been practiced since 1813, and many techniques have been developed to re-stabilise these support structures following uterus removal. Hysterectomy is often performed for medical reasons, however, it has become routine practice to remove the uterus during uterine prolapse repairs, even though the risk of subsequent prolapse is high (between 10 – 40%). POP is one of the the three most common reasons for performing a hysterectomy. The uterus itself is not typically the cause of prolapse, so removal without a good medical reason should be questioned. Some studies indicate that hysterectomy could accelerate menopause by compromising the flow of blood to the ovaries. Taking all of these things into consideration, the decision to remove the uterus without a valid medical reason should not be taken lightly. If you have a hysterectomy, there is a great support forum online called Hystersisters.
HOW IS PELVIC ORGAN PROLAPSE MEASURED?
POP is typically measured in stages (from 0 to 4). You may have heard of the POP-Q measuring system which was introduced in the late 90’s. It is a complicated method of establishing the stage of pelvic organ prolapse and not something you would do yourself at home. You are more likely to measure based on your pelvic organ prolapse symptoms. If you are interested knowing more on POP-Q, you can jump over to our POP-Q page. We will demonstrate the simpler output of POP-Q which shows how the stages are viewed based on the degree of pelvic organ prolapse. Note: during menstruation and even sometimes during pre and post ovulation, you may feel that you have stage 1 prolapse so its best to measure during your fertile time.
ARE THERE MULTIPLE TYPES OF PELVIC ORGAN PROLAPSE?
Yes. If you look down to your pelvic area, you will be looking at a 3 dimensional space filled with bones, muscles, fascia, organs, blood vessels and nerves . The movement pattern of your daily life contributes greatly to the distribution of load throughout your pelvis which in turn impacts the strength and function of your muscles and fascia in that area. We tend to favour one side, usually the side with which we write. It is seldom that we balance our weight evenly when we stand. All of this contributes to imbalance.
When there is injury to muscles, very often surrounding muscles and connective tissues will compensate for those injuries. Add imbalance to injury and the result can equal laxity that allows prolapse to occur. The location of the pelvic organ prolapse depends on where you have the most laxity. You can imagine that pressure takes the path of least resistance. Your weakest tissues will offer the path of least resistance.
There are 4 main types of pelvic organ prolapse. It is not unusual for someone to present with more than one type of POP at the same time. You can read more on the different types of pelvic organ prolapse by clicking on the “Learn More” buttons below.
Prolapse of the bladder into the vagina.
Prolapse of the rectum into the vagina.
Prolapse of the small intestine into the vagina.
Prolapse of the Uterus into the vagina
HOW IS PELVIC ORGAN PROLAPSE TREATED?
The primary pelvic organ prolapse treatment depends largely on the stage to which the prolapse has progressed. You don’t develop a full pelvic organ prolapse overnight. It takes time for the pelvic floor to weaken sufficiently to place dependency on the fascial supports. It takes more time for those fascial supports to become stretched as the organs move downwards. The development of a stage 3 or 4 pelvic organ prolapse can take years, and yet, many women wake up one morning to notice that their organs have popping out of their vagina. This is one of the reasons we have started the campaign to break the taboo around pelvic floor dysfunction. #breakthePFDtaboo.
If you have a good relationship with your lady-parts, and you maintain the strength of your pelvic floor, your chances of developing a stage 3 or 4 prolapse are greatly diminished. The sooner you begin pelvic floor muscle training, the better. If you have not noticed your pelvic organ prolapse until your organs have started to protrude outside of your vaginal opening, you may require a surgical repair. Regardless of whether or not surgery is needed, PFMT is always required. To have surgery without undertaking rehabilitation of your pelvic floor muscles is the equivalent to treating a symptom without addressing the root cause. Training your muscles also trains your connective tissue by encouraging fibroblasts to create new fibres in the supporting structures based on the pattern of your movements.
WHAT ARE THE SYMPTOMS OF PELVIC ORGAN PROLAPSE?
Pelvic organ prolapse symptoms often go ignored as they are sometimes similar to those sensations around menstruation. A feeling of heaviness or a sensation of your insides coming out or pulling can be normal when on your period. If you are feeling these sensations at other times, you should make an appointment with your pelvic health physiotherapist for a check-up. Stomach cramps, pain in the low-back or pelvis pain can also be a symptom, although having these types of pains does not indicate that you definitely have a pelvic organ prolapse. It can also feel like you have a ball inside your vagina, or you are sitting on a ball when you sit down.
Considering that POP can be caused by pelvic floor dysfunction, if you don’t have POP but experience urinary incontinence, sexual dysfunction or faecal incontinence, your risk of developing POP is higher as these are all signs that you may have dysfunctional pelvic floor. In cases with cystocele, you may have difficulty urinating due to urethral constriction. The same goes for rectocele, which can make it difficult to empty the bowel, sometimes requiring “splinting” where you push your fingers inside the back wall of your vagina to help your poop come out.
Having a good relationship with your vagina and monitoring your pelvic health, regardless of whether or not you have issues, will help to ensure you lower your risks and maintain optimal pelvic health. You can read more about how to do this in The Flower Empowered.
I THINK I MIGHT HAVE A PROLAPSE, WHO SHOULD I SEE FIRST?
If your organs are protruding out of your vagina, you should make an appointment with your urogynecologist. Otherwise, you should make an appointment with your nearest pelvic floor physiotherapist. Your pelvic health physio can make a full assessment of your pelvic floor and will refer you to a urogynecologist if required.
WHAT IS PELVIC FLOOR MUSCLE TRAINING (PFMT)?
Traditional PFMT involves exercising pelvic floor muscles to restore muscle strength and function. These exercises are often called Kegels – named after Dr. Arnold Kegel who first identified the importance of strengthening these muscles to maintain a stable vaginal canal. It is important to learn how to perform Kegels properly. You can work with a pelvic health physiotherapist to restore the strength and tone. This will help to “lift” your floor in order to provide better support of your pelvic floor organs, while giving your fascia the opportunity to readjust.
I AM HAVING SURGERY FOR STAGE 3 PROLAPSE, DO I STILL NEED PFMT?
Yes! An alarming number of urogynocologists believe that surgery alone should be sufficient to correct POP. Whereas this is true if you consider what “correct” implies – putting all the organs back in their “normal” positions, but it makes no sense if you consider that those organs, although now sitting in the correct “normal” position are still sitting on a weakened pelvic floor.
Over time, the weak pelvic floor will lower further allowing further strain on the fascial connections (or on the grafts that have been used during surgery) causing them to stretch. Eventually, the downward pressure will take the path of least resistance resulting in a new pop. This is often in a different position to the original pelvic organ prolapse. The graft, if used, most likely offers more resistance than the newly prolapsing area.
By undertaking a program of PFMT, you create a lift in the pelvic floor that offers a better support and decreases the risk of recurrent pelvic organ prolapse.
IS THERE ANYTHING ELSE I CAN DO COMBINED WITH MY PFMT?
Yes, PFMT is localised to your pelvic floor muscles so it creates localised strength. However, your pelvic floor muscles do not work in isolation. Taking a whole body, whole life, whole mind approach will improve your chances of optimising your pelvic health. You should note that age, race and general health all have an impact on POP. Age and race cannot be controlled, but there are many other small changes that can have a positive effect.
As your BMI increases, so too does your intra-abdominal pressure. An increase in intra-abdominal pressure directly increases the pressure on the pelvic floor. Over time, this added pressure can lead to weakness which in turn increases the risk of developing POP. A 2009 study found that “being overweight or obese is associated with progression of POP”. The same study found that weight loss does not appear to be significantly associated with regression of POP. They assumed that the damage to the pelvic floor from weight gain was irreversible. However, NONE of the participants in the study underwent PFMT. Studies into PFMT for clearly demonstrate that, not only does PFMT strengthen and tone the pelvic floor, it also significantly improves the symptoms POP.
Your posture and alignment can directly impact the stability of your pelvic floor and should be assessed as part of your rehabilitation. Your fascia holds your posture and distributes load. If you view your pelvic floor muscles in isolation, you are only looking at a small part of a complex puzzle. Working with a structural integrator or myofascial release therapist is a great addition to any program of pelvic floor rehabilitation.
A randomised study evaluated the effects of PFMT between two groups. Group 1 did PFMT at home, while group 2 did PFMT at home combined with one group training session per week. Group 2 participants showed significant improvement in pelvic floor muscle function compared with group 1. This emphasises the importance of community and working together to achieve our goals. Physically meeting with other women all sharing a common goal helps you to stay accountable thus increasing your chances of success. There are many classes that focus on pelvic health. If your pelvic health physiotherapist does not offer a weekly group sessions, try to find a pilates, yoga or hypopressive class focusing specifically on pelvic floor training.
A 2005 study concluded that “tobacco smoking is an independent risk factor for pelvic organ prolapse”. This is believed to be connected to a breakdown of vaginal elasticity which is caused by smoking. If you smoke or spend substantial time passively smoking (in the presence of a smoker), you should consider making some changes to limit your exposure. You should also consider the impact of coughing on your pelvic floor. Coughing is increased with smoking. Each cough gives a sudden burst of intra-abdominal pressure, which over time, can negatively impact your pelvic floor.
MEASURING YOUR PROGRESS
Any program of PFMT should begin with establishing your baseline. This allows you to properly assess your progress. There are multiple ways to measure your progress. Biofeedback is one of the most accurate, as a biofeedback device will actually measure the strength of your contractions. You can also use a biofeedback device as part of your pelvic floor training program.
If you go to see a pelvic floor PT or urogynecologist, they can also perform biofeedback testing or ultrasound to directly see the activation of the pelvic floor. They will also track your POP-Q scores which will help to show your progress. Dramatic improvement in symptoms is typically experienced with only slight improvements to POP-Q scores.
Always bear in mind that it takes a long time for POP to manifest. It can take as much time to reverse. Be patient with yourself.
PRODUCTS FOR PROLAPSE AND PFMT
PRODUCTS FOR PROLAPSE AND PFMT
Pessaries are also commonly used to manage pelvic organ prolapse symptoms and there are numerous products available to help with strengthening the pelvic floor. You should speak with your pelvic floor physiotherapist or urogynecologist before using these products. Reviews of these products will be covered on our YouTube channel. If there is a specific product that you would like to see reviewed, just get in touch and we will review. The images below link to the products on in your local amazon store.*
* I am an affiliate of amazon, iTunes and other affiliate services and may receive a small commission should you purchase through links on TheFlowerEmpowered.com
PFMT TAKES TIME, HOW CAN I MANAGE MY SYMPTOMS IN THE MEANTIME?
Pessaries are typically offered to help manage the pelvic organ prolapse symptoms while you work on improving the strength of your pelvic floor muscles. You can buy pessaries online, although it is best to select the right one with the help of your pelvic health specialist. They can suggest the correct size and shape for you and help you with fitting. You should not feel the pessary when it is in place, similar to how it feels to wear a tampon. Pessaries, like tampons and menstrual cups, do come with the risk of developing toxic shock syndrome. Although this is rare, you should still be aware of the signs.
I’VE HEARD POP GETS WORSE AFTER MENOPAUSE, IS THIS TRUE?
Pelvic organ prolapse is progressive until menopause, however, after menopause, POP can either progress or regress. Regression is more common in the earlier stages of POP (Stage 1 ∼25%). One 2004 study found that “Spontaneous regression is common, especially for grade 1 prolapse”. This is another good reason to stay on top of your pelvic floor muscle training (PFMT). If you can lessen the impact of your pelvic organ prolapse by optimising your pelvic health through PFMT and lifestyle changes you might increase your chances of regression after menopause.
MY SPECIALIST HAS RECOMMENDED SURGERY, WHAT DO I NEED TO KNOW?
There are a number of surgical options available and the options presented to you will be dependent on your surgeon’s experience and preferences. All surgeries carry risks, even those considered to be “minimally invasive”. Carefully consider your options and make sure to get a second opinion if you are unsure.
SET APPROPRIATE EXPECTATIONS
It is important to have realistic expectations if you are having surgery, and to ensure that your surgeon is aware of your expectations. What you believe to be surgical success might not be the same as your surgeons view of success. A 2010 study comparing the differing definitions for success following POP surgery found that great variations in definitions for success. The surgeon typically measures the objective cure rate, which is the anatomical cure (everything back in normal position), whereas the patient measures subjective cure rate – symptoms are alleviated and quality of life increases. How can these be different?
Let’s use a simple example: A patient has surgery for POP where a mesh graft is implanted. Following surgery, the pelvic organs are all back in their “normal” position, therefore she is objectively cured. However, she now suffers from chronic hip pain and cannot have sex due to mesh eroding through her vagina. Although her pelvic organs are no-longer prolapsed, she views this surgery as unsuccessful due to the impact on her quality of life.
WHAT ARE THE SURGICAL OPTIONS FOR TREATING PELVIC ORGAN PROLAPSE?
There are two main types of pelvic organ prolapse surgery; Obliterative surgery and reconstructive surgery. Obliterative surgery narrows or closes the vaginal passage meaning intercourse is no-longer possible. This type of treatment is sometimes offered to elderly patients who are suffering severe pelvic organ prolapse symptoms and are no-longer sexually active. Reconstructive surgery, on the other hand, attempts to restore organs to their original position. This type of surgery can be preformed by open abdominal surgery, laparoscopic abdominal surgery or vaginal surgery.
For reconstructive surgery, the actual procedure depends on the type and degree of prolapse. Pelvic organ prolapse surgery is not advised if you plan on having more children as pregnancy and childbirth will stretch the tissues which are nipped and tucked during repair. While you are still growing your family, it is best to use a pessary for POP management and focus on improving the strength of your pelvic floor. You can do PFMT both before and after your subsequent births and elect to have surgery when your pelvic floor is as strong as possible.
PFMT will increase the bulk and tone of your pelvic floor muscles and will mean that any surgery will be performed from a more stable foundation increasing your chances of success. Make sure to meet your pelvic floor physiotherapist after any repair surgery to plan your rehabilitation. This could be the difference between life long pelvic stability and recurring pelvic organ prolapse.
Oftentimes, multiple types of pelvic organ prolapse can be present at the same time resulting in multiple of the procedures listed below being performed at the same time.
An anterior vaginal repair (Anterior Colporrhaphy) is the primary treatment for cysotcele where the bladder prolapses through the front vaginal wall due to weakness of the tissues. In this procedure, both the connective tissues and vaginal wall on the front side are repaired using sutures. If native tissues are insufficient, a biological graft can be used to provide extra support. Biological grafts can be either from a cadaver (allograft) or from animal derived collagen tissues (xenograft – typically from a cow or a pig). When using a biological graft, it will be soaked in an antibiotic solution prior to implantation. A 2004 study concluded that “in cases of high grade cystocele interposition of porcine dermis represents a successful and safe treatment option”.
As mentioned above, anterior vaginal repair (Anterior Colporrhaphy) can sometimes require the use of a graft if native tissues are insufficient. Since its introduction to market, Synthetic mesh very quickly became the graft of choice, however, its continued use is under scrutiny due to the common occurrence of complications. NICE (the National Institute for Health and Care Excellence) has instructed that mesh for anterior and posterior vaginal repair should only be used for research purposes. If you will have this type of mesh repair, you need to be aware that you are a guniea pig.
There are several manufactures of mesh for posterior repairs, the main ones being; J&J Ethicon, Boston Scientific, American Medical Systems, Bard and Coloplast.
A posterior vaginal repair (Posterior Colporrhaphy) is the primary treatment for rectocele where the rectum prolapses through the back vaginal wall due to weakness of the tissues. In this procedure, both the connective tissues and vaginal wall on the back side are repaired using sutures. A biological graft can be used to provide extra support if there is insufficient native tissue. These grafts can be either from a cadaver (allograft) or or animal derived collagen tissues (xenograft – typically from a cow or a pig). If a biological graft is used, it will be soaked in an antibiotic solution before implantation. A 2012 study into the use of surgisis (a graft from porcine intestine) concluded that surgisis “may decrease recurrences seen with native tissue repair and long-term complications of synthetic mesh. Its use in posterior compartment repair in particular is promising.”
This procedure is often accompanied by perineal repairs. The perineal repairs are required if the genital hiatus has increased in size (read more on the POP-Q page). The perineal body is an intersection for many of the muscles within the three layers of the pelvic floor playing an important role in their functional stability. Repair to the Perineal area involves reconnecting the muscles and connective tissues that converge around the perineum by suturing them back to their appropriate locations. Sometimes permanent sutures are used to hold things in place.
As mentioned above, posterior vaginal repair (Posterior Colporrhaphy) can sometimes require the use of a graft if your own native tissues are insufficient. Synthetic mesh very quickly became the graft of choice following its introduction to the market but its continued use is under extreme scrutiny due to the common occurrence of complications. NICE (the National Institute for Health and Care Excellence) has instructed that mesh for anterior and posterior vaginal repair should only be used for research purposes. If you will have this type of mesh repair, you need to be aware that you are a guniea pig.
There are several manufactures of mesh for posterior repairs, the main ones being; J&J Ethicon, Boston Scientific, American Medical Systems, Bard and Coloplast.
Sacrocolpopexy is a procedure to restore support to the top of the vaginal vault (apex) following hysterectomy. Sacrohysteropexy is the same procedure but with the uterus still in place. These procedures use synthetic mesh which is classified as high risk by the FDA due to complications commonly occurring. If your surgeon is recommending this procedure, you should seek a second opinion. The procedure itself involves stitching mesh into the top of the vaginal fault if there is no uterus present, or into the top portion of the vagina and surrounding the cervix if the uterus is still in place. The mesh is stitched both on the front and back side of the vagina in both cases. The opposite end of the mesh is then stapled (with titanium stables) into your sacrum bone. As well as the common adverse reactions from mesh (including erosion, pain etc.) this particular procedure has resulted in some extremely unusual complications. The image below illustrates the Sacrocolpopexy (no uterus).
Removal of this type of mesh implant when issues occur is extremely difficult.
Uterosacral ligament suspension is a procedure designed to restore support to the top of the vagina (apex). This also provides support for the uterus if present. A recent study highlighted that “its all about the apex” emphasising the importance of the uterosacral and cardinal ligaments in preventing POP. In the absence of a uterus and if the Uterosacral ligament is unsuitable for some reason, a sacrospinous fixation is an alternative option. The image below shows approximate location of sutures for this type of repair. Some specialists argue that removal of the uterus compromises the support provided by these critical ligaments.
Sacrospinous Fixation was first performed in 1968. The procedure is used to treat vaginal vault prolapse or uterine prolapse (apical prolapse) when a hysterectomy is also given. This procedure is typically done in the absence of a womb. The vaginal vault is attached to the sacrospinous ligament either on one side only or bilaterally (both sides). A 2018 study showed that patient questionnaires showed a significant improvement in sexual function with the bilateral sacrospinous fixation, with the greatest improvement being for the “Physical Factor”. Ileococcygeus Suspension is another similar procedure which attaches the vaginal vault to the fascia covering the Ileococcygeus muscle instead of the sacrospinous ligament. In the image below, the vaginal vault has been attached to the sacrospinous ligament on the right side.
MY SURGEON WANTS TO USE MESH, WHAT DO I NEED TO KNOW?
It is important to note that all surgeries carry risks and none have a 100% success rate. Surgery in the pelvic area has the potential to damage organs (bladder, uterus, bowel) as well as nerves, blood vessels and muscle/fascia. Following POP repairs, you could experience symptoms that you did not have prior to your surgery, such as stress incontinence (SUI) or overactive bladder (OAB). This new incontinence is referred to as “denovo incontinence”. Pelvic pain and sexual dysfunction can manifest following repairs. The recurrence rate with POP is reported between 10 and 40% so often repeat surgeries are required. Each surgery introduces the potential for injury as well as creating more scar tissue.
All of the procedures listed above can result in these complications and require repeat surgeries, however, with synthetic mesh repairs, there are additional risks that are common hence the huge controversy that exists around the use of mesh. If you are based in USA, you can check the payments your surgeon has received from mesh manufacturers on Dollars for Docs or Open Payments Data. The decision to implant mesh is not one to be taken lightly. Let’s explore the data.
To mesh or not to mesh, that is the question...
WHAT DO THE SCIENTIFIC STUDIES SAY AND ARE THEY RELIABLE?
Did you know that in the US, the pharmaceutical and medical device industry now funds six times more clinical trials than the federal government? It is hard to trust scientific studies with such large conflicts of interest at play. Not only are there conflicts of interest but there are also massive conflicts in the results.
Scientific studies regarding medical devices should show the outcomes and risks associated with those devices. When a study is released, it should be followed by a replication study, where other scientists and institutions replicate the study to see if they get similar results. In order to actually show statistical significance, sample sizes (number of people) should be large. To help reduce bias, studies should also be randomised controlled trials (RCT’s), where the sample is split into two groups where one group is given the treatment being tested and the other group (the control group) is given a standard treatment or placebo. Studies into medical devices should also be carried out with long term follow-up to ensure that complications are picked up even if they occur many years after the original surgery.
Unfortunately, the majority of studies into mesh have been funded by the mesh manufactures. RCT’s have been few and far between, with many of the studies (on which decisions to implant mesh are based) being retrospective short term studies. Sample sizes are often small and studies are even subject to p-hacking – where the data is mined or broken into a smaller dataset in order to select outcomes that are in favour of the desired outcome.
A simplified explanation of P-hacking is that you scan the complete data for the research and select a subset that gives the conclusion you want. An example of this can be seen in the following comparison of two studies (best viewed on PC/laptop). These studies clearly come from the same dataset, with four of the same authors, almost the same date range and the same procedures being prepared. These studies were comparing Prosterior Vaginal repairs using mesh (POSTERIOR IVS) and Sacrospinous fixation (native tissues) for the management of pelvic organ prolapse. The first study states that “Both the procedures were highly effective in restoring anatomy in the upper vaginal segment.” , however, the second, which was used as a reference study for a mesh device needing FDA approval, concludes with some loosely worded text that is positive towards mesh and negative towards the native tissue repairs!
Does this make the researchers bad people? No – we have to realise that they are under immense pressure to produce positive results from studies. They can’t do studies if there is no funding, and most of the funding comes from big pharma. Again, their livelihood is under threat if they try to go against the current corrupt system.
Aim of study: To assess the efficacy of two different transvaginal procedures in the management of patients with cuff prolapse and associated pelvic floor defects.
Date ranges: February 2002 – December 2003
Researchers: Meschia M., Gattei U., Pifarotti P., Spennacchio M., Longatti D., Barbacini P.
Number of participants: 60 (66 with 10% dropout)
Number who had Sacrospinous fixation: 30
Number who had Prosterior IVS: 30
Patients in data analysed for conclusion: 32
Follow-up period: 3, 6, 12 and 24 months
Study conclusion: Sacrospinous fixation and posterior IVS are equally effective in restoring anatomy at the upper vaginal segment
Interpretation of results: Overall optimal or satisfactory results in restoring vaginal anatomy were achieved in 64% and 58% (p= 0.96) of the patients undergoing SACPROSPINOUS FIXATION or PROSTERIOR IVS (Mesh). Both the procedures were highly effective in restoring anatomy in the upper vaginal segment.
Aim of study: To assess the efficacy of two different transvaginal procedures in the management of patients with cuff prolapse and associated pelvic floor defects.
Date ranges: January 2002 – March 2003
Researchers: Meschia M., Gattei U., Pifarotti P., Spennacchio M., , Buonaguidi A.
Number of participants: 47
Number who had Sacrospinous fixation: 23
Number who had Prosterior IVS: 24
Patients in data analysed for conclusion: 32
Follow-up period: At least 6 months
Study conclusion: Loosly worded paragraph that does not actually conclude anything but is negative towards SACPROSPINOUS FIXATION and positive towards PROSTERIOR IVS (Mesh)
Interpretation of results: Not offered
Does this make the researchers bad people? No – we have to realise that they are under immense pressure to produce positive results from studies. They can’t do studies if there is no funding, and most of the funding comes pharmaceutical giants. Again, their livelihood is under threat if they try to go against the current corrupt system. The system has to change, which means governments have to legislate to ensure that this type of corruption cannot continue.
DON’T RESEARCHERS QUESTION THE DATA?
Yes, sometimes they do. One such example was a study from the Netherlands in 2004 entitled “Posterior IVS, minimally invasive or erosive?”. The study highlighted that surgeons in the Netherlands had been enthusiastic in the uptake of the Prosterior IVS concept. They went on to explain that with 25%* of the patients who underwent the posterior IVS procedure, vaginal erosion occurred soon after implantation. The high rate of erosion could not simply be explained away by “patient selection” and they concluded that the mesh material (multifilament polypropylene) was to blame. In the institution where this study was carried out, they agreed that the unacceptably high rate of erosions would deter them from using this procedure.
The standard category for defining frequency of side effects and complications for drugs and medical devices is as follows:
|Term||Numerical rate||Percentage rate|
|Very common||More than 1 in 10||10% or higher|
|Common||1 in 10 – 1 in 100||10% – 1%|
|Uncommon||1 in 100 to 1 in 1000||0.1% to 1%|
|Rare||1 in 1000 to 1 in 10,000||0.01% to 0.1%|
|Very rare||Less than 1 in 10,000||Less than 0,01%|
*In the dutch study, mesh erosion was “very common” with 1 in 4 women affected.
WHAT DOES THE FDA SAY ABOUT MESH FOR POP REPAIRS?
In July 2011, the FDA released an update on Urogynecologic Surgical Mesh, specifically focusing on transvaginal placement for Pelvic Organ Prolapse. They determined that “(1) serious adverse events are NOT rare, contrary to what was stated in the 2008 PHN, and (2) transvaginally placed mesh in POP repair does NOT conclusively improve clinical outcomes over traditional non-mesh repair.”. They also highlighted that “Based on data from 110 studies including 11,785 women, approximately 10 percent of women undergoing transvaginal POP repair with mesh experienced mesh erosion within 12 months of surgery”. 10% is common or very common, depending on whether your glass is half full or half empty. 10% equates to one in ten women. The FDA also recommended to health care providers that they “Recognize that in most cases, POP can be treated successfully without mesh thus avoiding the risk of mesh-related complications.”
ARE THE COMPLICATIONS ONLY WITH TRANSVAGINALLY PLACED MESH?
No, the evidence is very clear that transvaginally placed mesh (mesh inserted through the vagina instead of open surgery or laparoscopic surgery) will result in mesh erosion for 10% of women implanted, but this does not mean that it is the route of entry that causes the problem. Short of issuing an outright ban, NICE (the National Institute for Health and Care Excellence) in the UK specified that Pelvic Organ Prolapse Mesh should only be used for research purposes. Australia and New Zealand banned mesh products for urogynaecological repairs.
COULD IT JUST BE THAT SOME SURGEONS DON’T HAVE ENOUGH EXPERIENCE?
Lack of experience with specific devices or procedures could account for a small number of issues, however, the rate of complications point to a bigger problem. In a recent 60 minutes documentary a leading plastics expert explained that polypropylene should not be permanently implanted in the human body. Mesh devices are PERMANENT. Pelvic organ prolapse mesh can reach all the way from the front to the back of the pelvis in some cases, and is both difficult and dangerous to remove. Those who suffer complications can end up with repeated surgeries to have portions of the mesh snipped away, creating further damage and not necessarily resolving the issues. Even removal doesn’t guarantee a return to normal.
This is a global issue. You can watch documentaries from Sky News in UK, W5 in Canada and ABC News in Australia. Similar mesh is used for hernia operations which is also causing serious health issues according to this BBC documentary released in 2017. The decision to implant synthetic mesh is not one to be taken lightly.