The network of muscles, ligaments, and skin in and around a woman’s vagina acts as a complex support structure that holds pelvic organs, tissues, and structures in place. This support network includes the skin and muscles of the vaginal walls (a network of connective tissues called the fascia). Various parts of this support system may eventually weaken or break, causing a common condition called pelvic organ prolapse.
Pelvic organ prolapse is a condition in which structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself may begin to prolapse, or fall, out of their normal positions. Without medical treatment or surgery, these structures may eventually fall farther into the vagina or even through the vaginal opening if their supports weaken enough.
The symptoms that result from pelvic organ prolapse commonly affect sexual functions and bodily functions such as urination and defecation. Pelvic pressure and discomfort are also common symptoms.
The following are types of pelvic organ prolapse:
- Rectocele (prolapse of the rectum). This involves a prolapse of the back wall of the vagina (rectovaginal fascia). When this wall weakens, the rectal wall pushes against the vaginal wall, creating a bulge. This bulge may become especially noticeable during bowel movements.
- Cystocele (prolapse of the bladder, bladder drop). This can occur when the front wall of the vagina (pubocervical fascia) prolapses. As a result, the bladder may prolapse into the vagina. When this condition occurs, the urethra usually prolapses, as well. A urethral prolapse is also called a urethrocele. When both the bladder and urethra prolapse, this condition is known as a cystourethrocele. Urinary stress incontinence (urine leakage during coughing, sneezing, or exercise, for example) is a common symptom of this condition.
- Enterocele (herniated small bowel). The weakening of the upper vaginal supports can cause this type of prolapse. This condition primarily occurs following a hysterectomy. An enterocele results when the front and back walls of the vagina separate, allowing the intestines to push against the vaginal skin.
(womb). This involves a weakening of a group of ligaments called the uterosacral ligaments at the top of the vagina. This causes the uterus to fall, which commonly causes both the front and back walls of the vagina to weaken, as well. The following are stages of uterine prolapse:
- First-degree prolapse: The uterus droops into the upper portion of the vagina.
- Second-degree prolapse: The uterus falls into the lower part of the vagina.
- Third-degree prolapse: The cervix, which is located at the bottom of the uterus, sags to the vaginal opening and may protrude outside the body.
- Fourth-degree prolapse: The entire uterus protrudes entirely outside the vagina. This condition is also called procidentia, or complete prolapse.
- Vaginal vault prolapse. This type of prolapse may occur following a hysterectomy, which involves the removal of the uterus. Because the uterus provides support for the top of the vagina, this condition is common after a hysterectomy, with upwards of 10% of women developing some degree of vaginal vault prolapse after undergoing one. In vaginal vault prolapse, the top of the vagina falls toward the vaginal opening. This may cause the walls of the vagina to weaken as well. This could progress and the top of the vagina may protrude out of the body through the vaginal opening, effectively turning the vagina inside out. A vaginal vault prolapse often accompanies an enterocele.
Approximately 30%-40% of women develop some presentation of pelvic organ prolapse in their lifetime, usually following menopause, childbirth, or a hysterectomy. Most women who develop this condition are older than 40 years. Many women who develop symptoms of a prolapse do not seek medical help because of embarrassment or other reasons. Some women who develop a prolapse do not experience symptoms.
Causes of Pelvic Organ Prolapse
A network of muscles provides the main support for the pelvic viscera (the vagina and the surrounding tissues and organs within the pelvis). This network, which is located below most of the pelvic viscera and supports the viscera’s weight, is called the levator ani. Pelvic ligaments provide additional stabilizing support.
When parts of this support network are weakened or damaged, the vagina and surrounding structures may lose some or all of the support that holds them in place. Collectively, this condition is called pelvic floor relaxation. A pelvic organ prolapse occurs when the weight-bearing or stabilizing structures that keep the vagina in place weaken or deteriorate. This may cause the supports for the rectum, bladder, uterus, small bladder, urethra, or a combination of them to become less stable.
Common factors that may cause a vaginal prolapse include the following:
- Childbirth (especially multiple births): Childbirth is stressful to the tissues, muscles, and ligaments in and around the vagina. Long, difficult labors and large babies are especially stressful to these structures. Childbirth is the risk factor most commonly associated with cystoceles. A cystocele is a condition in which the bladder prolapses into the vagina. A cystocele is usually accompanied by a urethrocele, in which the urethra becomes displaced and prolapses. A cystocele and urethrocele together are called a cystourethrocele.
- Menopause: Estrogen is a hormone that helps to keep the muscles and tissues of the pelvic support structure strong. After menopause, the estrogen level decreases; this means that the support structures may weaken.
- Hysterectomy: The uterus is an important part of the support structure at the top of the vagina. A hysterectomy involves removing the uterus. Without the uterus, the top of the vagina may gradually fall toward the vaginal opening. This condition is called a vaginal vault prolapse. As the top of the vagina droops, added stress is placed on other ligaments. Hysterectomy is also commonly associated with a condition called an enterocele, in which the small bowel herniates near the top of the vagina.
Other risk factors of pelvic organ prolapse include the following:
- Advanced age
- Dysfunction of the nerves and tissues
- Abnormalities of the connective tissue
- Strenuous physical activity
- Prior pelvic surgery
Symptoms of Pelvic Organ Prolapse
The symptoms associated with a pelvic organ prolapse depend on the type and degree of prolapse present. The most common symptom of all types of prolapse is the sensation that tissues or structures in the vagina are out of place. Some women describe the feeling as "something coming down," "something is falling out,” or as a dragging sensation. This may involve a protrusion or pressure in the area of the sensation. Generally, the more advanced the prolapse, the more severe the symptoms.
The following are general symptoms of all types of pelvic organ prolapse:
- Pressure in the vagina or pelvis
- Painful intercourse (dyspareunia)
- A lump at the opening of the vagina
- A decrease in pain or pressure when the woman lies down
- Recurrent urinary tract infections
The following are symptoms that are specific to certain types of prolapse:
- Difficulty emptying bowel -- This may be indicative of an enterocele, rectocele, vaginal vault prolapse, or prolapsed uterus. A woman with difficulty emptying her bowel may find that she needs to place her fingers on the back wall of the vagina to help evacuate her bowel completely. This is referred to as splinting.
- Difficulty emptying bladder --This may be indicative of a cystocele, urethrocele, enterocele, vaginal vault prolapse, or a prolapsed uterus.
- Constipation -- This is the most common symptom of a rectocele.
- Urinary stress incontinence -- This is a common symptom of a cystocele.
- Pain that increases during long periods of standing -- This may be indicative of an enterocele, vaginal vault prolapse, or a prolapsed uterus.
- Protrusion of tissue at the back wall of the vagina -- This is a common symptom of a rectocele.
- Protrusion of tissue at the front wall of the vagina -- This is a common symptom of a cystocele or urethrocele.
- Enlarged, wide, and gaping vaginal opening -- This is a common symptom of a vaginal vault prolapse.
Some women who develop a pelvic organ prolapse do not experience symptoms.
When to Seek Medical Care
Any woman who experiences symptoms that may indicate a prolapse should contact her doctor. A prolapse is rarely a life-threatening condition. However, prolapses may gradually worsen. Thus, timely medical care is recommended to evaluate for and to prevent problematic symptoms and complications caused by weakening tissue and muscle in the vagina.
Exams and Tests for Prolapse
Generally, the most reliable way that a doctor can make a definite diagnosis of any type of prolapse involves a medical history and physical exam of the woman. This involves the doctor examining each section of the vagina separately to determine the type and extent of the prolapse and what type of treatment is most appropriate.
During the physical exam, the woman may need to sit in an upright position or stand and strain so that any prolapsed tissues are more likely to become apparent.
Some types of prolapse such as cystocele or rectocele are more easily identifiable during the physical exam than are types such as vaginal vault prolapse or enterocele.
The following are tests that the doctor may use to evaluate women with advanced pelvic organ prolapse. Since many of these women also have urinary incontinence, these tests can further evaluate the anatomy and function of the pelvic floor.
- Q-tip test: In this diagnostic test, the doctor inserts a small cotton-tipped applicator lubricated with an anesthetic gel into the woman’s urethra. The doctor then asks the woman to strain down. If the applicator raises 30 degrees or more as a result, this means that the urethra-bladder neck drops while straining and is a predictive factor of success of anti-incontinence surgery.
- Bladder function test: This involves a diagnostic procedure called urodynamics. This tests the ability of the bladder to store urine and to dispose of it (urinate). The first step of this test is called uroflowmetry, which involves measuring the amount and force of the urine stream. The second step is called a cystometrogram. In this step, a catheter is inserted into the bladder. The bladder is then filled with sterile water. The volume at which the patient experiences urgency and fullness are recorded. The pressures of the bladder and urethra are measured and the patient is asked to cough or bear down to elicit leakage with the prolapse pushed up (reduced). This is important information that may assist the surgeon in selecting the correct type of surgery.
- Pelvic floor strength: During the pelvic exam, the doctor tests the strength of the woman’s pelvic floor and of her sphincter muscles. The doctor also assesses the strength of the muscles and ligaments that support the vaginal walls, uterus, rectum, urethra, and bladder. These findings help the doctor determine if the woman would benefit from exercises to restore the strength of the muscles of the pelvic floor (for example, Kegel exercises).
The following are imaging tests the doctor may use for further diagnostic purposes, if indicated:
- Ultrasound: This diagnostic tool uses sound waves. Sound waves are reflected back when they contact relatively dense structures, such as fibrous tissue or blood vessel walls. These reflected sound waves are then converted into pictures of the internal structures being studied. With an ultrasound, the doctor may visualize the bladder in women with urinary incontinence or the muscles around the anus in women with anal incontinence.
- Cystourethroscopy: A cystoscope, which is a small, tube-like instrument, is lubricated with an anesthetic gel and inserted into the urethra. The end of the cystoscope has a light and camera, which produces images on a television screen. With this procedure, the doctor can view inside the urethra and bladder. This procedure is especially valuable for women who have symptoms of urinary urgency, frequency, bladder pain, or blood in the urine. It can be performed in the office using local anesthesia.
Treatment for Pelvic Organ Prolapse
Most worsening pelvic organ prolapses can only be fully corrected with surgery. However, the type of treatment that is appropriate to treat prolapse depends on factors such as the cause and severity of the prolapse, whether the woman is sexually active, and the woman’s treatment preference.
- Nonsurgical options may be most appropriate for women who are not sexually active, cannot undergo surgery because of medical reasons, or experience few or no symptoms associated with the condition.
- Surgery is the treatment option that most sexually active women who develop prolapse choose, because the procedure is usually effective and allows sexual activity.
Home Care for Pelvic Organ Prolapse
Home treatments for vaginal prolapse include one or a combination of the following:
- Activity modification: For a prolapse that causes minor or no symptoms, the doctor may recommend activity modification such as avoiding heavy lifting or straining.
- Pessary: A pessary is a small device, usually made of silicone, that is placed within the vagina for support. Pessaries come in several sizes and shapes. This nonsurgical treatment option may be the most appropriate for women who are not sexually active, cannot have surgery, or plan to have surgery but need a temporary nonsurgical option until surgery can be performed (such as women who are pregnant or in poor health). Pessaries must be removed and cleaned at regular intervals to prevent infection. Some pessaries are designed to allow the woman to do this herself. A doctor must remove and clean other types. Estrogen cream is commonly used along with a pessary to help prevent infection and vaginal wall erosion. Some women find that pessaries are uncomfortable or that they easily fall out.
- Kegel exercises: These are exercises used to tighten the muscles of the pelvic floor. Kegel exercises might be used to treat mild-to-moderate cases of prolapse or to supplement other treatments for prolapses that are more serious.
Medications for Pelvic Organ Prolapse
Estrogen replacement therapy may be used to help the body strengthen the muscles in and around the vagina. The therapy may not be an option for some women (such as in those with certain types of cancer). Women’s bodies stop creating estrogen naturally after menopause, and the muscles of the vagina may weaken as a result. In mild cases of prolapse, estrogen may be prescribed in an attempt to reverse prolapse symptoms, such as vaginal weakening and incontinence. For more severe prolapses, estrogen replacement therapy may be used along with other types of treatment.
Pelvic Organ Prolapse Surgery
A generalized weakness of the vaginal muscles and ligaments is much more likely to develop than are isolated defects. If a woman develops symptoms of one type of pelvic organ prolapse, she is likely to have or develop other types, as well. Therefore, a thorough physical exam is necessary for the surgeon to detail what steps are necessary to correct the prolapse completely. The typical surgical strategy is to correct all vaginal weaknesses at once.
Surgery is usually performed while the woman is under general anesthesia. Some women receive a spinal epidural. The type of anesthesia given usually depends on how invasive and lengthy the surgery is expected to be.
Laparoscopic surgery is a minimally invasive surgical procedure that involves slender instruments and advanced camera systems. This surgical technique is becoming more common for securing the vaginal vault after a hysterectomy and correcting some types of prolapse such as enteroceles or uterine prolapses.
- Vaginal vault prolapse: This is a defect that occurs high in the vagina, so it may entail a surgical approach through the vagina or abdomen. The surgical correction of this condition usually involves a technique called a vaginal vault suspension, in which the surgeon attaches the vagina to strong tissue in the pelvis or to a bone called the sacrum, which is located at the base of the spine.
- Prolapsed uterus: For women who are postmenopausal or do not want to have more children, a prolapsed uterus is usually corrected with a hysterectomy. The common approach for this procedure is through the vagina.
- Cystocele and rectocele: These are corrected through the vagina. Typically, the surgeon makes an incision in the vaginal wall and pushes the organ up. The surgeon then secures the vaginal wall to secure the organ in its normal position. Any excess tissue is then removed, and the vaginal wall is closed. If urinary incontinence is present, the surgeon may need to support the urethra. This usually involves a procedure called a bladder neck suspension.
- In some select cases, a woman may no longer desire to retain the ability to have intercourse. There is a surgery called a LeForte procedure in which the internal vagina is sutured closed. This narrowing of the vagina pushes up the prolapsing organs.
Women who undergo surgery for pelvic organ prolapse repair should normally expect to spend one or more days in the hospital, depending on the type and extent of surgery involved. After surgery, women are usually advised to avoid heavy lifting for approximately six to nine weeks.
Other Prolapse Therapy
- Electrical stimulation: A doctor can apply a probe to targeted muscles within the vagina or on the pelvic floor. The probe is hooked up to a device that measures and delivers small electrical currents that contract the muscles. These contractions help strengthen the muscles. A less intrusive type of electrical stimulation is available that magnetically stimulates the pudendal nerve from outside the body. This activates the muscles of the pelvic floor and may help treat incontinence.
- Biofeedback: A sensor is used to monitor muscle activity in the vagina and on the pelvic floor. The doctor can recommend exercises that the woman can use to strengthen these muscles. In some cases, these exercises may help strengthen the muscles enough to reverse or relieve some symptoms related to prolapse. The sensor can monitor the muscular contractions during the exercises, and the doctor may be able to determine if the targeted muscles would benefit from the exercises.
After Prolapse Surgery
After surgery, most women can expect to return to a normal level of activity after one to three months.
Follow-Up Care for Pelvic Organ Prolapse
A woman undergoing treatment for pelvic organ prolapse should schedule follow-up visits with her doctor to evaluate progress. Pessaries need to be removed and cleaned at regular intervals to prevent infection.
Women at risk for prolapse should avoid heavy lifting and, if possible, becoming constipated.
Obesity puts extra stress on the muscles and ligaments within the pelvis and vagina. Weight control may help prevent this condition from developing.
Outlook for Pelvic Organ Prolapse
Pelvic organ prolapse is rarely a life-threatening condition. Some cases that are mild can be treated without surgery, and most severe cases of prolapse can be completely corrected with surgery.
Prolapse surgery results are usually good, with a low recurrence rate.