Pelvic Organ Prolapse (POP) Surgery: Everything You Need to Know

Surgery to correct a vaginal hernia, also called pelvic organ prolapse (POP), can help restore the integrity of compromised tissue and muscles meant to hold pelvic organs like the bladder and rectum in place. Known as POP surgery, the procedure is aimed at reducing symptoms like pelvic pressure and urine leaks by putting the pelvic structures back into position and surgically creating support to prevent them from dropping toward or outside the vagina.

Surgical mesh on a blue table
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What Is Pelvic Organ Prolapse Surgery?

POP surgery is an operation that lifts pelvic organs that have sunk into or out of the vagina. Herniation of the bladder is the most common of these, but the rectum, uterus, intestine, and cervix can do this as well.

This type of surgery involves reinforcing ligaments and muscles with sutures. If the existing connective tissue and muscles cannot be properly repaired or strengthened in this way, artificial mesh—a screen-like medical device—may be placed to provide adequate support.

Surgical Approaches

Surgical correction of pelvic organ prolapse can be done transvaginally (through the vagina), laparoscopically (with a small lower abdominal incision), or as a robot-assisted procedure. All of these minimally invasive approaches are done with a surgical device that's equipped with a camera.

Sometimes extensive operations with hysterectomy (removal of the uterus) are done with an open laparotomy and a large lower abdominal incision. With an open procedure, your surgeon will visualize your pelvic organs directly.

Vaginal prolapse surgery is done with general anesthesia for pain control.

Procedures

There are several procedures considered POP surgeries:

Procedure Purpose Usual Surgical Approach
Anterior vaginal wall repair Strengthen connective tissue between the vagina and the bladder  Transvaginally or via abdominal incision
Posterior vaginal wall repair Strengthen the connective tissue between the vagina and the rectum  Transvaginally
Sacrocolpopexy Attach the top of the vagina to the tailbone  Abdominal incision
Sacrohysteropexy Attach the cervix to the tailbone Abdominal incision
Sacrospinous fixation Attach the vagina to the ligaments of the pelvis Transvaginally



 

Reconstructive surgery may be done to maintain the position of the pelvic structures. And sometimes obliterative surgery is done, in which the vaginal wall is surgically narrowed as a means of supporting the pelvic structures. (This makes future vaginal intercourse no longer possible.)

Contraindications

You might not be able to have pelvic organ prolapse surgery if you have a high risk of complications. For instance, a history of adhesions (surgical scarring), major medical illnesses, or a bleeding disorder can lead to substantial problems after surgery.

Pelvic organ prolapse surgery can involve a hysterectomy if the uterus is prolapsed. Sometimes surgical repair to support the uterus isn't possible or there may be a high risk of another prolapse if the surrounding supportive tissue is especially weak or atrophied (thinned). As a woman cannot become pregnant and will experience medical menopause if a hysterectomy is done, the decision to have the uterus removed has to be made with these considerations in mind.

Potential Risks

There are side effects associated with general anesthesia and surgery. In addition to those, pelvic organ prolapse surgery can cause:

  • Bleeding
  • Infections
  • Injury to the structures in the pelvis
  • Adhesions

Surgical Mesh Concerns

The Food and Drug Administration (FDA) has issued a statement about the possible complications of surgical mesh, which include pain, recurrent prolapse, and injuries that require surgical intervention. Transvaginal mesh is associated with a higher complication rate than mesh placed in the abdomen.

With all of that said, surgical mesh can be highly effective in the surgical treatment of POP. You and your doctor should discuss the risks and benefits of surgical mesh in your case and whether or not using it is advised.

Purpose of POP Surgery

Pelvic organ prolapse surgery is done to remove pressure on the vagina from pelvic organs. The pressure can cause a variety of concerns, including incontinence of urine or stool, infections, and erosion of the vaginal tissue.

There are different types of vaginal hernias:

  • A cystocele is herniation of the bladder into the vagina, and it is located in the anterior vaginal wall (front wall of the vagina).
  • A urethrocele is a sagging of the urethra, which is the duct that urine travels through before exiting the body.
  • A rectocele is a herniation of the rectum into the vagina, and it is located in the posterior vaginal wall (back wall of the vagina).
  • An enterocele is a hernia of the small bowel into the vagina, and it usually results from loss of pelvic support at the top of the vagina, close to the cervix.
  • Uterine prolapse is herniation of the uterus into the vagina, and it results from weakness of the cardinal or uterosacral ligaments that support the uterus.

Injury or weakness in the pelvic floor muscles can cause pelvic organs to drop into the vagina. When the pelvic support structures weaken, it's likely that two or three pelvic organs can drop together; you may have a cystocele with a urethrocele or another combination of prolapse.

Most women with pelvic organ prolapse actually don't experience any noticeable effects, in which case interventions are generally not needed.

But when symptoms do occur, they can include:

  • Bulging in the vagina
  • Heaviness, fullness, aching, or pulling in the vagina, often worsening at the end of the day or during a bowel movement
  • Difficulty completely emptying the bladder
  • Pain with urination
  • Sexual difficulties
  • Urinary tract infections
  • Leaking urine, especially while coughing, exercising, or laughing
  • Constipation
  • Leaking stool
  • Trouble controlling gas

Your specific pelvic organ prolapse symptoms depend on which pelvic organs have herniated through your vagina. For instance, cystoceles cause urinary symptoms.

Conservative management, such as pelvic floor exercises or placement of a pessary (a flexible device that gets inserted into the vagina), is often effective for reducing these symptoms.

Surgery may be considered if such conservative measures have not worked.

How to Prepare

Surgery preparation includes an assessment of the anatomical structures involved in your vaginal hernia for procedural planning, as well as tests for anesthesia preparation.

Your doctor will review your symptoms and do a pelvic examination. Diagnostic imaging tests such as abdominal and pelvic computerized tomography (CT) will be used to assess the organs that have prolapsed and the extent to which they are out of position. A decision about whether you will need surgical mesh placement will be made.

You will also have a urinalysis or urine function tests, like a voiding cystourethrogram (VCUG) test to assess bladder involvement. Pre-anesthesia testing will include a complete blood count (CBC), blood chemistry tests, a chest X-ray, and an electrocardiogram (EKG).

Location

You will have your surgery in a hospital operating room. You will need to stay in the hospital for a few days after your surgery before getting discharged. Arrange for someone to drive you home.

Food and Drink

You will need to abstain from food and drink after midnight the night before your pelvic prolapse surgery.

Medications

You may need to make some adjustments to any medications you take in the week before your surgery.

If you regularly take blood thinners, your doctor will give you instructions about stopping or decreasing your dose. Additionally, you may need to temporarily adjust your dose of diabetes medication, steroids, or non-steroidal anti-inflammatories in the days before your surgery.

Be sure your doctor is aware of any and all drugs and supplements you take.

What to Bring

Pack clothes to go home in that are loose and comfortable, as you may have some soreness and swelling around your pelvic and lower abdominal area.

Make sure that you have your identification, insurance information, and a form of payment for any portion of the surgical fee you are responsible for.

Pre-Op Lifestyle Changes

You might be instructed to use a bowel prep the day before surgery. This is a medication that causes you to have bowel movements that empty your colon, and it may decrease the risk of postoperative infection after POP surgery.

What to Expect on the Day of Surgery

When you go to your surgery appointment, you will need to register and sign a consent form.

You will go to a pre-operative area where your temperature, pulse, blood pressure, respiratory rate, and oxygen saturation will be monitored. You will have an intravenous (IV, in a vein) line placed on your arm or hand to be used for medication administration, such as an anesthetic.

You may have same-day tests, such as CBC, blood chemistry levels, and a urine test.

You may have a urinary catheter placed, and your surgeon and anesthesiologist may examine you before your procedure. You will then go to the operating room.

Before the Surgery

If a catheter was not already placed, one will be now. Anesthesia will be started with medications injected in your IV to make you sleep, to prevent you from feeling pain, and to reduce your muscle movement. You will have a breathing tube placed in your throat to allow for mechanically assisted breathing throughout your surgery.

Your blood pressure, pulse, breathing, and oxygen saturation will be monitored throughout your procedure.

A surgical drape will be placed over your abdomen and pelvis. The surgical area will be exposed and cleaned with an antiseptic solution.

During the Surgery

Your surgeon will make an incision in your abdomen or vagina. A transvaginal or laparoscopic abdominal incision will be small, measuring about an inch in length. For an open laparotomy, the incision will be larger, measuring between three and six inches.

For a laparoscopic surgery or an open laparotomy, your peritoneal covering will be cut as well. The peritoneum is a thin membrane under your skin that encloses your pelvic and abdominal organs. (It usually doesn't need to be cut if you are having a transvaginal procedure because the vagina is within the peritoneum.)

If applicable, a camera device will be inserted into your surgical incision. Weakened ligaments and any structures that are out of place will have already been identified on pre-operative imaging, and your surgeon will navigate to them at this time.

Using surgical tools, your surgeon will gently move your pelvic organs into the optimal position and then create the support that's needed using suture and/or surgical mesh.

One or more techniques for maintaining support of your pelvic organs will be used, including:

  • Strengthening muscle and/or ligaments by repositioning them and holding them together with sutures
  • Attaching a portion of your vagina to nearby structures
  • Tightening your vaginal wall by reducing the size of the vaginal opening with suture
  • Placing mesh to hold the herniated organs in place
  • Removing the uterus if it cannot be supported with these methods

Which one(s) your surgeon uses will have been planned prior to your surgery, but some details of your procedure—such as how many sutures are placed or the exact size of the mesh—will need to be determined while it is in progress and your surgeon is securing the anatomical structures in place.

Sometimes unexpected issues can arise. For instance, your vagina might have atrophied more than anticipated, and you might need to have your cervix secured to your tailbone in addition to, or instead of, having your vagina secured to your tailbone. Your surgeon will need to adjust the surgical plan in such a case.

Removal of the uterus, however, would only be done if you consented to it prior to surgery.

After your pelvic structures are secured, the laparoscopic device (if your surgeon is using one) and any surgical tools are removed. The incision in the abdomen or vagina will be closed with stitches, and the wound will be covered with surgical bandages.

Your anesthetic medication will then be stopped or reversed, and the breathing tube will be removed. Your anesthesia team will make sure you can breathe on your own before you leave the operating room.

After the Surgery

You will wake up in the recovery area and receive pain medication as needed. You will be transported to your hospital room within a few hours.

The urinary catheter will be removed approximately two days after your surgery. You may have some vaginal bleeding or blood in your urine, and your surgical team will monitor the amount to ensure that you are properly healing.

Before you can go home, you must be able to pass urine on your own, as well as stool and gas without difficulty. If you can and are otherwise recovering as expected, you will be discharged.

You will receive a prescription or a recommendation for an over-the-counter pain medication, as well as any other medications that you need to take (such as hormone replacement therapy if you've had a hysterectomy). Instructions regarding next steps, at-home care, and when to call your doctor will be provided.

Recovery

It will take several weeks for you to recover after POP surgery. Procedures that involve more extensive repair can take longer to recover from than those that are less complicated.

You will need to see your doctor within a week and again several weeks after surgery. They will examine your wound and remove stitches. You may also have imaging tests to assess the repair.

Healing

Keep your wound clean and dry as you are healing. You can take your pain medication as directed, if needed; cold packs can help reduce pelvic swelling.

You may continue to have some vaginal bleeding or blood in your urine. You can use a sanitary pad to absorb vaginal blood, but do not place a tampon or anything else in your vagina while you are still healing. It is important that you contact your surgeon's office if you are having more bleeding than you were told to anticipate.

When to Call Your Doctor

Call your doctor's office if you experience any of these signs of complications:

  • Fever
  • Excessive bleeding
  • Worsening or excessive pain
  • Blood clots in the urine or from the vagina
  • Puss coming from the wound
  • Redness or tenderness around the wound
  • Severe constipation
  • Inability to pass urine
  • Abdominal distension (enlargement)

Coping With Recovery

You will have restrictions regarding driving, exercising, and heavy lifting. But having to limit your physical activity doesn't mean you shouldn't be active at all.

Staying in bed for weeks can increase the risk of blood clots and muscle atrophy (thinning), so it's critical that you get some activity. Move around as directed by your doctor. This might mean taking short walks in your neighborhood or around your house.

Your doctor will advise you to abstain from sexual intercourse for several weeks while you are recovering.

After several weeks, you will be able to increase your physical activity as tolerated and advised by your surgeon. Your doctor will tell you when you have the green light for activities like driving and exercise.

Your activities will be limited for longer if you've had an open laparotomy or if you've had complications like bleeding or an infection after surgery.

Long-Term Care

You might be advised to do pelvic floor exercises to strengthen your pelvic muscle control after surgery.

If you had a hysterectomy as part of your POP surgery and haven't already reached menopause, then you will experience menopause abruptly after your surgery. This can cause a number of issues, such as fatigue, osteoporosis, and weight changes.

You and your doctor may discuss long-term treatment, such as hormone replacement therapy.

Possible Future Surgeries

Vaginal hernia repair surgery is intended as a one-time procedure, but you can be at risk of recurrent pelvic organ prolapse after a surgical repair.

If you develop recurrent pelvic organ prolapse or complications, such as due to mesh placement, you may need one or more additional surgical procedures for repair.

Lifestyle Adjustments

You may need to make major lifestyle adjustments after pelvic organ prolapse surgery.

If you had an obliterative procedure, vaginal intercourse is no longer an option for you. That can be a major adjustment even if you felt you understood and accepted this consequence prior to your surgery. You (or you and your partner) may benefit from speaking to a therapist about how this change affects your life.

Additionally, you may need to make adjustments to your bowel and bladder habits. For instance, you might make sure that you are always near a toilet in case you experience urgency. Or your doctor may advise you to periodically empty your bladder on a schedule to avoid leaking.

A Word From Verywell

Often, vaginal herniation doesn't require intervention or it can be managed with non-surgical methods. If you have pelvic organ prolapse, you may have subtle effects that can get worse over time, so it's important that you talk to your doctor if you experience bladder issues or pelvic pressure. Surgery is not the most common treatment for pelvic organ prolapse, but it can be necessary to prevent serious complications.

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Article Sources
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