When a prolapse affects the back wall of the vagina, the common symptoms are a feeling of a lump in the vagina, a feeling of dragging and discomfort, and sometimes a feeling of difficulty and bulging on trying to open your bowels. Constipation is not usually a problem. It is important to realise however that just because there is a weakness there does not mean that something needs to be done. If you have no problems then you are usually best doing nothing until you start to have a problem.
Have a look at the drawing below.
As you can see there are two types of weakness here. A weakness of the lower part of the back wall is technically known as a “rectocele”, and is due to stretching and weakness of the tissues between the backpassage and the vagina. A weakness of the upper part is called an “enterocele”, and is a form of hernia containing abdominal contents. Neither is dangerous but both can be uncomfortable and give various symptoms.
If you have fairly minor symptoms a bowel management program combined with physiotherapy may help. Oestrogen creams and pessaries may also be of benefit.
A bowel management program includes a diet high in fiber and a reasonable quantity of fluid each day. Fiber acts like a sponge. It soaks up fluid so that less is removed as the stool travels around the colon. The stools will be larger, softer and easier to pass. You may wish to add a fiber supplement such as “Fybogel” and/or a stool softener to this regimen to improve stool consistency. This helps to smooth and lubricate the stool. Avoid prolonged straining. If you cannot completely empty, get up and return later. Holding pressure with a finger to support the rectocele and encouraging the stool to go in the correct direction is often helpful. This may be accomplished by pressing against the lower back wall of the vagina or along the posterior rim of the vagina. Avoid placing a finger inside the anus to pull the stool out as this may cause harm.
Physiotherapy takes the form of pelvic floor exercises. To perform these exercises a woman squeezes the pubococcygeus muscle, which is done by squeezing the muscles around the vagina. These muscles are contracted for 10 seconds, and then relaxed for 10 seconds. This repetitive activity is done in sets of 10 to 20 about 3 to 5 times a day. Maximum results are obtained in 3 to 6 months.
If simple measures are not successful then surgery is indicated. This may be done under a general or a spinal anaesthetic; both are effective and you will feel nothing. To deal with this type of prolapse, the back wall of the vagina needs to be strengthened and supported. This is done through the vagina and involves taking out a tuck of redundant skin, and then putting in stitches to pull the underlying muscles and ligaments together. When this repairs a rectocele it is known as a posterior repair. If it involves an enterocele then extra sutures are used to pull together the uterosacral ligaments. This blocks the space at the top of the vagina preventing bowel being pushed into it. This is called a McCall Culdoplasty. The stitches used are buried and do take a little longer to dissolve as they need to give more support.
Sometimes it may be necessary to use an extra reinforcing patch of collagen to strengthen the repair if the tissues are very weak or you have had a previous unsuccessful operation. The materials used are natural and are called PELVICOL and SIS. More information is available by clicking on the links.
When you return from the operating theatre you may have a catheter in the bladder overnight or a pack in the vagina. These are removed the next day and all being well you should be home within 2-4 days.
In either case there will be stitches in the vagina which will take upto 6 weeks to dissolve. Do not be concerned if there is some discharge or if small pieces of suture come away. Usually there will also be a few stitches in the skin between the vagina and the backpassage. These may feel a little tight but should come away within about 10 days.
You must remember that to start with the only thing holding the repair together is the stitches. Over the next few weeks your own body will heal around the stitches and leave tough tissue which acts as a new support. Whilst this is happening it is very important not to overdo things, especially straining or lifting, if you want to give the repair the maximum, chance of success. In particular avoid constipation by using lactulose, extra fibre or increased fruit/vegetables etc.
Depending on the size of the repair and your job, you should be able to return to work in 3-6 weeks. We would then usually see you in the clinic after about 6 weeks to make sure all is well.
Usually this operation is very successful. As with any operation however problems can sometimes arise, and you must be aware of these. Sometimes after the operation an infection can arise in the vagina and give rise to pain or a discharge. This usually resolves with antibiotics and often any collection of blood will escape spontaneously. If this happens do not worry or panic; let your GP or ourselves know and get the correct antibiotic tablets.
We obviously want to do the best possible repair, but this always involves a balance between making things too tight or too loose. There is a small chance that the vagina may feel too tight during intercourse, and to avoid this I would usually err, if anything, on the loose side. However hard we try it is not possible to return things to the way they were when you were a teenager! Because of this in a small number of women the operation may not work and the problem may recur. This is very uncommon but we cannot give a 100% guarantee of success.