VAGINAL VAULT PROLAPSE
If you’ve had a hysterectomy, part of your surgery involved securing the top of the vaginal tube (also called its apex) to nearby pelvic ligaments. When these new attachments are strong, the posthysterectomy vagina will have a length and depth that allows normal sexual function; the absence of a uterus and cervix will, of course, mean no more periods. However, if these attachments weaken, the upper vagina can begin to bulge downward, causing vaginal vault prolapse. By definition, this prolapse type can occur only in women who have had a hysterectomy. To the untrained eye, prolapse of the vault can appear quite similar to prolapse of the vagina’s upper wall or lower wall—all three look like a bulge of tissue at the vaginal opening. In fact, all three can be similarly managed with pessaries, diaphragmlike devices that you’ll learn about later. But repairing vaginal vault prolapse requires its own specific surgery, called a vault suspension.
ENTEROCELE
An enterocele is a bulging of the small intestine into the top of the vagina: in medical terms, an actual hernia into this especially vulnerable area of the female body. In terms of their general appearance, enteroceles look much like any other vaginal prolapse bulge. The difference is that lying behind an enterocele bulge are the intestines, rather than the bladder or rectum.
Because virtually any physical exertion tends to cause pressures to rise in the intestinal cavity, an enterocele bulge can expand like a balloon during activity and will often progress rapidly once it reaches a certain size. During periods of reduced physical activity, an enterocele may bulge much less, or even fully reduce. Just like a hernia, an enterocele will progress more rapidly if a woman performs heavy lifting, strains on the toilet, or fails to treat a chronic cough.
Although large enteroceles are usually easy to identify, determining whether or not you have a small enterocele can be somewhat difficult. Sometimes they’re found only during surgery. On rare occasions, high-tech radiology tests are used to help make the diagnosis. Finding and repairing enteroceles is one of your doctor’s important tasks, to reduce your chances of a recurrent prolapse. If a small enterocele is not recognized, it may grow in size, begin to protrude, and weaken the nearby areas of surgical repair.
Common prolapse “bulges”: (A)cystocele, (B) rectocele, (C) uterine prolapse
IS THAT PROLAPSE I’M FEELING?
If you’ve been aware of pelvic symptoms and feeling that something’s not quite right down there, it’s not always easy to decipher which of them are being caused by prolapse. Early prolapse symptoms tend to be vague and can be easy to confuse with other common symptoms arising in the pelvis, bladder, vagina, and even lower back. But determining the cause of your symptoms is important, not only so you’ll know what might improve with treatment, but also to avoid unnecessary procedures. After all, you wouldn’t want to go through a major operation for what seems to be worsening prolapse symptoms when all you need is a stool softener for chronic constipation or a lower-back massage for muscle strain. Here are some useful clues to keep in mind.
Do you have bulging, pelvic or vaginal discomfort, or a dragging sensation in the lower abdomen or back that becomes worse when you’re standing and improves when you lie down? This is how prolapse symptoms often behave. If the reverse is true, and your symptoms worsen while you’re at rest or sleeping, consider other causes. Try keeping a diary of your symptoms and activities for two to three days. This diary may be your first step toward finding relief (see “Voiding and Symptom Diary” Appendix B).
Are your symptoms worse at the end of the day? That’s pelvic prolapse’s typical pattern. Pressure symptoms tend to become more severe after a long day of activity, exercise, and the simple downward force of gravity. The morning hours, after a good night’s sleep, are usually the most symptom-free.
Do your symptoms improve when you’re wearing a tampon or diaphragm? For mild cases of prolapse, inserting a tampon or diaphragm can provide enough support to the vagina, rectum, and bladder that you’ll notice an improvement in symptoms of either prolapse or incontinence. If you’re familiar with the use of these devices, it’s safe to try them before seeing your doctor, as long as you follow the usual instructions for use and never leave them inserted for longer than the recommended time. If they make you feel better, speak with your doctor about a longer-term support device (see “Vaginal Continence Devices,” chapter 8).
Do your symptoms improve with the pessary test? Pessaries are diaphragm-like devices inserted vaginally for the nonsurgical relief of prolapse, which you’ll learn about in the next section. Trying one, even if only for a few days, might help you to better understand vague symptoms. For instance, is your lower-back discomfort arising from the prolapse of an enterocele or vaginal vault, or just a simple muscle strain? If pelvic symptoms disappear with the pessary in place, that’s pretty good evidence that they’re related to the loss of vaginal supports. The pessary test can help you to predict how you might feel after your prolapse is surgically repaired.
Has your urinary stream become weaker? As prolapse bulges enlarge around the bladder and urethra, it’s common to notice a weaker urinary stream.
Did your long-standing stress incontinence start to improve on its own? Ironically, as prolapse becomes more advanced, you may notice an improvement in stress incontinence. That’s because a large prolapse bulge will actually cause a bend or kink to form in the urethral tube (like putting a bend in that leaky garden hose we discussed), reducing the odds of accidental leakage during physical stress (see “Increased Incontinence,”).
Do you double-void, dribble, or feel full right after urinating? Signs of urinary retention or incomplete voiding become common as certain prolapse bulges enlarge.
Does urinating become much easier after you’ve emptied your bowels? Sometimes the stool filling a rectocele can actually push the bulging lower vaginal wall up against the urethra or bladder. After the rectocele is emptied with a bowel movement, the urinary stream will usually flow more easily.
Nonsurgical Remedies for Prolapse
MEDICATIONS FOR PROLAPSE-RELATED SYMPTOMS
There is no medication to fix pelvic prolapse, no wonder drug to address this challenging area of gynecology. There are, however, a handful of medications that can help you to deal with the symptoms that pelvic relaxation might cause. Anal incontinence (loss of stools), fecal soiling (staining of the underwear), and fecal urgency (sudden strong desires to have a bowel movement) can each result from the presence of a rectocele bulge. A high-fiber bowel diet and the bowel drill for behavioral therapy (see chapter 10) may be enough to relieve symptoms. If not, they can be alleviated with the help of a few simple products that maintain the right consistency of your stool. You should know the differences between the various common stool softeners, laxatives, and cathartics discussed in chapter 10, so you’ll be able to improve your symptoms while doing no harm.
WHY ALL THE FUSS OVER CONSTIPATION?
We’ve said it before, but just in case you haven’t heard: constipation is an archenemy of the pelvic floor. If you have a rectocele, constipation and hard stools can make the symptoms associated with this type of prolapse feel much worse. Occasionally, a rectocele filled with hard stool may even partially obstruct the urethra, making urination slow and difficult until the bulge finally empties along with a bowel movement. Good hydration and lots of fiber will minimize your troubles; if not, be sure to discuss other strategies with your doctor.
PESSARIES
The pessary—a device that fits into the vagina to support a bulging prolapse—may be the most enduring tool in the history of medicine. For millennia, in various forms, it has provided the major nonsurgical approach to supporting prolapse and relieving symptoms of pressure and discomfort. As early as 1500 B.C., pessaries were made of vine and natural extracts in Egypt. Three thousand years later, in eighteenth-century Paris, mothers were fitted with pessaries made of cork surrounded by layers of wax, “to hold her womb where it belongs … its ligaments … loosened by
the strains of childbirth.” Repeatedly dipping the device into wax would make it larger and more likely to stay in place, and a hole was left in the center to allow for conception.
Pessaries have, of course, changed in appearance over the years—thank goodness, we’ve come a long way since the 1700s—but they’re still very much a part of gynecologic practice today. Modern pessaries are made of silicone and latex, in various shapes and sizes—such as rings, donuts, cubes, and bridges. When fitted properly, they can hold back bulging pelvic tissues and provide an invisible, effective, low-tech treatment alternative for prolapse.
Which women usually choose pessaries? In general, pessaries tend to be less popular among young and sexually active women, who are often more attracted to the quick fix of surgery. Women who are uncomfortable with the idea of wearing a device inside their body, don’t like inserting or removing a pessary on their own, or cannot make fairly regular visits to the doctor’s office also tend to choose another option. But for women of any age who wish to avoid surgery and are willing to accept these management issues, pessaries can be a real help.
HAVING A PESSARY FITTED
The right pessary is different for each woman, varying with her individual body shape and size. The only rule is a simple one: whichever pessary works for you is the right one. Pessaries are fitted in the doctor’s office, where the doctor or nurse will most likely try a few different shapes and sizes, fitted according to the type and severity of your prolapse. In general, the largest pessary that fits comfortably is the most effective. Each will be checked for stability and comfort while you’re lying down, standing, straining, and walking around. Fitting a pessary is a process of trial and error, and for better or worse, it has become something of a lost art as the popularity of surgery for prolapse has increased. Not every gynecologist will stock every type of pessary. So if your prolapse is advanced, you may be referred to a specialist.
When a pessary fits just right, you shouldn’t be able to feel it inside, and it shouldn’t block your flow of urine. An occasional awareness of something inside isn’t unusual, but any pain or strong pressure will indicate it’s not a good fit. Before leaving the office, you may be asked to empty your bladder to assure that the pessary isn’t causing any sort of obstruction. Some pessaries need to be changed at the doctor’s office, and others can be easily inserted and removed at home. Here are some of the most common:
Common pessary types
Ring. The simplest pessary type, for supporting mild prolapse bulges. Easy to remove and insert on your own.
Ring with support. A simple variation of the ring pessary; looks just like a diaphragm.
Shotz. A pessary shaped like a flying saucer, able to stay inside more firmly than a ring in situations where vaginal and perineal supports are very weak.
Smith-Hodge. Specifically designed to support prolapse of the uterus and cervix.
Gelhorn. Can provide very strong support but is rather difficult for women to insert and remove on their own. Inserted with the stem pointing out.
Gehrung. An arch-shaped pessary, good for large cystoceles and/or rectoceles. Its awkward shape can make it difficult to insert and remove on your own.
Cube. This type of pessary is designed to support very advanced prolapse bulges. Because the cube relies on suction against the vaginal walls rather than muscle support to stay inside, it may be effective even after almost all vaginal and perineal tone has been lost or as a last-ditch option when simpler pessaries have failed. However, because of its odd shape, it’s difficult for most women to remove on their own and will often predispose to a buildup of (usually noninfectious) vaginal discharge, due to irritation of the vaginal walls, and partial blockage of the normal outflow of vaginal moisture.
Donut. Another last-ditch pessary; bulky and difficult for most women to manage without frequent office visits.
CARING FOR YOUR PESSARY, AND POTENTIAL PROBLEMS
Some women can comfortably manage a pessary for years, with nothing more involved than regular removal and cleansing. But certain issues and problems can arise.
Vaginal discharge and irritation. These can sometimes result simply from contact of the device against the vaginal skin and blocking of its normal drainage. Removing your pessary at bedtime, thoroughly rinsing it with warm water, and leaving it out for the night to rest the vaginal skin will reduce the odds of this problem. Most pessaries can be removed once or twice a week, or even much less often, but larger pessaries sometimes require nightly removal. The doctor or nurse will instruct you on the most appropriate routine. If you’re not comfortable managing your pessary at home, then you’ll need to make more frequent visits to the doctor’s office.
Applying a dollop of lubricant on the pessary surface can help to prevent irritation during insertion and removal. Remember to always use a water-soluble type (Trimo-San, K-Y jelly, Astroglide).
For some women, an occasional dilute vinegar douche may help counteract odor or discharge resulting from a pessary. This is by no means necessary for all pessary users, and douching should never be done regularly (otherwise, the vagina will have trouble restoring its normal balance of bacteria).
Atrophic vaginal skin is far likelier to become irritated and occasionally eroded by the friction of a pessary. Treatment with estrogen vaginal creams will make the vaginal skin less prone to irritation or erosion. Alternatively, an estrogen ring can be inserted right along with some pessaries, then exchanged for a new estrogen ring every three months.
Pressure sores. If a pessary fits too tightly or sits inside for too long, or the vaginal skin is abnormally thin or dry, a pressure sore, or ulcer, may develop. In this case, the device must be removed and left out for a period of time specified by your doctor or nurse, to allow for proper wound healing. Again, the best way to prevent this problem is regular nightly removal of the pessary to rest the vaginal skin, along with maintaining proper lubrication and a healthy estrogen supply to the vagina.
Infections. While wearing a pessary, some women may notice more frequent bladder infections, due to the sometimes heavy vaginal discharge that might allow bacteria easier access to the urethra. You can minimize this problem with regular removal and a healthy estrogen supply to the vaginal skin. Likewise, occasional yeast infections or other forms of vaginitis may occur. The risk of a more serious infection is extremely low.
Increased incontinence. Urogynecologists constantly face this rather tricky paradox: when a large prolapse bulge is supported, stress incontinence may appear for the first time, or already existing stress incontinence may worsen. The reason for this is actually quite simple: when prolapse is unsupported and bulging out, a slight bend will often form in the urethral tube and serve to hold back leakage of urine, like an artificial valve. Compare it to bending the garden hose, which produces a kink that stops the flow of water. Conversely, supporting or reducing the prolapse bulge may increase the tendency to leak urine as the urethra is unbent. This is called potential stress incontinence. With surgery, prolapse and incontinence can be simultaneously fixed with good success. But with a pessary, addressing both problems in tandem poses a much greater challenge.
Still bulging. If prolapse becomes more advanced, a pessary may need to be upsized. Even women who have been satisfied with their pessary for a long time may eventually find their prolapse has progressed, and surgery becomes the only effective option.
Urinary obstruction. As already mentioned, during your pessary fitting, the doctor or nurse will usually check to be sure your pessary isn’t blocking the urethra. Nevertheless, if you’re ever unable to void when your bladder feels distended, call your doctor.
CAN PESSARIES CURE PROLAPSE?
Pessaries can definitely make a case of prolapse feel better. But can wearing one actually halt its progression? Common sense would suggest that a well-fitting pessary might reduce the burden on weakened pelvic supports bearing the weight of a prolapse bulge—and perhaps, as a result, slow its progress. On the other hand, the pessary i
tself can further stretch the surrounding tissues and may not hold back the entire bulge when prolapse becomes advanced. The bottom line? Wearing a pessary successfully for years does not eliminate the possibility that your prolapse will continue to progress, ultimately requiring an operation.
WHEN A PESSARY MIGHT NOT BE THE RIGHT CHOICE
Sometimes very advanced prolapse simply can’t be propped up by an odd-shaped piece of plastic. For most pessaries to stay inside and work effectively, some degree of pelvic support is required within either the levator muscles or the perineum. By strengthening these areas, Kegel exercises may help to improve the support around a pessary. If all pelvic supports are gone, then there’s little hope that the pessary will be the answer for you.
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