Vaginal Prolapse

What Is a Vaginal or Pelvic Organ Prolapse (POP)?

Muscles, ligaments and skin, in and around the vagina, support and hold the female pelvic organs and tissues in place by acting as a hammock. However, pregnancy, childbirth, ageing, and the menopause, all contribute to the stretching and weakening of these pelvic floor muscles. The result can be a vaginal prolapse - where the pelvic organs, such as the uterus, rectum, bladder, urethra, small bowel, or even the vagina itself, fall out of their normal position. As a vaginal prolapse usually involves the vagina, plus another organ, it is often referred to as a Pelvic Organ Prolapse (POP).

Around 40% of us will be affected by a vaginal prolapse by the time we reach our 60's, and this figure rises to 50% of us over 50. Although not life-threatening, it can cause severe pain and discomfort, especially in later stages if the prolapse becomes exposed outside of your vagina. So read on to learn about the causes, treatments and preventable measures.

As with most medical problems, it’s important not to put off treatment. Allowing your prolapse to go untreated for a long period of time leads to weakened pelvic muscles and damage to associated nerves - increasing the risk of a prolapse reoccurring. So avoid unnecessary delays and speak to your doctor if you have any concerns.


Types of Vaginal / Pelvic Organ Prolapse

There are many different types of pelvic organ prolapse, each one has a different name depending on the pelvic organ affected:

  • Rectocele prolapse – A prolapse of the back wall of the vagina (the rectovaginal fascia). This occurs when the rectal wall pushes against the vaginal wall, creating a bulge into the vagina. The effects of this bulge may be more noticeable during a bowel movement.
  • Cystocele or bladder prolapse – When the front wall of the vagina weakens, and allows the bladder to protrude into the vagina. If the urethra is also affected, it is called a urethrocele.
  • Enterocele or small bowel prolapse – Also known as a herniated small bowel, this occurs when the upper vaginal supporting muscle becomes weakened. Resulting in the front and back walls of the vagina to separate, allowing the small intestines to push against the vaginal walls.
  • Uterine prolapse – Weakening of the uterosacral ligaments at the top of the vagina can cause the uterus to fall and move downwards. Often, during a prolapsed uterus, both the front and back walls of the vagina start to weaken as well.
  • Vaginal vault prolapse – Around 15% of women who have had a hysterectomy (complete removal of the womb and cervix) suffer a vaginal vault prolapse. The uterus provides support for the top of the vagina, if it is no longer there then the top of the vagina can gradually fall towards the vaginal opening and the vaginal walls weaken. Eventually, the top of the vagina can protrude out through the opening of the vagina.

What Are the Stages of a Vaginal or Pelvic Organ Prolapse?

There are four main stages of a pelvic organ prolapse, as graded using the Pelvic Organ Prolapse Quantification System (POP-Q). The example organ used here is the uterus:

  • First stage uterine prolapse – The uterus drops into the lower part of the vagina but cannot be seen from outside of the vagina.
  • Second stage uterine prolapse – The uterus drops as far as the opening of the vagina but is still not visible from the outside.
  • Third stage uterine prolapse – The cervix, the area between the opening of the uterus and the top of the vagina, is pushed to the outside of the vagina by the collapsing uterus.
  • Fourth stage uterine prolapse – The entire uterus and cervix has dropped so low that it has fallen out of the vagina and is entirely visible from the outside. This is known as a ‘complete prolapse’ or procidentia.

Learn more about the stages of a prolapse here.


What Are the Symptoms of a Vaginal / Pelvic Organ Prolapse?

If you’re developing a vaginal or pelvic organ prolapse, then you may notice an odd feeling inside your vagina, like there’s something inside that is falling out. But it’s important to not feel embarrassed and speak to your doctor. In the early stages of a pelvic organ prolapse you may have no symptoms at all and it therefore may be diagnosed during a routine examination, such as a smear test.

As a prolapse advances, you may experience some or all of the following complaints:

  • a feeling of pressure inside the vagina, especially when sitting down
  • a dragging feeling inside the vagina, and/or feeling that something is going to fall out
  • vaginal bleeding, outside of menstruation
  • an excessively widened vagina, so much so that tampons don’t stay in place
  • noticeable tissue protruding from the vagina, that may also be painful and bleed
  • discomfort or pain during sex
  • loss of feeling or ‘tightness’ when having sex
  • pelvic or lower back pain
  • pain that reduces when you lay down and increases when you stand for a long time
  • persistent or frequent urinary tract infections (cystitis)
  • urinary stress incontinence – the inability to hold in urine when you cough, sneeze, laugh, exercise or lift heavy objects
  • a frequent need to urinate
  • difficulty passing urine
  • difficulty having a bowel movement – constipation and a feeling of not having fully emptied the bowel

With the number of different prolapse conditions and their close proximity to each other in the body, it can be difficult to know which symptoms point to which condition. Visiting your doctor to get a diagnosis is important, and can help you decide which course of treatment is best for you.


What Causes a Vaginal or Pelvic Organ Prolapse?

There are a few risk factors which may lead to you experiencing a vaginal or pelvic organ prolapse:

  • Pregnancy – Around 50% of women who have carried a baby to full term will experience some kind of vaginal prolapse. This is in part due to the extra weight that the baby adds to the pelvic area, which can weaken the pelvic floor muscles. It is also thought to be caused by pregnancy hormones allowing vaginal tissues to stretch beyond their rebound limits. Multiple pregnancies will further increase your risk.
  • Childbirth – Again, around 50% of women who give birth vaginally will experience some level of prolapse. A large baby or a difficult birth where you’ve had to push a lot or forceps were used may increase your risk. More than one birth also increases your risk of experiencing a vaginal prolapse. Mothers who have delivered four babies vaginally are at 12 times greater risk than women who have not given birth vaginally.
  • Menopause – The change in hormones you experience during this time of your life, particularly the drop in oestrogen, can cause your pelvic floor muscles to weaken. Effects can be worsened by the general loss of muscle tone associated with ageing.
  • Body weight – Being overweight or obese can increase your chances of suffering a pelvic organ prolapse due to the weight on your pelvic area causing strain.
  • Genetics – If a family member has suffered a vaginal prolapse, then there may be a genetic reason that puts you at an increased risk.
  • Constipation – Continued straining to pass a stool will put extra pressure on the pelvic floor, and could cause it to weaken.
  • Persistent coughing – Constant heavy coughing can add pressure to the pelvic floor. If you smoke and have a persistent smokers cough or if you have a lung condition that results in a cough, such as asthma or bronchitis, then you could be at a higher risk.
  • Heavy lifting – Repetitive heavy lifting, and lifting incorrectly, increases the pressure put on the pelvic floor.
  • Strenuous activity – Heavy, high impact exercise such as running or plyometric training (jump training) can cause the pelvic floor muscles to weaken.
  • Previous pelvic surgeries – A hysterectomy or previous vaginal prolapse surgery can weaken the pelvic floor muscles, and is likely to be part of the cause of any future pelvic organ prolapses.
  • Pelvic conditions – Heavy fibroids or a tumour somewhere in your pelvis can add weight to the area and weaken the pelvic floor muscles.
  • Hysterectomy – Up to 40% of women who have had a hysterectomy (the complete removal of the womb and cervix) suffer a vaginal vault prolapse. The uterus provides support for the top of the vagina, if it is no longer there, then the top of the vagina can gradually fall towards the vaginal opening and the vaginal walls weaken.


How Can I Prevent a Vaginal or Pelvic Organ Prolapse?

If you think you might be at risk of a vaginal prolapse, there are steps you can take to prevent one:

  • Kegel exercises – Also known as pelvic floor exercises, you can do them quickly and easily at any point in the day as no one will know you’re doing them. They help to strengthen the pelvic floor muscles. You can make them even more effective by using an electronic toner.
  • Maintain your weight – Making sure you stick to a healthy weight will put less pressure on your pelvic floor muscles, giving you more chance of keeping them strong. The National Institute for Heath and Care Excellence (NICE) recommend keeping your BMI under 30.
  • Avoiding constipation – Eating a high fibre diet of fruits, vegetables and wholegrain cereals will help your bowels stay regular, as will drinking plenty of water.
  • Avoid straining on the toilet - Straining on the toilet puts unnecessary pressure on the pelvic floor muscles. Using a toilet stool when you pass a bowel movement will help avoid straining as it puts your body in the optimum position for fully emptying your bowels.
  • Lift heavy weights (and children) safely – Lifting correctly will make all the difference to not only your back, but your pelvic area too. The National Health Service (NHS) suggest holding the load close to your waist and avoid bending your back.
  • Avoid too much high impact exercise – High impact exercises are great for overall health. But if you’re worried about a prolapse, then gentler, lower impact exercise like swimming may be better for you.
  • Treat that cough – Persistent heavy coughing can cause a weakening in the pelvic floor muscles that may not become apparent straight away. Get medical help for a cough that lasts longer than a week or so.

Even if you’re young, of a healthy weight and have no plans to have a baby any time soon, these steps are still worth taking.


What Treatments Are Available for a Vaginal or Pelvic Organ Prolapse?

If you’re suffering through a vaginal prolapse, speak to your doctor about what treatments may work for you. There are numerous different vaginal prolapse treatments that work, and depend on your personal circumstances. Targeted pelvic floor muscle exercises are a popular choice for seeing a quick and effective improvement in your prolapse.

Surgery is considered as an option only when symptoms are severe and cannot be treated through other means, as there is a risk of further damage in the case of complications. Non-surgical treatments are also preferred when future children are desired, which can reduce the success of previous surgical procedures:

  • Pelvic floor exercises – These exercises help to strengthen the pelvic floor. Used in conjunction with an electronic pelvic toner, they could make all the difference.
  • Lifestyle treatments – You may be surprised how much difference losing weight, avoiding constipation, lifting properly, exercising differently or giving up smoking can make.
  • Hormone treatment – Hormone supplements and topical oestrogen creams can help boost the levels of the hormones you may be lacking through menopause or age that weaken the pelvic floor.
  • Wearing a vaginal pessary – A vaginal pessary will help to better support a pelvic organ prolapse. It’s a small device, usually made from silicone, that is placed inside the vagina to help support the vaginal wall and prevent other pelvic organs collapsing further into it. Different shapes and sizes of vaginal pessaries suit different shapes and sizes of women. Your doctor can help you find the right one and help you change the pessary every four to six months. This is commonly the favoured treatment for those unable to undergo surgery due to other medical conditions or those wishing to have children in the future. Pessaries can support even very severe prolapses.

Learn more about non-surgical treatments here.

In the circumstance of non-surgical treatments not fully relieving your symptoms and they remain severe, you may be advised to have surgical intervention for your vaginal prolapse. Several surgical procedures are currently available and may be completed in conjunction to repair all prolapses you are experiencing at once:

  • Hysterectomy - This is the complete removal of the uterus and is often performed in a uterine prolapse emergency or when a uterine prolapse is severe. This can be performed through the vagina, or through the abdomen. The vaginal walls are then attached to healthy ligaments as support for the other organs. This surgery prevents any future pregnancies and is often followed by further pelvic organ prolapses as the uterus is no longer there to support the other pelvic organs, so it is important to consider other options before choosing a hysterectomy.
  • Uterine suspension sling / a uterine or vault suspension (without support) - These surgeries all include a repair where the prolapsed organs are stitched back into place. Most procedures use stitches that dissolve over 4-6 months. However, some procedures, such as the uterine suspension sling, use a synthetic mesh lining for additional support. Using a mesh lining is currently only recommended within the context of research, as current evidence into the safety of the procedure is insufficient.
  • Sacrocolpopexy or sacrospinous fixation - Often recommended when your condition is the result of a previous hysterectomy. A sacrospinous fixation involves the top of the vagina being stitched to the sacrospinous ligament,which is near the tail bone, for support. This procedure has a 70-80% success rate.
  • Obliterative surgery - This surgery can be considered as an extreme option. The surgeon will narrow or close off the vagina to prevent prolapsed organs from prolapsing outside the vagina. This prevents sex intercourse and vaginal childbirth.

It is important to note that surgery is unable to repair the pelvic floor muscles, so you will need to perform pelvic floor exercises after your recovery to prevent the prolapse from returning and to support any synthetic or biological mesh from stretching which could lead to a prolapse recurrence.

To learn more about each surgical option and what other treatments are available, visit our Prolapse Treatment section.


How Long Does It Take to Recover from Vaginal or Pelvic Organ Prolapse Surgery?

Vaginal prolapse surgery is usually carried out under a general anaesthetic, but may require a spinal anaesthetic resulting in numbness to your lower body throughout the operation. Your surgeon will make cuts through your vaginal wall by entering your vagina to access the problem area. Following a sacrospinous fixation, you may be required to spend up to two days in hospital before being discharged. Depending on the pelvic organ involved, and your health, your recovery should take between four to eight weeks. During this period, it is not recommended that you drive or spend prolonged periods sitting.

If you do opt for surgery, it is important to note that surgery cannot repair your pelvic floor muscles. You will need to perform pelvic floor exercises after you recover from your surgery, to prevent the prolapse from recurring and to support any synthetic or biological mesh from stretching. There is a 30% chance of developing a future prolapse following a vaginal surgery, due to the damage to the vaginal tissue. Other non-surgical treatments should also be followed to prevent future prolapses; such as eating well to avoid constipation, and maintaining a healthy weight.

It is important to note that no operation can be guaranteed to cure your prolapse, and some women may experience a reoccurring prolapse, among other symptoms, in the future.

In some cases, the repair of a vaginal prolapse can uncover other related underlying conditions such as damage to the bladder or bowel. Your doctor will discuss whether these require further treatment following your recovery.

Following the recovery from a vaginal prolapse surgery, you may notice different or less sensations during sex. This can be improved by building pelvic floor / Kegel exercises, into your routine. A physiotherapist will be able to advice on the best pelvic floor exercises for you.


Sources

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