within the pelvic cavity, or space. To see the organs within the pelvic space from the side, we will remove part of the pelvic bones, but leave important landmarks for reference. These landmarks include the front part of the hip bone, the pubic symphysis, and the sacrum, commonly called the backbone. The organs within the pelvic space include the bladder, where urine is stored before it is eliminated through the urethra, the rectum, where feces are stored before they are eliminated through the anus, and the uterus and vagina, along with the ovaries and fallopian tubes, make up the internal female reproductive organs. The uterus and vagina are found between the bladder and rectum. The uterus communicates with the vagina through the cervix, which is the lowest part of the uterus. The vagina is a hollow organ that can be separated into three different sections or compartments, anterior or front, posterior or back, and central or top. The pelvic organs are supported by the pelvic floor muscles and by connective tissue that attaches the uterus and vagina to the bony pelvis. Pelvic organ prolapse is a condition where the support to the pelvic organs is lost and parts of the organs fall into or through the vaginal canal. It is a common condition that is most often noted in women who have had vaginal births. Prolapse may or may not bother women. Bothersome symptoms include pressure or bulge and feelings of incomplete emptying of urine or stool. Common options for pelvic organ prolapse include observation, pessary, and surgery. Pessaries and surgery are offered once the prolapse is bothersome to women. Women who are not bothered by the prolapse can be safely managed by monitoring the condition. As previously mentioned, the vagina can be separated into three different sections or compartments, anterior or front, posterior or back, and central or top. Normal support of each vaginal section contributes to the support of other organs. Note that the vagina is bordered by the bladder, rectum, and uterus at each of the sections. Loss of support of the front or anterior vaginal compartment can result in the bladder descending or falling into the vaginal canal and sometimes through the vaginal opening. This is also known as systocele. Similarly, loss of support of the back or posterior vaginal compartment can result in the displacement of the rectum into the vaginal canal and sometimes through the vaginal opening. This is also known as rectocele. Lastly, loss of support of the top or central compartment of the vagina can lead to a downward displacement of the cervix and uterus into the vaginal canal or through the vaginal opening. This is called uterovaginal prolapse. Women who have had their uterus removed in a surgery called a hysterectomy can also experience loss of support of the top compartment of the vagina. This is known as post-hysterectomy vaginal vault prolapse. In these cases, portions of the small intestines can often be found just above the prolapsed vaginal walls. It is common for the different sections of the vagina to lose support simultaneously. Frequently, prolapse of the front and or back sections of the vagina are associated with loss of support of the top section. So, evaluating and treating loss of support of the top compartment is a critical step to any prolapse exam and surgery. Your doctor can tell you if you have pelvic organ prolapse by performing a detailed pelvic exam. To determine if you have prolapse of the top compartment, your doctor will first measure the length of your vaginal canal at rest and then measure the change of its length with you bearing down. If you have not had a hysterectomy, he or she will also assess the position of your cervix relative to the vaginal opening. In prolapse where the bladder descends into or through the vaginal opening, the urethra may be displaced or kinked. This kinking effect on the urethra may mask or conceal a condition known as stress urinary incontinence. Stress urinary incontinence is characterized by leakage of urine with activities such as coughing, sneezing, and exercising. In many women, stress urinary incontinence may manifest after correction of the prolapse when the urethra is straightened. For this reason, when considering surgery for prolapse, your doctor may recommend a bladder test known as a urodynamic study to evaluate the potential for stress urinary incontinence after correction of the prolapse. In summary, there are three vaginal sections or compartments, and loss of support of any of these can lead to bothersome pelvic organ prolapse. Prolapse of more than one compartment is common and usually involves the top compartment. Sacral colopexy is a common surgical procedure used to correct prolapse of the central or top vaginal compartment. This procedure generally involves the placement of synthetic or permanent mesh to suspend the top third of the vagina to the sacrum or backbone. As discussed in the prolapse section, the top portion of the vagina can prolapse or fall in women with or without a uterus. Prolapse of the cervix and uterus through the top section of the vagina is known as uterovaginal prolapse. Prolapse of the top section of the vagina into or through the vaginal canal after a hysterectomy is known as vaginal vault prolapse. Women who have not had their uterus previously removed will typically have it removed at the time of sacral colopexy procedure. The uterus may be removed just above the cervix in a procedure known as a supracervical hysterectomy, or it may be removed completely in a procedure known as a total hysterectomy. Ask your doctor to discuss the pros and cons of both types of hysterectomies with you. During a sacral colopexy, one strip of mesh material is attached or sewn to the front wall of the vagina, and another strip is attached to the back wall. The upper part of both strips of mesh are secured to a ligament that runs in front of the sacrum or backbone. The end result of the sacral colopexy procedure is that the upper one-third of the vagina is lifted and suspended close to its natural position before the prolapse developed. Traditionally, a sacral colopexy has been done through a single abdominal incision, or the open approach. This is referred to as the abdominal sacral colopexy. This surgery has been shown to have one of the highest long-term anatomic success rates compared to other vaginal procedures used to correct pelvic organ prolapse. The success rates of this procedure to correct vaginal apex prolapse range from 78 to 100%. However, the abdominal sacral colopexy has also been associated with higher complication rates and longer recovery time when compared to vaginal procedures for prolapse repair. In an attempt to reduce some of these surgical complications and the longer recovery time associated with the open approach, many surgeons have adopted the laparoscopic approach to sacral colopexy. With the laparoscopic approach, four to five small finger-width size incisions are made in the abdomen to allow the passage of surgical trocars and instruments. When compared to the open approach, the laparoscopic approach has been associated with less blood loss and shorter hospital stays while preserving the good anatomic outcomes of the open approach. However, the laparoscopic approach requires different technical or surgical skills and often requires longer operating times than the open approach. More recently, the robotic-assisted approach to sacral colopexy has been introduced in attempts to circumvent some of the technical challenges of the traditional laparoscopic approach. If your doctor believes the sacral colopexy is a good option to treat your pelvic organ prolapse, ask to discuss other options as well as the optimal surgical approach given your personal preference, extent of prolapse, and his or her technical skills. For more information, visit www.FEMA.gov

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