11 % of women will undergo some surgery in their lifetime for vaginal prolapse or incontinence.
As a pelvic floor reconstructive surgeon or vaginal restorative surgeon, one of the important functions of the vagina, sexual activity, can not be overlooked. Not everyone desires to be sexually active, however if you do and are looking for repair of your vaginal prolapse, it is important to consider some facts that I will discuss.
Vaginal prolapse is the descent of the bladder, uterus, small bowel or rectum into the vagina. Often a “bulge” is seen or palpated.
Sexual activity pertains often to intercourse, but obviously encompasses more than that
There are prolapse repairs that will close a vagina. Not only do they give an unacceptable complication rate of about 30%, I prefer not to take away the option to ever participate in sexual activity and wil not perform this intervention.
Most women who have gone through vaginal childbirth have some descent of their vaginal walls. Some women choose to have their vagina tightened for this, which would classify as cosmetic gynecology. The purpose of the tightening is to enhance sexual pleasure for the woman and likely her partner and it often boosts self-confidence.
Sometimes vaginal walls descend to a degree where they form almost an obstruction to intercourse. In reality they can almost always at least temporarily be brought back in, however it can be uncomfortable for the woman and some also feel embarrassed about their vagina in prolapsed state.
Even though vaginal walls and organs behind it can come down past the vaginal opening, the organs will not be lost, the vaginal walls will keep on stretching. You will not wake up one day with your bladder lying next to you on the pillow.
When considering prolapse surgery there are several options, mostly limited to laparoscopic/robotic surgery (through the abdomen with small incisions and camera) or surgery through the vagina.
So what does sexual activity have to do with it? When women are young and sexually active and the bladder, uterus or vaginal cuff are severely prolapsed, a laparoscopic/robotic repair is often preferred since the vagina will remain highly functional. A polypropylene mesh material is mostly used connecting the vagina to a ligament on the sacrum (back). There is a very low chance that this mesh will protrude in the vagina. The flexibility of the vagina will be better preserved than with a vaginal mesh insertion.
Mesh protrusion in the vagina can give no symptoms to bleeding or discharge, however if you are sexually active with a male partner, he may be less enthused. When mesh comes through the vaginal wall, a male partner can be ”injured”. Obviously if the partner does not have a good erection it may go unnoticed.
If a mesh is implanted vaginally, the chance that it protrudes is higher than when it is placed through the abdomen, however if it comes through, also easier to fix.
In general most urogynecologists would not insert vaginal mesh on the front and back side of the vagina in a young sexually active woman, who is in a good medical condition. A sacrocolpopexy would be preferred.
If only one side is needed especially if it is the back side of the vagina, a vaginal repair is often chosen.
Not everybody needs a repair with a polypropylene mesh, however if there is significant prolapse to or past the vaginal opening, pulling weak tissue together will not create a flexible vagina that will tolerate pleasant intercourse. Often there is too much tension on these repairs, and they will not hold up well.
Non surgical repair with a pessary (support shelf) is an option, however will have to be removed for sexual intimacy.
Choosing the right repair for your vaginal prolapse is important. Have a discussion with your urogynecologist about your options.
Dr. Sprock is a fellowship trained urogynecologist, located in Rockledge FL, who offers laparoscopic as well as vaginal prolapse repair and pessary placement if desired.