Prolapse surgery

What prolapse is

Prolapse means that one or more of the organs in the pelvis has dropped from its normal position and bulges into the vagina. It happens when the muscles and ligaments that support them have been stretched or weakened, most often by childbirth, and later by the menopause, age, long-term constipation, a long-standing cough, heavy lifting or being overweight.

Prolapse is common. It is not dangerous, although it can affect your comfort and your daily life.

There are four main kinds, and more than one often happens together:

• front wall prolapse, in which the bladder bulges into the front wall of the vagina;
• back wall prolapse, in which the bowel bulges into the back wall;
• prolapse of the womb (uterine prolapse), in which the womb comes down into the vagina;
• vault prolapse, in which the top of the vagina comes down, after a hysterectomy.

Symptoms

You may notice:

• a feeling of heaviness or dragging in the vagina, often worse at the end of the day or after standing for a long time;
• a bulge in the vagina, or coming out of it, which you may feel or see;
• bladder symptoms, such as a slow stream, a feeling that your bladder has not emptied, or needing to pass urine often;
• bowel symptoms, such as difficulty emptying your bowel, sometimes needing to press on the vagina to do so;
• discomfort, or a change in sensation, during sex.

Some women have no symptoms, and the prolapse is found during an examination. A prolapse that does not trouble you does not need treatment.

Treatment without surgery

The National Institute for Health and Care Excellence (NICE) advises trying these before surgery:

• pelvic floor muscle training with a specialist physiotherapist, usually for at least 16 weeks, for a mild or moderate prolapse;
• a vaginal pessary, a removable support, often a soft ring, which holds the organs in place and is changed or cleaned every few months.

Looking after the pelvic floor helps too: avoiding constipation and heavy lifting, treating a long-standing cough, and losing weight if you are overweight. After the menopause, vaginal oestrogen can help if the vagina is dry or sore.

For many women these are enough. Surgery is for when they have not helped, or are not right for you, and the decision is always yours.

Deciding about surgery

Before you decide, we will talk through what each operation involves, its chance of success, its effects on your bladder, bowel and sex life, the chance that the prolapse comes back and, for operations that use mesh, what is still unknown about the long term.

NICE has published decision aids that set out the options side by side, for prolapse of the womb and for prolapse of the top of the vagina. You may find it helpful to read the one that applies to you before we meet. The Royal College of Obstetricians and Gynaecologists (RCOG) has patient information on prolapse, and the British Society of Urogynaecology has leaflets on sacrocolpopexy and sacrohysteropexy.

Prolapse surgery is usually left until you have completed your family.

The operations I carry out

I have been carrying out these operations since 2013, in the NHS and privately. The operations that lift the womb or the top of the vagina are keyhole operations, robotic or laparoscopic, under a general anaesthetic.

Sacrocolpopexy, for prolapse of the top of the vagina

After a hysterectomy, the top of the vagina (the vault) can lose its support and come down. In a sacrocolpopexy, I free the top of the vagina from the bladder in front and the bowel behind, attach a strip of mesh to its front and back walls, and fix the other end to the sacrum, the bone at the base of the spine, at its upper edge (the sacral promontory). The mesh then holds the top of the vagina in its normal position.

NICE recommends sacrocolpopexy as one of two choices for vault prolapse, alongside a vaginal operation that uses stitches (sacrospinous fixation). A Cochrane review of the randomised trials found that, compared with vaginal operations, fewer women were aware of a prolapse after a sacrocolpopexy (about 8 in 100, compared with 18 in 100) and fewer needed another operation for prolapse (about 6 in 100, compared with 14 in 100) (Maher and colleagues, 2023).

Sacrohysteropexy, for prolapse of the womb, keeping the womb

A sacrohysteropexy takes the same approach for prolapse of the womb, in women who wish to keep it. I attach the strip of mesh to the back of the cervix (the neck of the womb) and fix it to the sacrum, which lifts the womb and the top of the vagina with it.

NICE includes sacrohysteropexy among the options for prolapse of the womb. In a large UK trial, keeping the womb gave similar results at one year to a vaginal hysterectomy (Hemming and colleagues, 2020), so the choice usually depends on your own preference and circumstances.

Hysterectomy with uterosacral ligament suspension, without mesh

If you would prefer to have the womb removed, or there is another reason to remove it, I carry out a keyhole hysterectomy and then fix the top of the vagina with stitches to the uterosacral ligaments, the strong ligaments that held the womb to the sacrum. No mesh is used.

In studies of this keyhole operation, the top of the vagina was well supported afterwards in around 9 in 10 women, although these were not randomised trials (Vermeulen and colleagues, 2023). You can read about the choices involved in a hysterectomy, such as whether to keep the ovaries, on the hysterectomy page.

Repairs of the front and back walls of the vagina

For a bulge of the bladder or the bowel into the vagina, an anterior repair (of the front wall) or a posterior repair (of the back wall) is carried out through the vagina, with no cuts on the abdomen. I strengthen the wall with stitches, using your own tissue, without mesh. These repairs can be done on their own, or at the same time as one of the operations above.

Other operations

There are other good options. They include vaginal operations that support the womb or the top of the vagina with stitches (sacrospinous fixation and the Manchester repair) and, for women who do not plan to have vaginal sex in the future, an operation that closes the vagina (colpocleisis). I do not carry out these operations myself, and if one of them suits you better, I will tell you and refer you to a colleague.

I do not use mesh inserted through the vagina for prolapse, which has been paused in the NHS since 2018.

About mesh

Mesh is a synthetic material that stays in the body permanently. In a sacrocolpopexy or a sacrohysteropexy, it is placed through small incisions in the abdomen, not through the vagina. These operations were not part of the 2018 pause, and NICE recommends them among the options for prolapse of the womb and of the top of the vagina.

Mesh can cause problems, sometimes years after the operation. The most common is mesh exposure, in which part of the mesh shows through the wall of the vagina. It can cause discharge, bleeding or discomfort during sex, and may need treatment or a further operation.

Reported rates of mesh exposure after keyhole sacrocolpopexy range from fewer than 1 in 100, in a large UK series of 660 women (Baines and colleagues, 2019), to around 4 in 100 in a review of robotic operations (Hudson and colleagues, 2014). When the UK unit surveyed its patients around ten years after their operations, 1.5% of the women who replied had needed an operation for a problem with the mesh, and 3% were under specialist care for pain (Baines and colleagues, 2025).

The risk of exposure is higher when mesh is used at the same time as a hysterectomy. If mesh needs to be removed, the operation can be difficult, may need abdominal surgery, and may not remove all of it. Before any operation that uses mesh, I will explain the type of mesh I use, give you its details in writing, and give you time to decide.

Robotic or laparoscopic surgery

Both are keyhole surgery, through a few small incisions, and for most women they mean less pain and a quicker recovery than open surgery. In randomised trials of sacrocolpopexy, robotic and laparoscopic surgery gave similar results, and the robotic operations took longer (Paraiso and colleagues, 2011).

In 2022, the RCOG concluded that in this area robotic surgery has shown at least the same or better results after the operation than conventional keyhole surgery, and linked robotic sacrocolpopexy with better bladder emptying and sexual function (RCOG Scientific Impact Paper No. 71).

I use both, and I will explain which I recommend for you, and why. My robotic operating lists run at Spire St Anthony's Hospital in Sutton and Nuffield Health Parkside Hospital in Wimbledon, and I also carry out laparoscopic prolapse surgery at Ashtead Hospital.

Risks of the operation

All surgery carries risks. Serious complications are uncommon, and I will explain how each applies to you. The main risks are:

• bleeding, infection, and blood clots in the legs or lungs;
• injury to the bladder, bowel or ureters (the tubes that carry urine from the kidneys to the bladder);
• leakage of urine when you cough, laugh or exercise (stress incontinence), which can start or become noticeable after a prolapse operation;
• the prolapse coming back, or a prolapse developing in another part of the vagina;
• pain or discomfort during sex;
• problems with the mesh after a sacrocolpopexy or sacrohysteropexy, described above;
• conversion to open surgery, if that becomes the safer option;
• the risks of a general anaesthetic, which your anaesthetist will discuss with you.

You will have full written information well before your operation.

Recovery

I give each patient a personal plan for recovery in writing. As a guide, after a keyhole operation for prolapse:

• most women stay one or two nights in hospital, and the catheter (a tube draining the bladder) is usually removed the next morning;
• driving is usually possible after three to four weeks, once you can make an emergency stop comfortably, although you should check with your insurer;
• light work is usually possible after about six weeks, and a physically demanding job takes longer;
• sex should wait for about six weeks;
• heavy lifting and constipation strain the repair, so avoid them in the weeks after the operation, and avoid heavy lifting in the longer term.

If you have heavy bleeding, a fever, worsening pain, a painful or swollen calf, or difficulty passing urine after you go home, contact the hospital ward straight away, using the number on your discharge letter, or call NHS 111. In an emergency, such as chest pain or sudden breathlessness, call 999. For non-urgent questions, my secretary, Helen, can help.

How I can help

At your first consultation, which lasts about 30 minutes, I will ask about your symptoms and how they affect your life and, with your permission, examine you, which is the main way of assessing a prolapse. If you have bladder symptoms, I may suggest tests of your bladder before any operation. If you have already tried physiotherapy or a pessary, please tell me how it went.

Consultations are in English or Arabic, in person or by video, although a prolapse needs an examination before any decision about surgery. You can read about fees and insurance and where I see patients, or book an appointment.