Pelvic Organ Prolapse

By OBOS Pelvic Organ Prolapse Contributors | August 3, 2016

Revised from a fact sheet from Women’s Health Queensland Wide.

Pelvic organ prolapse occurs when one or more of the pelvic organs — the uterus, bladder, or rectum — slip down from their normal position and either press against the wall of the vagina or protrude into the vagina. An organ can bulge out the vaginal opening as well.

The pelvic organs are usually supported by ligaments, muscles, connective tissue, and fascia that are collectively known as the pelvic floor. Weakening of or damage to these support structures allows the pelvic organs to slip, or prolapse, down.

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These conditions are most common in postmenopausal women who have given birth, but can also occur in younger women and women who have not given birth. It is estimated that at least half the women who have given birth to more than one child have some degree of genital prolapse. However, only 10-20 percent of women who have a genital prolapse actually experience symptoms or discomfort.

If you find out you have a prolapse but aren’t experiencing problems, you don’t need to be treated. Prolapse is a quality of life issue, not something that requires fixing for health reasons.

Normal female pelvic anatomy

Normal female pelvic anatomy

Types of pelvic organ prolapse

There are a number of different types of prolapse. The prolapse of a pelvic organ may occur independently or along with other pelvic organ prolapses. Prolapses are graded according to their severity: first, second, third, or fourth degree prolapse.

Cystocele (prolapse of the bladder)

graphic of cystocele

Cystocele

A cystocele occurs when the tissues supporting the wall between the bladder and vagina weaken and a portion of the bladder pushes into the vaginal walls, which then bulge into the vagina.

Urethrocele

A urethrocele occurs when the urethra (the tube leading from the bladder to the outside of the body) descends and pushes into the vaginal walls, which then bulge into the vagina. A urethrocele rarely occurs alone; usually it happens when a woman already has a cystocele. The term cystourethrocele is used to refer to the prolapse of both part of the bladder and the urethra.

Uterine prolapse

drawing of a uterine prolapse

prolapse of the uterus

A uterine prolapse occurs when the uterus and cervix descend down into the vagina, due to weak or damaged pelvic support structures.

Vaginal vault prolapse

A vaginal vault prolapse occurs when the top of the vagina descends in women who have had a hysterectomy.

Rectocele (prolapse of the rectum)

drawing of a prolapsed rectum

rectocele

A rectocele occurs when the tissues supporting the wall between the vagina and rectum weaken, allowing the rectum to push into the vaginal walls, which then bulge into the vagina.

Enterocele

An enterocele is similar to a rectocele, but instead involves the Pouch of Douglas (an area between the uterus and the rectum) descending and pushing into the vagina walls, which then bulge into the vagina.  An enterocele often contains small bowel.

Symptoms

Symptoms of prolapse differ according to the organs involved and the severity of the prolapse. Many women with minor prolapses have no or only minor symptoms.

Women who do experience symptoms commonly report feeling:

  • A lump or bulge in the vagina or vaginal entrance.
  • A dragging sensation or feeling that something is falling down. These sensations tend to be most prominent when lifting or changing positions, with physical exertion, after long periods of standing, or at the end of the day.
  • An aching discomfort in the pelvic region.
  • A dull backache.

Some women with a cystocele or urethrocele experience urinary problems. The change in position of the bladder that can occur with prolapse may lead to stress incontinence (leaking of urine when coughing, sneezing, laughing), frequent urination, incomplete emptying of the bladder, and urinary infections.

Women who have a rectocele may experience difficulty passing stool.

Sexuality

In some women,  the loss of pelvic tone can result in decreased sensation. Because women who have a cystocele or urethrocele may experience a loss of urine during vaginal penetration, some feel insecure or self-conscious about having sex.

However, it is safe to have intercourse and other types of penetration, as  prolapses can easily move out of the way. Prolapses generally don’t interfere with orgasm or sexual satisfaction.

Causes

Prolapses occur due to a weakness or damage that has occurred to the pelvic floor, the structures which hold the pelvic organs in place.

There are a number of factors that contribute to this weakness or damage, including:

Pregnancy and childbirth

The most significant contributor to prolapse is pregnancy and birth. During pregnancy, hormonal changes and the extra weight and pressure of the baby can contribute to the weakening of the pelvic floor. In addition, a vaginal birth can result in stretching or tearing of the supporting pelvic structures. Damage to the pelvic floor is more likely to occur during long second stages of labor, instrumental deliveries (the use of forceps or vacuum extraction), and the birth of large infants. Often damage that occurs during pregnancy and vaginal birth goes unnoticed at the time, with symptoms only developing later in life, following menopause.

Menopause/aging

The hormone estrogen plays an important role in maintaining the strength of the pelvic floor. At menopause, a woman’s estrogen levels decrease and, as a result, the pelvic floor becomes weaker. The lack of estrogen at this time often exacerbates existing damage that may have occurred as a result of childbirth or other factors. The pelvic support structures also relax due to the natural aging process and due to the effects of gravity: when we are standing, the weight of the abdominal and pelvic organs put pressure on the vagina. In four-legged mammals, the vagina is horizontal and prolapse is much less common.

Pressure in the abdomen

Certain factors and movements place added pressure on the pelvic floor. These include chronic coughing (for example, coughing associated with smoking or conditions like bronchitis or asthma), repetitive heavy lifting, chronic straining during a bowel movement or when urinating, being overweight, and the presence of pelvic masses such as fibroids. If these pressures are sustained over a long period of time they can weaken the pelvic floor.

Genetic

Some women are born with a weakness in their pelvic floor muscles and so are at a higher risk of prolapse. Congenital weakness explains why some women who have never given birth develop a prolapse. This might be genetic weakness of the collagen, or a neuromuscular disease like muscular dystrophy.

Pelvic surgery

Women who have previously had pelvic organ prolapse surgery may be at increased risk of developing another prolapse.

Diagnosis

If you experience distressing symptoms that you think may be associated with a prolapse, contact your healthcare provider. The provider should take a complete medical history and perform an abdominal exam and a pelvic exam that may include both a vaginal and rectal exam. You may be asked to cough or bear down during the exam as this raises the pressure in the abdomen and pushes any prolapse downward, making it easier to see or feel. Coughing or pushing down can also help identify any associated stress incontinence. These examinations may also be conducted while you are in a standing position. If you also have incontinence, it may be necessary to conduct other tests to fully investigate the cause/s of this.

Treatment

There are a range of treatment options available for prolapse. The most appropriate treatment will depend upon the type of prolapse, its severity, your age, the state of your health, and whether you plan on getting pregnant. Treatments can be divided into two types: conservative and surgical. Because surgical treatments always carry some risk, conservative treatments are generally tried first. They are considered most helpful for those with a mild prolapse, as well as for women who wish to become pregnant and women who are poor candidates for surgery or don’t want surgery.

Conservative treatment options
Lifestyle changes

Since prolapses are exacerbated by pressure on the pelvic floor, simple measures, including avoiding repetitive lifting of heavy objects, using proper lifting techniques, reducing high impact sports, and treating conditions like chronic coughing and constipation may help alleviate symptoms.  If you smoke or are overweight, quitting smoking and losing weight, if possible, may also help.

Pelvic floor exercises

There is some evidence that doing individualized pelvic floor muscle training can improve the symptoms and progression of pelvic organ prolapse. Because these exercises can be difficult to perform correctly, need to be performed in conjunction with other exercises or with biofeedback, and are often different for different people, it’s best to see a physical therapist who specializes in pelvic floor treatment. Finding one can be difficult and you may need to travel to a city. The American Physical Therapy Association maintains a list of physical therapists who have received specialized training in women’s health issues.

Pessaries
photos of different types of pessaries

different types of pessaries

A pessary is a device which is inserted into the vagina to provide support to the pelvic structures. The majority of pessaries are made of silicone and come in a number of shapes and sizes. A pessary needs to be initially fitted by a medical professional. Once in place, you should not be able to feel it. You can learn to insert and remove some kind of pessaries yourself. In this case, the pessary is usually removed once a week, washed with mild soap and water, and then reinserted. If you are unable to insert and remove the pessary yourself, it can remain in place for 3-4 months. Your doctor or other medical provider can remove the pessary for you, clean it, and then reinsert it. A vaginal exam will also be done at this time to ensure the tissue is healthy.

Pessaries provide a temporary solution to prolapse symptoms for pregnant women, women who have recently given birth, or women waiting to have surgery. Pessaries can also be used permanently by women who do not wish to have surgery or who are unsuitable candidates.

If a pessary is too small it may fall out and if too tight-fitting it can cause irritation, ulceration, bleeding, and pain.  If you experience any of these problems, see the provider who fitted the pessary. Pessaries may be used in conjunction with a topical, low-dose estrogen cream to improve skin tone and elasticity and, therefore, reduce skin erosion.

While conservative measures have proven to be effective in the treatment of conditions such as urinary incontinence, there are fewer quality studies into their use for genital prolapse. More studies are required to determine how beneficial lifestyle changes and pelvic floor exercises are in treating genital prolapse.

Surgical OPTIONS

If non-surgical treatment options do not provide sufficient relief from symptoms, surgical repair of the prolapse is recommended. Generally, the aim of surgery is to repair and reconstruct the pelvic support structures so that the pelvic organs are restored to their normal positions. Restoring and maintaining bladder, bowel, and sexual function (when appropriate) are also key factors.

There are a number of different surgical procedures and approaches to treat prolapse. The most appropriate procedure will depend on which organ(s) have descended, your age, history of previous pelvic surgery, and whether you wish to retain your uterus. In many cases more than one pelvic organ has prolapsed and so a combination of procedures is required. Women are often advised to delay surgery until after their childbearing is complete as future pregnancies can increase the risk of recurrence.

Vaginal wall repair

A vaginal wall repair involves a repair to the tissues supporting the vaginal wall. There are a few different types of vaginal wall repair, depending on where the weakness is located (front vaginal wall with a cystocele versus the back vaginal wall with a rectocele). A vaginal wall repair is generally performed through the vagina but is sometimes performed laparoscopically. During laparoscopic surgery, the surgeon will carry out the procedure by making 3 to 4 tiny incisions in the abdomen, with the assistance of a laparoscope (a telescope like instrument). Sometimes this approach involves robotic-assisted technology as well.

Vaginal vault repair

A vaginal vault repair is performed when the top of the vagina has prolapsed down and/or needs to be resuspended. There are two main approaches to repair vaginal vault prolapse. The most minimally invasive route is performed through the vagina and involves securing the top of the vagina to ligaments in the pelvis. There are a few different ligaments that can serve this purpose. The second approach attaches a piece of synthetic mesh or fascia to the top of the vagina and then anchors it to the sacrum (bone near the tailbone). It can be performed abdominally or laparoscopically. Either approach can be done with or without a hysterectomy, depending on the severity of the prolapse and the health of the uterus. There are risks and benefits of both approaches.

Hysterectomy

Hysterectomy, the removal of the uterus, may be included in the treatment of uterine prolapse. A hysterectomy is often performed in conjunction with other procedures (for example, a vaginal wall repair). A hysterectomy for prolapse is usually done through the vagina but an abdominal approach may be required if the uterus is large.

Having a hysterectomy does not treat the prolapse. It must be accompanied by other procedures that restore normal support to the top of the vagina and vaginal walls.  It is done when the uterus is so out of place that it might be difficult to get it back into the proper position.  Sometimes there are other anatomic considerations that lead to hysterectomy, like a large cystocele or a very long cervix which occurs over many years of prolapse.

While there are no proven medical harms to not having a uterus, there are clear harms to having the ovaries removed with a hysterectomy. For more information, see Hysterectomy and Ovarian Conservation.

Uterine preservation surgery

Women with uterine prolapse who wish to preserve their uterus have several options. If this is true for you, ask your provider which uterine preservation procedures are currently available and if they are appropriate for you. You may be able to have a vaginal vault repair without a hysterectomy.

Vaginal closure surgery

Women who cannot have longer surgeries due to health risks and who don’t plan on having sex that involves vaginal penetration can consider vaginal closure surgery, which involves sewing the front and back walls of the vagina together to prevent the pelvic organs from sliding out. While women cannot have vaginal penetration after this procedure, they can still participate in other sexual activity if desired. This approach to surgery is shorter and less invasive than some of the other surgeries for prolapse.

Surgery risks and recovery

As with any surgical procedure, the surgical treatment of pelvic organ prolapse carries the risks associated with the use of anesthesia and the possibility of bleeding and infection. Other possible adverse effects of prolapse surgery include injuries to adjacent organs, urinary problems (retention of urine, stress incontinence, urinary infection, urinary urgency), pain during sex (dyspareunia), and the formation of blood clots.

The length of hospital stay and recovery time will depend on the type of procedure performed and how it was carried out. Generally a woman will stay in the hospital for two nights for abdominal surgery, and one night for vaginal or laparoscopic surgery.

After leaving the hospital, care should be taken not to place any strain on the pelvic floor. Avoid lifting heavy objects, excessive straining with bowel movements, and coughing. You will generally be able to return to work in approximately 4-6 weeks. You should wait two months before having intercourse or placing anything in the vagina.

You may have a recurrence of prolapse following surgery. This may be due to the presence of other weaknesses in the pelvic support structures not being evident or not being recognized at the time of surgery. If these weaknesses go unrepaired they can progress, leading to either the recurrence of the original prolapse or the prolapse of other pelvic organs. Conditions that place persistent strain on the pelvic floor, such as chronic constipation or coughing, can also increase the risk of recurrence. Treatment options for recurrent prolapse are the same as those previously discussed.

Prevention of pelvic organ prolapse

While women have little control over some contributing factors to prolapse (for example, having a long labor or giving birth to a large infant), there are other steps you can take to reduce your risk:

  • Avoid constipation and straining during bladder and bowel movements. If you find it difficult to avoid straining, request to see your physician, a physical therapist or continence nurse. She or he can provide information on toileting positions to minimize risk to the pelvic floor and assist in the complete emptying of the bladder and bowel.
  • Treat the cause of any chronic cough (if it is smoking-related seek assistance in quitting).
  • If you are overweight, lose weight if possible.
  • Avoid repetitive lifting of heavy objects. If lifting heavy objects, make sure to bend at the knees and keep the back straight.

For more information on pelvic organ prolapse, see: