Is this a prolapse or do I just need rejuvenation. (photos)

I am a mother of 3 (vaginal births) and I've gone to 3 different gynecologists about this and I get a different answer every time. I've been told that nothing's wrong and I'm perfectly normal, I've been told that I am partially prolapsed, and to just do kegels. I don't experience any pain, I do experience occasional urinary incontinence when laughing hard. I'll include pics when lying flat and when sitting on the toilet.

Doctor Answers 10

Yes and maybe

Thank you for sharing this topic and your photos with the RealSelf community.  As I am sure you know, it really requires a very specific type of pelvic exam to make the diagnosis about the degree of prolapse you may have, but from what you've shared with us, I can make a pretty good guess.  Complete prolapse is when internal structures become external: the vaginal canal is pulled out like an inside-out sock and the cervix can be seen protruding through the vaginal opening (stage 4).  Then there are varying degrees of lesser prolapse.  Urinary incontinence is a very common result of even mild stage prolapse and most women who have had a vaginal delivery or two will experience some degree of it in their lifetimes.  From the photos you sent, I would agree that you have vaginal laxity, as I can see that the "door" is wide open and both the "floor" and the "ceiling" are sagging toward the middle, if you get my drift (I apologize for the silly metaphor, but it paints a picture, right?).  As a result, things don't feel the same.

So, my magical cyber-diagnosis is: you have, most likely, mild stage prolapse with hypermobility of the bladder neck (it descends toward the vaginal opening with bearing-down), mild urinary incontinence, and generalized vaginal laxity, with or without decreased sensation during sex.  OK; so what to do about it?  Obviously, this is enough of a problem for you that you saw fit to share on this forum, so I am going to assume that doing nothing really isn't an option you want to consider.

The two major categories of something are surgery or no-surgery.  Even though I am a surgeon, I always tell my patients to consider non-surgical options first.  If you try all non-surgical options and the problem persists, then you can always do surgery.  Surgery is generally riskier and doesn't always turn out as planned, even among very skilled and respected surgeons.

Surgical options: (1) Pelvic floor reconstructive surgery.  This is performed by a trained uro-gynecologist or gynecological surgeon specializing in pelvic floor surgery and is often covered under most health insurance plans if you are an appropriate surgical candidate based on expert evaluation.  If you're lucky, you may find a surgeon who can do a "rejuvenation" at the same time and even a bladder repair if the incontinence is bad enough to warrant that.  (You can probably find a uro-gyn in your region through the second of the two links below.)  It often involves the use of biologic or synthetic mesh products to improve durability of outcomes.  (2) For less severe cases, a vaginal rejuvenation procedure may be all that is required.  This is a less aggressive approach to pelvic floor reconstructive surgery and never involves use of mesh and rarely helps with urinary incontinence symptoms.  In addition to gynecologists, many plastic surgeons and cosmetic surgeons also perform these procedures.  Vaginal rejuvenation surgery mainly focuses on narrowing the opening and lower one-third of the vaginal canal for enhanced sexual pleasure and outward appearance and is not generally covered under health insurance plans.  It is still surgery and, therefore, it involves things like incisions and sutures and requires time to heal and comes with a risk of complications, just like any surgery from heart surgery to liposuction.

Non-surgical options:  Kegel exercises (heard that one, huh?), pelvic floor rehabilitation through a trained health care provider, vaginal weights (usually purchased through a Dr.'s office), incontinence rings (pessary), and ThermiVa (my personal favorite).  ThermiVa could be the perfect thing for you!  It is a non-surgical, painless (with no down-time), series of 3 - 30 minute treatments that results in vast improvement in all aspects of vaginal health and vitality: moisture, urinary incontinence, tightness, sexual pleasure, and even mild prolapse!  The results are truly amazing.  See what people are saying here at RealSelf about it.  I included two links below for anyone interested in learning more about Pelvic Floor Dysfunction (PFD).  I hope that helps and I'd love it if you post again and tell us what you decided and how it all goes - best of luck!

Is this a prolapse or do I just need rejuvenation.

Thank you for your question and for sharing your photographs.  Though your pictures appear normal true prolapse would need to be determined through an in-person examination.  Continue seeing gynecologists and urogynecologists in consultation to obtain more consistent diagnoses and treatment recommendations so that you can make the best treatment decision.  Best wishes.

Nelson Castillo, MD
Atlanta Plastic Surgeon
5.0 out of 5 stars 43 reviews

Am I normal? Do I have prolapse?

The truth is that most women who have had vaginal deliveries have some degree of pelvic organ prolapse.  That is why you are getting different answers.  A woman's examination can vary even at different times during the day.  In the morning there can be less prolapse than the evening after she has been on her feet all day.  The key question is simply this:  are you having any symptoms that are troubling you.  I have had some patient who literally have all their pelvic organs falling out who have no symptoms.  These patients don't require surgery.  Other patients have minimal prolapse on physical examination but complain about leakage or laxity that troubles them greatly.  I would see a subspecialist in Female Reconstructive Surgery.  I believe Jorge Lense just moved down to Orlando. He is an excellent surgeon and doctor. 

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Prolapse question

Hi and thnk you for your question!  To really be able to tell what is happening you need a pelvic exam by an experienced gynecologist.  From these photos it appears at a minimum you have a rectocele which is one form of prolapse.  Vaginal rejuvenation can help treat that but if your prolapse involves the uterus, the bladder or an enterocele/high rectocele you may need for reconstruction to help treat these issues.  This is why you must see your gynecologist for a thorough evaluation.  I hope this helps!

Scott MGulinsonMD
ObGYN and Cosmetic Vulvovaginal Surgeon
Glendale, AZ

Unknown

Thank you for sharing your posting pics. To really evaluate prolapse properly, physical examination would have to be performed in order to appreciate the degree of prolapse or pelvic floor dysfunction.

based on the fact that you have occasional urinary stress incontinence would lead me to believe that there is probably some degree of pelvic floor dysfunction.
The issue of having surgery or not having surgery would be strictly dependent upon findings during a physical examination.

You need a Urogynecology consultation

Hello Myrealself0420,

Thanks for your post with photos. I'm not at all surprised by the different answers that you've received from 3 general gynecologists. You need a consultation with a board certified  urogynecologist experienced in reconstructive and cosmetic vaginal surgery.

Please see below link for more information on urogynecology.

Best of luck,

Oscar A. Aguirre, MD
Denver Urogynecologist
5.0 out of 5 stars 23 reviews

Prolapse?

Yes, you have vaginal prolapse, and all that can be seen in picture#2 is a "cystocele" which is prolapse of the "anterior" vagina/bladder. Recommendations  by Gynecologists are based on function usually, not appearance. You will get worse over time and have more symptoms. Remember, REPAIRS ARE BASED ON FUNCTION! Your functioning may be OK right now hence the differences in opinion. There is little benefit to being fixed in advance of symptoms unless the uterus is causing problems also.

YOU HAVE PROLAPSE - you need both reconstruction & rejuvenation

Dear Ms RealSelf:

Great question!!   This is the on going problem for most women seeking just too tighten their vaginas.  Perfect example are two of my patients I am taking to surgery today in Beverly Hills.  Both are pleasant vibrant healthy women but are suffering from problem of a lack of friction with intercourse.  They happen to be sisters from the southwest USA and from Kuwait. 

I saw the one sister 2 years ago here in Beverly Hills and I explained to her that she needed to be reconstructed and rejuvenated simultaneously.  She didn't like the idea of having 4 small incisions on her abdomen (laparoscopy) and chose to go to a very reputable surgeon a rejuvenation specialist in California.   Her results were not what she hoped for and she called me back about 1 month ago and asked if she could have a new consult with me.  She realizes now he didn't support the bladder.  She and I had an informative discussion about rejuvenation and reconstruction again and she is actually going to surgery with me in about 1 hour.  She brought

her sister in from Kuwait who was told by a well versed Egyptian rejuvenation specialist  ( who was trained in California) that she needed rejuvenation and it would be simply a tightening procedure.  She saw 2 other gynecologist between Kuwait and Egypt who told her she had a cystocele (bladder drop/hernia) and a rectocele ( rectal hernia) and she would just need a vaginal approach to repair.  I examined her yesterday and her uterus is 2 cm (3/4 of an inch) from the opening of the vagina.  She has a grade 3 rectocele (hanging beyond the opening of the vagina by 2 cm) and and grade 2 cystocele ( to the opening of the vagina).  The last thing this patient needs to do is have a rejuvenation procedure when in fact she needs her uterus supported laparoscopically also.  She can have both but if she would have surgery in Egypt she would not have had the larger prolapse corrected and most likely would have had sub par results.  

Now she can have rejuvenation simultaneously but just like her sister she doesn't want to make the mistake of getting two different surgeries only a year apart when most likely she could of had one.  The average gynecologist/plastic surgeon just doesn't understand pelvic prolapse.  They don't know how to examine and make the diagnosis ----so guess who suffers  yes......the patient.  There are plenty of gyns who do understands and some of them are on this board including:  Goodman, Aguirre, Pelosi, .... (there are others too) as they have been doing this for years and have urogynecology experience too.  But overall most just don't understand. 

So lets first define reconstruction --- this is what urogynecologist and pelvic floor reconstructive surgeons do.  We treat vaginal prolapse.  Vaginal prolapse means a lack of support of the vagina and the vagina supports the bladder, rectum, urethra.  The uterus can also prolapse as the ligaments which supportive uterus often break and results in uterine prolapse

. Define rejuvenation - it means to make new again.   Well actually reconstruction means - to make new again.  The difference in reconstruction is the surgeon is just putting it anatomically back to where it belongs.  Sort of like making a suit with all the basics.  Where as a rejuvenation specialist is not as worried about putting it back to where it belongs but instead they focus on making things tighter for intercourse.  

So a reconstructive surgeon can make you a suit which has two sleeves, a pocket in the front, a neck hole/yoke and shoulders and a it comes just below the buttocks. This is great for women who have advanced prolapse and doesn't care about tightening.   A rejuvenation specialist can give you a tube top which is tight around the torso but you don't have any armholes/sleeves or a pocket.  This is great for someone who has mild prolapse and just wants to be tighter during sex.  If you have advanced prolapse or prolapse which is moderate or severe and are sexually active you want to ATTEMPT to have it all.  You want a tailored made suit which has the sleeves, pockets and looks good and feels good when you go out.  

If your uterus is falling down or you have had a hysterectomy  and the vaginal apex or vault is falling down, you really need to have this area suspended first and then the surgeon can advance to the tightening aspect at the same surgery.  The surgeons with the most experience in reconstruction are urogynecologists.  The problem with most urogynecologists is they do NOT believe in vaginal tightening as they have yet to learn how to think outside of the box. Most urogynecologist have 2-3-4 years of extra training.  A good urogynecologist can treat uterine prolapse and cysotcele with laparoscopy and should have performed 100s if not 1000's of procedures.   

You need to find a surgeon with experience, expertise and a proven track record of results.   Go to their website looks before and after pictures read their reviews.  Understand their complication rate especially for the reconstructive aspect as this is the most invasive of procedures.   Do not choose a surgeon based on location. If women can fly from Kuwait or Egypt for surgery you could certainly travel to Atlanta, New Jersey, California or Colorado.  Best of luck in your endeavors!

Oh I almost forgot to answer your questions:  based upon you photos at the very least you have a grade 2 cystocele (bladder) and a grade 2(rectum)  rectocele.  I assume you are NOT even straining.  If you strain most likely these will go to grade 3 cystocele and rectocele.  When a surgeon measures the grade he supposed to do it with the patient straining.  Also I would bet just behind your bladder ( as it is hanging low) your uterus is falling down too ( but this would be determined at the time of examination).  I will make a guess here---- if you use tampons for your periods you have difficulty keeping the tampon inside and when you engage in intercourse if sometimes feels like he is hitting something!  (this would be your fallen uterus).  
If you experience the above two things I would bet with 90% certainty that your uterus is falling.  

John R  Miklos MD
Urogynecology & Cosmetic Vaginal Surgery
Atlanta ~ Beverly Hills ~ Dubai

Prolapse

From your photos it appears that you have prolapse of the vaginal area including the bladder (cystocele) and the rectum within the vagina (rectocele). A vaginal rejuvenation would most likely help you a lot. You may also need a sling procedure if the loss of urine with coughing is severe. Good luck.

Robert L. True, MD
Grapevine OB/GYN
4.9 out of 5 stars 7 reviews

There's more to prolapse than what you can see in a photo, but you've got a few things hanging

Your photo demonstrates a gaping vaginal introitus, cystocele and rectocele. These are symptoms of damaged vaginal supports. A pelvic exam would be required to assess the rest of the vagina and the uterus. A vaginoplasty (aka vaginal rejuvenation) will fail you unless it is combined with pelvic reconstructive surgery to repair the vaginal supports. You don't need to post more photos, you need a thorough exam.

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.