Vaginal prolapse is basically the dropping of the bladder in the vagina, which is called cystocele, which is the front part of the vagina. And if you have the womb and the womb support structures are failing it, then the womb can come down below in the vagina or in occasional cases, can start coming out of your body. That's called uterine prolapse or the womb prolapse. Some patients who had hysterectomy in the past will have the top of the vagina, which can come down, which is called vault prolapse. Similarly, on the back of the vagina, when the bowel is trying to push into the vagina, that's called rectocele, or the bowel prolapses.

One simple thing is obviously childbirth. Vaginal childbirth can cause trauma, which is trauma to the pelvic floor which causes weakness and then causes predisposition to prolapse. Often instrumental delivery, especially forceps, is known to cause a traumatic effect. Patients who have to strain for one reason or the other, either lifting heavy weights all the time or constipation, these are risk factors for prolapse. Then patients who go into menopause, lack of hormones can make tissues weaken and then they can get some trouble with prolapse. Some people are born with a weakness in their connective tissue, which is what can predispose to prolapse, especially if patients have a prolapse at a young age. That's maybe because of your collagen, which is your supporting structure in the body, which is constitutionally weak, which is genetically linked.

Usually, prolapse doesn't cause any symptoms. Some people do present with bowel issues or bladder issues, like not being able to empty the bladder well or they empty and then they think that they have not completely emptied and have to go back and empty the bladder. Some patients feel a chronic cystitis. Some people feel they take a long time to empty the bladder. For patients who have prolapse in the back of the vagina where the bowel is coming down, then they can also present as not being able to empty the bowel well and may have to splint or support that area to empty the bowel. And obviously, if you have a prolapse, which is uncomfortable, some people feel an uncomfortable dragging sensation. Patients sometimes describe it as sitting on a ball. Those kinds of symptoms are the common symptoms. Uncommonly, prolapses cause pain. They can cause a lot of discomfort.

Some prolapses are easy to diagnose. Patients can feel the bulge sometimes coming out, you can feel it, but which compartment is prolapsing, front, middle or the back is usually with an examination. So the examination depends on how much prolapse you've got. It can be done simply, like when we do a smear test, a similar kind of examination when we ask you to push and we have a look where prolapse comes back. Occasionally, we may have to examine in a slightly different position or even standing up to diagnose exactly what extent of prolapse and compartment is coming down.

Optimising your health conditions like high BMI, then it's better to control that first, reduce your weight. And if you are constipated, make sure that constipation is addressed. If you're lifting heavy weights, make sure that that's addressed and you continue pelvic exercises. So this is the most conservative option for dealing with prolapse. Some of the prolapses are quite big and the conservative options don't work in those circumstances. The second conservative option is a pessary, which is like a ring or comes in different sizes and shapes.

Surgical options for the front wall, which is your bladder coming down, is a repair. Similarly, when the back of your vagina has the bowel coming down, this is a repair operation. Again, they both use stitches. When the womb is coming down, then the options are either a traditional option of a hysterectomy or you can restitch with a strong ligament called the sacrospinous ligament or you go through the tummy and put the mesh around the womb. So if your bladder is coming down or the back of the vagina is coming down, what we call it is a repair. In medical language, it is called colporrhaphy. So basically, what we do is we open the vagina, depending on where we're doing it, in the front or the back of the vagina, push either your bowel on the back or the bladder in the front back to where it's supposed to be and bring your native tissues together with stitches, either the muscles of the back or something called fascia in the front, bring it together with the stitches and then suture that part up. So basically, we tighten your own tissues to give you better strength there.

On the day of the surgery, you will find a catheter draining your waters for usually 24 hours and a pack inside the vagina, which will come out the next day. And hopefully, you will be able to go home either on day one or day two. We ask you to avoid lifting heavy weights and constipation and we give you a laxative to take home. You shouldn't get heavy bleeding. A small amount of bleeding is acceptable. You shouldn't get heavy bleeding. Some discharge is quite common. The stitches take around six weeks to 12 weeks to dissolve and during that time they can give you discharge. It shouldn't be an excruciating pain and simple pain relief like Nurofen should be more than enough.

So, vaginal prolapse can reoccur and if you look into different literature, it says around one to three in ten women will undergo a repeat procedure in five to ten years' time after this procedure. But what can we do to prevent them or reduce the chances of happening? It again is modification of your lifestyle.