Colporrhaphy: When is surgery needed to repair vaginal prolapse?

In this expert guide to colporrhaphy, a surgical procedure used to treat vaginal prolapse, highly respected consultant gynaecologist Professor Stephen Radley describes what patients should expect from their time in hospital and the recovery period that follows. The leading pelvic floor specialist also sheds light on the rates of recurrence of prolapse following surgery and when procedures of this type are indicated.

What is colporrhaphy?

Colporrhaphy (or vaginal repair) is a surgical treatment carried out for women with symptomatic prolapse. The repair procedure is usually performed under a general or spinal anaesthetic on a short stay basis or occasionally as a day-case.

Colporrhaphy can be combined with other procedures such as hysterectomy if a patient has uterine prolapse. Alternatively, if the patient prefers to preserve her uterus, then this can itself be lifted and supported during an operation. Repairs can be made to the front wall of the vagina, if the bladder is dropping down, or to the back wall of the vagina, if there is prolapse of the bowel into the vagina.

Prolapse usually (though not always) follows childbearing and occurs more commonly in women who had vaginal births. Women may experience prolapse-related bowel, bladder, vaginal and sexual symptoms, many of which can be improved with surgical and non-surgical treatments.

A repair operation usually takes under an hour to perform, though this can vary depending on the nature of the prolapse and whether prolapse is affecting more than one site in the vagina. The stitches that are used are all dissolving and mesh is not used.

In terms of recovery, patients are usually in hospital for a day or two, though in some cases colporrhaphy is a day case procedure. Patients are typically back to most normal activities after a couple of weeks, with full total recovery taking up to three months. This is because the stitches take around three months to dissolve completely.

When is colporrhaphy necessary?

We would normally consider prolapse surgery for patients who have significant prolapse, where the uterus or the vagina comes down to the extent where this is causing problematic symptoms such as discomfort, protrusion of a lump or bulge, with bladder, bowel or sexual symptoms. In cases where the prolapse is quite mild, although patients might be worried, they may only require reassurance and advice or physiotherapy, rather than surgery.

When a patient’s quality of life is affected, for instance relating to bowel, bladder or sexual function, or prolapse is causing a significant amount of pain or discomfort, surgery should be seriously considered. Surgery may also be required if a prolapse has been present for a while and isn’t responding to simple interventions, such as pessaries, hormone replacement therapy such as vaginal oestrogen, or physiotherapy, all of which can help improve some of the most bothersome symptoms.

If a patient’s symptoms are persistent and prolapse is of moderate or severe degree, it may be appropriate to discuss surgery, such as vaginal repair or colporrhaphy, which may or may not include a hysterectomy to support the vagina. Occasionally an extra stitch can be used to provide additional vaginal support; this is called a ‘sacro-spinous fixation’, which can reduce the chance of developing another prolapse, or to treat a prolapse that has come back after a previous operation. This extra procedure is also carried out vaginally, again using stitches that dissolve.

What are the main risks involved?

A significant risk of colporrhaphy is that of recurrent prolapse. Around twelve per cent of women undergo prolapse surgery at some point in their lifetime, and of all the women who have a prolapse operation, as many as a third might undergo a second operation. This may be because of developing prolapse in a new place or because a prolapse has recurred in the same place.

Due to the rates of recurrence of prolapse, meshes have been used to try to improve the outcomes of surgery but over time these have proved risky and ineffective. In my own practice, I don’t use vaginal mesh and I never have for vaginal prolapse because I’m aware of the risks of using them in this context. Instead, I use what we call ‘native tissue repair’, which means using stitches to support and reconstruct the natural tissues such as ligaments that support the vaginal walls.

Other risks with surgery include vaginal infection, post-operative pain and issues with anaesthesia and recovery. However, the use of good methods of anaesthesia and sound, well-established surgical techniques helps to minimise risks so that most patients are able to go home the day after their surgery.

If you have prolapse and are considering surgical treatment, it is important to see a specialist who can help you to choose the right operation which offers the best outcomes to improve the likelihood of success and reduce any risks.

How effective are the results of colporrhaphy?

Prolapse surgery is usually successful, though in the long-term, as many as one in three patients may need another operation. In terms of recovery, return to work and normal physical activities, results are generally very good, with bowel, bladder, vaginal and sexual symptoms usually being improved following prolapse surgery involving native tissue repair. The recovery from prolapse surgery is often over the course of around three months, though most patients are back to normal activities, including driving, at around two weeks or so.

Will I need to undergo colporrhaphy more than once?

Colporrhaphy may sometimes need to be repeated. My view in relation to prolapse surgery is that it’s better to do ‘too little’ than ‘too much’, meaning that it’s preferable to avoid excessive surgery in the first instance. For example, we sometimes have to accept that we may not repair the front, back and top of the vagina all at the same time and acknowledge that there is a risk of prolapse coming back. This is something we discuss at the time with patients on an individual basis, so the patient can make the best decision that is well considered and well informed.

Additionally, it’s also important for patients to understand that if at the time surgery, an element of prolapse looks less severe than we thought, we may exclude a component of a planned operation. Equally, if the prolapse is more severe than expected, we might actually add an extra component, such as a posterior repair or sacro-spinous fixation at the time of doing an anterior repair, though these possibilities are always discussed before an operation is started, taking into account the patient’s feelings and personal preferences.

If you are considering surgical treatment for vaginal prolapse and wish to schedule a consultation with Professor Radley, you can do so by visiting his Top Doctors profile.