Pelvic Organ Prolapse Treatment in Singapore

Anterior prolapse is the most common; it is is medically called a cystocele, and involves the bladder bulging into the vaginal canal through the front wall.

This is medically called a rectocele if it involves the rectum bulging into the vaginal canal through the lower back wall, and an enterocele if it involves the small intestine bulging into the vaginal canal through the upper back wall.

This is second most common, where the uterus drops into the vaginal canal (uterine prolapse). For women with previous hysterectomy (removal of the uterus), the top of the vagina may collapse downwards out of the vaginal opening.

Most women will have a combination of 1 or more prolapse. Because of the common cause of weakened pelvic floor muscles, many women may suffer from both pelvic organ prolapse and urinary incontinence. 

These strengthen the weakened pelvic floor muscle tone and can improve mild pelvic organ prolapse. Kegel exercises need consistent daily efforts for at least 3 to 6 months to see results.

Here are some tips on how to do Kegel exercises:

• Try and imagine that you are trying to stop a fart from coming out, or trying to stop your urine flow in the middle of the stream. You may find it useful to find the correct muscles by actually doing this while you are sitting on the toilet bowl, but do not do it routinely as you may teach your bladder bad habits!
• Lie down on your bed with your knees bent and legs slightly apart
• Put a small mirror in between your legs and observe your vagina and anus openings while you try and squeeze your pelvic floor muscles. You should see the openings getting smaller and being lifted in and upwards

It is normal for you to take some time to learn which are the correct muscles and how to squeeze and relax sufficiently at first. Don’t worry and be patient!

Once you have identified the correct muscles:

1. Squeeze your pelvic floor muscles and hold for 1 second – repeat 5 times
2. Squeeze and hold for 5 seconds – repeat 5 times
3. Step 1 + Step 2 = 1 cycle (30 seconds)
4. Do 5 cycles (2-3 minutes) three or four times a day (7-10 minutes)

The key is remembering to do your Kegel exercises daily. You can do them any time, in any place and in any position as nobody can tell that you are doing them! Don’t limit yourself to the sets above – if you can do it more often, do so.

If you have difficulty grasping the technique of Kegel’s exercises, speak with your urogynaecologist who can refer you to a specialised physiotherapist.

As it is likely that your pelvic floor muscles have weakened, you may not see results until you have put in consistent efforts for at least 3 to 6 months. Remember – slow and steady wins the race!

Avoid increased pressure on pelvic floor muscles by losing weight to maintain a healthy body mass index (BMI), treating conditions such as chronic cough and constipation, not lifting heavy loads.

These are soft, removable devices that is inserted in your vagina to support your prolapsed pelvic organs and hence provide relief of your symptoms of POP. This is temporary as if the pessary is removed, POP will recur. Vaginal pessaries come in many different shapes and sizes. The most commonly used one is the ring pessary, which needs to be removed, washed and replaced by your gynaecologist every 3-4 months or so.

This is the most common approach as the pelvic organs are drooping out from the vagina. If the uterus is prolapsed, there is no plans for more children and the woman has no desire to keep her uterus, a vaginal hysterectomy will be performed. The ovaries can be conserved if they are normal.

Surgery for prolapse in the other compartments (pelvic floor repair) involves making a cut in the vagina and separating the prolapsed organ away from the vaginal wall. Stitches or mesh are used to strengthen the defect in the supporting tissue, and the vaginal skin is closed to reduce the bulge.

If this is done for the bladder (anterior prolapse or cystocele), it is known as an anterior repair or colporraphy. If this is done for the rectum, it is known as a posterior repair or colporraphy. In some cases, additional permanent sutures may be placed to hitch the top of the vagina to a strong ligament in the pelvis to provide additional support (sacrospinous ligament fixation/SSLF). Overall, there are no cuts on the abdomen.

Risks of surgery include:

Common (affecting 1-5% of patients):

• Vaginal bleeding / haematoma – in cases of significant bleeding, blood transfusion and/or additional procedures may be required to stop the bleeding
• Postoperative pain (in cases of SSLF, this is usually involves the right buttock and usually resolves in a few weeks)
• Urinary retention, infection, frequency, urgency, urge and urinary incontinence
• Wound infection
• Constipation
• Difficulty and/or pain with intercourse
• Failure to achieve the desired result; recurrence of prolapse
• Earlier onset of menopause

Uncommon (affecting 0.1-1% of patients):

• Injury to the bladder
• Pelvic abscess
• Venous thrombosis (Blood clot in legs) / Pulmonary embolism (Blood clot in lungs)

Rare (affecting <0.1% of patients):

• Serious adverse reactions to general anaesthesia
• Excessive bleeding requiring transfusion or return to theatre
• Injury to the urinary tract / bowel
• Admission to the intensive care unit for monitoring should the operation be of prolonged duration or result in complications
• Death: the risk is approximately less than 1 in 4000

This is an option for women with previous hysterectomy and an apical prolapse (top of vagina collapsing downwards out of the vaginal opening). It involves making cuts in the abdomen and using a permanent synthetic mesh to hitch the vagina up to the sacrum, which is a large triangular bone at the base of the spine.

In a few instances, vaginal closure surgery may be recommended for women with severe prolapse who are medically unfit for vaginal pelvic reconstructive surgery and are not sexually active. This surgery involves pushing the prolapsed organs back into the vagina and stitching the vaginal walls together.