Colpocleisis: Closing the Vagina to Optimize Quality of Life

If you randomly asked any woman whether she would consider having her vagina sewn shut to eliminate a long-term health issue, she’d likely react with horrified silence. Ask any woman who has suffered for years, and in some cases decades, with the discomfort of vaginal tissue bulge, vaginal pressure, or pain with intimacy that often accompanies pelvic organ prolapse (POP), and you might be surprised at the response. These women simply want to feel normal again, and some are willing to do anything to recapture their former quality of life.

If you randomly asked any woman whether she would consider having her vagina sewn shut to eliminate a long-term health issue, she’d likely react with horrified silence.

Women ranging from mid-teens through end of life experience a multitude of POP symptoms that impact their physical, emotional, social, and sexual well-being, along with their fitness and employment routines. Considering pelvic organ prolapse has 5 types and 4 grades of severity, and with most women experiencing combinations of POP types, it’s not shocking that one treatment does not fit all needs. Women are as unique on the inside as they are on the outside, and because lifestyle, behaviors and socio-cultural norms vary substantially, it is imperative that we remain open-minded to what individual women need, and more importantly, what they want in the way of treatment.

A considerable variety of surgical procedures and protocols exist to address pelvic organ prolapse. Surgery may be vaginal, abdominal, laparoscopic, or robotic in approach, or a combination of these methods. Some surgeries involve mesh; others are mesh-less.

Women are as unique on the inside as they are on the outside, and because lifestyle, behaviors and sociocultural norms vary substantially, it is imperative that we remain open-minded to what individual women need, and more importantly, what they want in the way of treatment.

Colpocleisis is a procedure that stands alone in a sea of surgical choices. The first report of colpocleisis dates back to 1823 when Gerardin described exposing the anterior and posterior vaginal wall at the introitus and suturing them. The most widely accepted technique, however, is a modification described by Leon Clement Le Fort in 1877, which is a partial colpocleisis with the uterus left intact. Vaginal partitioning is a similar, but seldom utilized procedure.

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Unlike other POP surgical procedures, colpocleisis closes the vagina, eliminating the potential for vaginal intercourse, while creating a platform of sorts to shore up fallen organs and tissue inside the pelvic cavity. This eliminates vaginal tissue bulge and pressure. The procedure is highly successful long term, and relatively easy and quick to perform in relation to alternate POP surgeries, with the most common risk of complication being a urinary tract infection. No mesh is used in colpocleisis procedures.  A very short amount of the vaginal canal is left open, less than 2 inches in length, to enable vaginal secretions to naturally escape. Post-op recovery is relatively quick with minimal discomfort. The same post-op restrictions apply to colpocleisis as applies to other POP surgeries. Women should engage in life-long core and pelvic floor exercise and restrict heavy lifting and hard foot-strike fitness activities to reduce risk of POP recurrence. However, colpocleisis provides a stable internal support platform. If a woman has had long-term non-POP related constipation, colpocleisis is not the fix.

Colpocleisis is most typically utilized by mature women (65 years of age and older) to treat POP. Some women are shocked when they hear this procedure
exists - they can’t imagine eliminating a canal that has been a pivotal portal of life and love for the majority of their womanhood. But some women who have suffered extensively from diverse quality of life impacts of POP are relieved they have a non-mesh option that provides a long-term fix.

At times women become aware of colpocleisis via “Dr. Google”, and request the procedure. Women in their early or mid-60s are often refused, informed they are too young.

Some women are shocked when they hear this procedure exists - they can’t imagine eliminating a canal that has been a pivotal portal of life and love for the majority of their womanhood.

Women who suffer with Ehlers Danlos Syndrome, a condition that displays as connective-tissue abnormalities and distinctive defects in soft tissue strength, integrity, elasticity, and healing, are predisposed to pelvic organ prolapse and surgical failure as young as their 30s and 40s. This sector of women may toss the topic on the table with their specialists, but are typically denied access because of their young age.

This solicits multiple questions. What about a woman’s right to choose treatment? Shouldn't there be consideration of the uniqueness of women's vaginal health needs regardless her age?

sHOULDN’T THERE BE CONSIDERATION OF THE UNIQUENESS OF WOMEN’S VAGINAL HEALTH NEEDS REGARDLESS THEIR AGE?

A thread querying the needs and curiosities of women in APOPS patient support forum revealed the following questions, which were graciously answered by Vanderbilt University FPMRS urologist Roger R. Dmochowski, MD, MMHC:

1. Is colpocleisis of value to relieve rectocele or enterocele symptoms, or only of value for bladder and uterus indications?
   ~It helps all elements and can be a real symptom resolver, but women may require simultaneous procedures to address incontinence or posterior repairs, depending on types of POP and grade of severity.

2. Are there any protocols to screen for gynecologic cancers after colpocleisis?
   ~No, other than an external exam. A pre-operative pap is standard procedure to assure there are no issues prior to surgery.

3. If a woman engages in horseback riding and lifts heavy weight such as bags of horse feed, would a colpocleisis procedure hold up long term?
   ~It should. But repetitive heavy lifting is not a good thing after any surgical procedure, especially regarding the core of the body where a multitude of organs, soft tissues, structural supports, and nerves come together in a very intricate space.

4. What is the appropriate incontinence test to have prior to a colpocleisis procedure to indicate and clarify consideration of a sling procedure simultaneously with colpocleisis?
   ~Minimally, a full bladder stress test - I personally do urodynamics (UDS) on all patients given risk of overactive bladder (OAB), and to clarify if bladder and urethra are performing their job of storing and releasing urine properly.

5. Women have concerns with functional urinating and defecating after colpocleisis. Are there any potential issues?
   ~If the urinary system is not checked prior to colpocleisis, undetected incontinence may be an issue post-surgery because grades 3 and 4 prolapse may mask this issue.

6. Tissue integrity issues reduce potential for successful surgical procedures, and may increase the risk of surgical failure long-term. Is colpocleisis an option a young woman with Ehlers Danlos who has had multiple failed POP surgeries should consider? And should young post-menopausal women be offered this option?
   ~It is reasonable to mention but is not generally offered to young women given inability for intercourse post-op. It is always appropriate to offer counseling about long term irreversible change to female sexuality. Colpocleisis is an alternative POP procedure for the EDS sector to consider for long term durability, although a fairly radical procedure for young women.

7. Can OAB become worse after colpocleisis?
   ~Yes, it can just as can stress incontinence, and patients need to be counseled regarding these issues prior to surgery.

8. Will an enterocele be addressed with the colpocleisis procedure? An enterocele may drop down into the lower pelvic cavity behind or in front of the uterus (or the uterine space in women who have had their uterus removed).
   ~The closure may reduce an enterocele, depending on location. The degree of severity is very individual, so procedures are addressed based on the unique needs of the patient.

9. If women have already had a mesh procedure, would that complicate a colpocleisis procedure?
   ~It could – every women’s situation is unique, so it’s difficult to say for sure. It could complicate tissue coaptation (the joining of tissues together in the healing process).

Ultimately as pelvic organ prolapse awareness goes mainstream, women will require more evolved options. Surgical procedures that show themselves to be effective in the general population will continue. Infrequently provided procedures of value to an appropriate subpopulation such as younger mature women or young women with EDS may be considered more readily. Colpocleisis should be an option more readily discussed and accessible to the women requesting it. Choice matters.