Treating and Preventing Prolapse: a Q & A with Charles Nager
In 2011, the Food and Drug Administration updated a safety warning about serious health complications associated with the use of surgical mesh to treat pelvic organ prolapse (POP), a condition in which the muscles and ligaments supporting a woman’s pelvic organs weaken, allowing organs like the bladder to slip out of place.
Photo courtesy of Paul Body and San Diego Magazine.
In some cases, surgeons remedy POP by permanently implanting mesh to reinforce the weakened or damaged tissue. The new FDA warning cautions that the mesh may eventually cause serious problems, including erosion through the vagina, pain, infection, bleeding and urinary problems. Charles Nager, MD, professor of reproductive medicine at the University of California, San Diego School of Medicine talks about POP, its causes and diverse treatment options.
Q: What causes pelvic organ prolapse? How common is it? What are the symptoms?
A: Pelvic organ prolapse is a very common condition that affects about 30 percent of women. It is a weakness in the muscles of the pelvic floor or the walls of the vagina that causes symptoms of a bulge or pressure in the vagina. Other symptoms include pressure, discomfort, a feeling that something is falling out, looseness with sex or incomplete emptying of the bladder or rectum. Prolapse is often associated with urinary leakage.
There are different types of prolapse, depending upon the area affected. These conditions are caused by a combination of factors including obesity, chronic cough, smoking, constipation, vaginal birth, aging effects and probably genetic factors.
Q: What are the options for treatment? What issues should a patient consider?
A: The treatment options can include vaginal supportive devices similar to diaphragms, called pessaries, or surgical therapy. The patient chooses which treatment option is right for her after a discussion with her doctor. Her doctor should offer her the full spectrum of conservative and surgical treatments. There are specialty physicians who have done extra training in this area. Patients may want to consider going to a doctor who is fellowship-trained or who spends all or most of his or her practice taking care of prolapse and incontinence.
Q: Surgical mesh seems to be a last resort remedy. Under what conditions is it appropriate?
A: There is almost always more than one surgical option for different prolapse conditions. Most surgery for prolapse is done vaginally and usually with native tissue, using suturing techniques. In general, most primary procedures should be done this way. When primary procedures fail or the prolapse is very advanced, sometimes surgical mesh can give a more durable anatomic result, but often at the expense of potential long-term complications, including mesh erosion into the vagina, pain with sex or pelvic pain. If your surgeon is recommending mesh, ask about non-mesh options and understand why they are recommending treatment of prolapse with mesh.
Q: Are there new or emerging treatments for pelvic organ prolapsed? Can it be prevented?
A: New treatments for prolapse include doing some very successful abdominal operations laparoscopically or with robotic assistance to avoid a large incision in the lower abdomen. Newer and lighter meshes may avoid some complications, but these await further study. Conditions that put you at higher risk for pelvic organ prolapse are obesity, smoking, chronic cough, constipation and vaginal birth.