Pelvic Organ Prolapse
The organs within a woman’s pelvis (uterus, bladder and rectum) are normally held in place by ligaments and muscles known as the pelvic floor. If these support structures are weakened by overstretching, the pelvic organs can bulge (prolapse) from their natural position into the vagina. When this happens it is known as pelvic organ prolapse. Sometimes a prolapse may be large enough to protrude outside the vagina.
Who gets pelvic organ prolapse?
Pelvic floor disorders (urinary incontinence, fecal incontinence, and pelvic organ prolapse) affect one in five women in the United States. Pelvic organ prolapse is less common than urinary or fecal incontinence but affects almost 3 percent of U.S. women. Pelvic organ prolapse happens more often in older women and in white and Hispanic women than in younger women or women of other racial/ethnic groups. Some women develop more than one pelvic floor disorder, such as pelvic organ prolapse with urinary incontinence.
What are the symptoms of pelvic organ prolapse?
• You may not have any symptoms at all and may only find out that you have a prolapse after a vaginal examination by a healthcare professional, for example when you have a smear test. A small amount of prolapse can often be normal.
• The most common symptom is the sensation of a lump ‘coming down’. You may also have had backache, heaviness or a dragging discomfort inside your vagina. These symptoms are often worse if you have been standing (or sitting) for a long time or at the end of the day. These symptoms often improve on lying down.
• You may be able to feel or see a lump or bulge. You should see your doctor if this is the case because the prolapse may become sore, ulcerated or infected.
• If your bladder has prolapsed into the vagina, you may: experience the need to pass urine more frequently, have difficulty in passing urine or a sensation that your bladder is not emptying properly, and leak urine when coughing, laughing or lifting heavy objects, have frequent urinary tract infections (cystitis).
• If your bowel is affected, you may experience low back pain, constipation or incomplete bowel emptying. You may need to push back the prolapse to allow stools to pass.
• Sex may be uncomfortable and you may also experience a lack of sensation during intercourse.
• Laxity – a feeling that the vagina is wider, looser or more open than normal
• Difficulty inserting or keeping tampons in. They may also shift position and be uncomfortable
What causes pelvic organs to prolapse?
The main cause is damage to the nerves, ligaments and muscles which support the pelvic organs and may result from the following:
• Pregnancy and childbirth are considered to be major factors leading to weakening of the vagina and its supports. Prolapse affects about one in three women who have had one or more children. A prolapse may occur during or shortly after a pregnancy or may take many years to develop. However, it is important to emphasize that only 1 out of 9 women (11%) will ever need surgery for prolapse in their lifetime
• Aging and menopause may cause further weakening of the pelvic floor structures
• Conditions that cause excessive pressure on the pelvic floor like obesity, chronic cough, chronic constipation, heavy lifting and straining
• Some women may have an inherited risk for prolapse, while some diseases affect the strength of connective tissue e.g. Marfan syndrome and Ehlers-Danlos syndrome
Front vaginal wall prolapse (previously called a cystocele)
This is the most common prolapse. The wall supporting the bladder bulges down into the vagina. This may contribute to bladder symptoms such as:
• Problems with emptying which may mean frequent urinary tract infections
• Urgency – a strong need to empty the bladder
• Frequency – needing to go to the toilet more often including at night (nocturia)
• Incontinence – leakage of urine which may be related to coughing/activity or may be associated with urgency
• Difficulty in starting to pass urine or a slow flow when emptying the bladder. You may find that you have to change position on the toilet to empty your bladder properly
Back vaginal wall prolapse (previously called a rectocele)
The wall supporting the rectum/back passage bulges down into the vagina. This may contribute to bowel symptoms such as:
• Difficulty emptying your bowels or incomplete emptying which leads to straining more than normal
• Bowel or wind leakage and smearing/staining at the anus
• Bowel urgency – a sudden need to open your bowels
• Needing to use your fingers to press around the vagina or anus to help empty your bowel
Uterine prolapse (previously known as the womb coming down or ‘fallen womb’)
The uterus moves downwards into the vagina due to the lack of support. The cervix will then sit lower in the vagina which might be noticed when you have a smear test. This does not necessarily mean that you have a prolapse.
Vaginal vault prolapse
After a hysterectomy, when the uterus has been removed, the top of the vagina (known as the vault) can bulge downwards.
How is prolapse diagnosed?
A prolapse is diagnosed by performing a vaginal examination. Your doctor will usually insert a speculum (a plastic or metal instrument used to separate the walls of the vagina to show or reach the cervix) into the vagina to see exactly which organ(s) are prolapsing. You may be asked to lie on your left side with your knees drawn up slightly towards your chest in order to for this examination to be performed. You may also be examined standing up.
How is pelvic organ prolapse treated?
Treatment for pelvic organ prolapse depends on the type of prolapse you have, your symptoms, your age, other health problems, and whether you are sexually active. Your treatment may include one or more of the following:
• Pessary. A pessary is a removable device inserted into the vagina to support the pelvic organs. Pessaries are often the first treatment your doctor will try.
• Pelvic floor muscle therapy. Pelvic floor exercises help strengthen the pelvic floor muscles. These exercises can also help women who have urinary incontinence.
•Changing eating habits. If you have bowel problems, your doctor may recommend eating more foods with fiber. Fiber helps prevent constipation and straining during bowel movements.
• Surgery to support the uterus or vagina. During surgery, your doctor may use your own body tissue or synthetic mesh to help repair the prolapse and build pelvic floor support. This type of surgery is recommended for sexually active women with serious prolapse of the vagina or uterus. Surgery for prolapse can be done with or without mesh and either through your vagina or abdomen. The Food and Drug Administration (FDA) recently strengthened the safety requirements for new mesh devices that repair pelvic organ prolapse through the vagina.
• Surgery to close the vagina. This surgery, called colpocleisis, treats prolapse by closing the vaginal opening. This can be a good option for women who do not plan to have or who no longer have vaginal intercourse.
What can you do to help a pelvic organ prolapse?
Pelvic organ prolapse is not a life threatening condition, and not all prolapses get worse; some may improve. If you have been told that you have a pelvic organ prolapse you may have the following choices:
• do nothing and wait and see how your symptoms change
• adopt good bladder and bowel habits
• make lifestyle changes to reduce the downward pressures through your pelvis e.g. weight loss, no heavy lifting
• improve the strength of your pelvic floor muscles to increase the vaginal support
• try a vaginal pessary which will support the vaginal walls (see glossary)
• have an operation if the doctor has suggested that this might help
It is important to avoid constipation. This puts extra strain on the pelvic floor muscles and can worsen prolapse symptoms. Eating plenty of fruit, vegetables and fibre can help. Make sure you are also drinking enough (between 1.5 to 2 litres of fluid per day).
• do not strain
• sit fully on the toilet: do not ‘hover’
• have your feet apart and raised up on a stool/support, with your arms resting comfortably on your legs
• keeping your tummy relaxed; don’t tighten your abdominals
• avoid breath holding; try to have a relaxed breathing pattern
• a slight bearing down will help the stool to open the back passage for the bowel movement
• do not rush to pee ‘just in case’, but try to go when your bladder needs emptying
• after peeing, you may also find it helpful to lean forward and back several times to help make sure that all the urine comes out
• do not push or strain to empty your bladder; you might increase the prolapse
• try not to reduce your daily fluids to avoid frequency
Some women may find it helpful to support the perineum (the area between the back passage and the vagina) when emptying their bowels. Applying some pressure vaginally on the bulging wall towards the back passage may help to empty the bowels more fully and effectively.
Having sex with a prolapse is safe and will not damage or make the bulge worse. It may help to try different positions for sexual intercourse, and use a suitable lubricant to help with vaginal dryness and discomfort with penetration
Being overweight puts extra strain on the pelvic floor muscles. Your symptoms may improve if you lose weight.