17939 Sacrocolpopexy

Overview

Sacrocolpopexy is an operation used to repair a pelvic organ prolapse, usually a 'vaginal vault prolapse'. Prolapse happens when the muscles and tissues that hold the pelvic organs in place become weak, so the top of the vagina drops down towards, or out of, the vaginal opening. During sacrocolpopexy, the surgeon lifts the top of the vagina back into place and secures it to the lower spine (the sacrum) using a small strip of surgical mesh. It can be done through a few small cuts in the tummy (keyhole surgery, sometimes with a robot helping) or, less often, through a larger cut.

Pelvic organ prolapse is very common — it affects a large number of women at some point, especially after childbirth and after menopause. Sacrocolpopexy is one of several operations used to repair it, so it is a well-established and familiar procedure for gynaecology teams.

It mainly affects women, particularly those who have had a hysterectomy, have had one or more vaginal births, or have gone through the menopause. It can also be offered to some women who still have their womb (a similar operation called a sacrohysteropexy), and it is very occasionally used in other pelvic reconstructions. It is not performed on children.

Symptoms

Common symptoms

• A feeling of heaviness, dragging or a bulge in the vagina, like a tampon that is coming out
• A soft lump you can see or feel at the vaginal opening, which may be worse after standing, coughing or at the end of the day
• Discomfort or pain during sex, or a feeling that the vagina is loose or changed
• Trouble emptying the bladder fully, needing to push the bulge back to pass urine, or leaking urine
• Constipation, needing to press on the vagina to pass a stool, or a feeling of not finishing a bowel movement
• Lower back ache that eases when you lie down
• Vaginal discharge, spotting or soreness if the prolapse rubs against clothing

Symptoms in children

• Sacrocolpopexy is not carried out in children. Prolapse in a child is very rare and would always be investigated and treated by a specialist children's team.

Symptoms in older adults

• Prolapse becomes more common after the menopause because the tissues become thinner and less elastic
• Symptoms can feel worse if there is also arthritis, a long-term cough or constipation, or difficulty walking to the toilet
• Age alone does not rule out surgery — decisions are based on your general health and what matters to you
• A longer recovery, extra help at home and a careful anaesthetic review are usually planned in advance
• Some older adults prefer a removable support device (a pessary) instead of surgery, and that is a perfectly reasonable choice

Causes

Main causes

• Weakening of the muscles, ligaments and connective tissue that normally hold the pelvic organs up
• Pregnancy and vaginal childbirth, which stretch and sometimes tear the pelvic support tissues
• Hysterectomy (removal of the womb), which can leave the top of the vagina less supported
• Falling levels of oestrogen after the menopause, which makes vaginal tissue thinner and weaker
• Long-term increased pressure inside the tummy from a persistent cough, constipation and straining, heavy lifting, or being overweight

Risk factors

• Having had one or more vaginal births, especially with large babies or an assisted delivery
• Previous pelvic surgery, including hysterectomy or an earlier prolapse repair
• Being overweight or obese
• Long-term constipation or a chronic cough, including smoker's cough or asthma
• Jobs or hobbies that involve regular heavy lifting or long periods of standing
• A family history of prolapse, or conditions that make connective tissue weaker
• Getting older and going through the menopause

When to see a doctor

See a doctor urgently if:

• You cannot pass urine at all and your bladder feels full and painful
• The prolapse has come outside and cannot be gently pushed back in, with pain, bleeding or a bad smell
• You have heavy vaginal bleeding, or bleeding between periods or after the menopause
• You have severe Pelvic pain with fever or feeling generally very unwell

Book a routine appointment if:

• You notice a bulge, heaviness or dragging in the vagina that is affecting your daily life
• Sex has become uncomfortable or you feel less confident about your body
• You are straining to empty your bladder or bowel, or you leak urine
• You have a discharge or soreness from tissue rubbing
• You have had prolapse surgery before and symptoms are returning

Diagnosis

A doctor or specialist nurse will talk with you about your symptoms and how they affect your life, then offer an internal vaginal examination. They usually examine you both lying down and standing up, and may ask you to cough or bear down as if passing a stool, because prolapse can be more obvious when you are upright and straining. They will check which part of the vaginal wall has dropped, how far, and how well your pelvic floor muscles squeeze. Your GP can start this, and a hospital gynaecology clinic will confirm the details.

Tests that may be done

• Internal vaginal examination to see and feel the prolapse
• Asking you to empty your bladder afterwards, or a bladder scan, to check whether your bladder empties fully
• A urine test to rule out infection
• Pelvic floor muscle assessment, sometimes with a specialist physiotherapist
• Bladder pressure tests (urodynamics) if you also have leaking or urgency
• An ultrasound scan, and occasionally an MRI scan, if the prolapse is complex or you have had surgery before
• A camera test of the bladder or bowel in some cases

What to expect at your appointment

The examination can feel undignified, but it is quick and staff are used to helping people feel at ease. You can ask for a chaperone, a female clinician, or to stop at any point. You may be given a diagram to show you what is happening, and you will usually be asked what symptoms bother you most so that any treatment targets the things that matter to you.

Treatment

Treatment depends on how much the prolapse bothers you, how far it has dropped, your general health and whether you may want more children. Options range from doing nothing at all with regular check-ups, through pelvic floor exercises and a removable support device called a pessary, to surgery. Sacrocolpopexy is one surgical option, usually chosen when the top of the vagina has dropped after a hysterectomy, when other repairs have not worked, or when a longer-lasting repair is wanted in someone who is fit for an operation.

Self-care at home

• Learn pelvic floor exercises with a specialist physiotherapist and practise them regularly — they help symptoms and support healing
• Avoid heavy lifting and long periods of standing or straining in the early weeks after surgery
• Treat constipation early with plenty of fluid, fibre and gentle movement, and go to the toilet without straining
• Aim for a healthy weight, as extra weight increases pressure on the pelvic floor
• Get help to stop smoking and to control a persistent cough
• Follow your surgeon's advice on when to return to driving, work, exercise and sex

Medical treatments

Non-surgical approaches are always worth discussing first. These include supervised pelvic floor muscle training, changing toilet habits, treating constipation, weight management and sometimes hormone treatment applied to the vagina to improve tissue quality. A vaginal pessary — a soft, removable ring or support device fitted by a clinician — can hold the prolapse in place and is a good option for many people, including those who prefer to avoid surgery or are not fit for an anaesthetic. Surgery is only one part of the picture, and you should feel free to ask about all of these before deciding.

When is surgery considered?

Sacrocolpopexy is done under a general anaesthetic, usually by keyhole surgery, and takes roughly one to three hours. The surgeon makes a small opening in the tissue over the lower spine, attaches a strip of mesh to it, and brings the other end down to support the top of the vagina. Sometimes other repairs are done at the same time, such as tightening the front or back wall of the vagina or a procedure to help bladder control. You will normally have a catheter for a short time and stay in hospital for a few days. Mesh used in prolapse surgery has been reviewed for safety in several countries, so it is very reasonable to ask your surgeon which type of mesh they use, how often they perform this operation, what their results are, and what the alternatives are. Ask about the risks too: bleeding, infection, injury to the bladder or bowel, blood clots, pain during sex, mesh becoming exposed in the vagina, and the possibility that the prolapse could come back later.

Living with this condition

For the first week or two you will feel tired and sore, and you may have some light vaginal bleeding or discharge. Gentle walking is encouraged, but you will need to avoid lifting, housework, heavy shopping and driving until your surgeon says it is safe — often around two to six weeks. Most people feel close to normal by six weeks and fully healed by around three months. Build activity back gradually and listen to your body rather than pushing through pain.

Lifestyle tips

• Keep up your pelvic floor exercises once you are cleared to restart them — they are the main way to protect your repair
• Break up long periods of standing and avoid lifting anything heavy, including toddlers, for the first few weeks
• Use a stool softener or ask your pharmacist for advice if stools are hard, so you do not have to strain
• Return to work when your surgeon advises — office work is usually sooner than a job with lifting or long shifts
• Follow the guidance you are given about waiting before using tampons, having sex or swimming

Diet and exercise

Eat regular meals with plenty of fibre — wholegrains, fruit, vegetables, beans and lentils — and drink enough fluid so your urine is pale. This keeps stools soft and reduces straining. Once you are healing well, gentle walking, swimming and stationary cycling are good choices. Ask your pelvic health physiotherapist before returning to running, heavy weights, trampolining or high-impact classes, as these put extra strain on the pelvic floor. There is no special diet that repairs prolapse, but staying a healthy weight genuinely helps.

Mental health and emotional wellbeing

Prolapse and the surgery around it can affect how you feel about your body, your confidence and your relationships. Many people feel embarrassed or worried about sex, or anxious about the operation and whether it will work. These feelings are very common and worth mentioning — they are part of your care, not a side issue. If low mood, worry or feelings of hopelessness last more than a couple of weeks or affect your daily life, please tell your GP or specialist team. If you ever have thoughts of harming yourself, contact your local emergency number or a crisis line in your country straight away, or ask someone to stay with you until help arrives.

Prevention

You cannot fully prevent prolapse, and it is not your fault if it happens. But you can lower the strain on your pelvic floor, which helps both before and after surgery. Keeping your pelvic floor muscles strong, avoiding constipation, not smoking, keeping to a healthy weight and lifting with good technique all make a real difference. If you are offered pelvic floor physiotherapy after childbirth, it is worth taking up.

Screening programmes

There is no national screening programme for prolapse. Prolapse is usually found when you mention symptoms or during a routine pelvic examination, such as a smear test. After sacrocolpopexy, your surgeon will arrange a follow-up appointment to check healing and how well the repair is holding.

Complications

If left untreated

• The prolapse may gradually drop further and become more uncomfortable
• The vaginal tissue can rub, become sore, bleed or form an ulcer
• The bladder or bowel may not empty properly, leading to infections or constipation
• In unusual cases, severe prolapse can affect the kidneys, and a prolapse that comes fully outside needs urgent medical attention
• Ongoing discomfort can affect sleep, work, exercise and intimate relationships

Long-term outlook

Most people who have sacrocolpopexy get good, lasting relief from their symptoms and feel positive about the result. As with any prolapse repair, there is a chance the prolapse could come back in the future, and a small number of people have problems with the mesh. Knowing those risks helps you make a choice that suits you. Whether you choose exercises, a pessary, surgery or simply watching and waiting, you deserve clear information and time to decide — and your team will support you either way.

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