Pelvic Organ Prolapse

Pelvic organ prolapse (POP) occurs when the pelvic floor muscles and connective tissue weaken or tear, causing one or more of the pelvic organs (bladder, urethra, uterus and/or rectum) to fall downward into the vagina. Many women with prolapse experience no symptoms. For other women, symptoms may include a feeling of pressure on or in the vagina, not being able to wear a tampon (or feeling like a tampon is always half in and half out), pelvic pain, lower back pain, pain during sex, vaginal dryness or irritation, trouble urinating or having bowel movements, and urinary or fecal incontinence. As prolapse progresses, women may feel or see tissue coming out of the opening of their vagina.

There are various types of pelvic organ prolapse, including:
  • Bladder Prolapse (Cystocele) or Urethral Prolapse (Urethrocele): The front, or anterior, wall of the vagina sags downward or outward, allowing the bladder and/or urethra to drop from their normal position.
  • Enterocele: Support to the top of the vagina weakens, allowing bulging of the small intestine into the vagina.
  • Rectocele: The rectum bulges upward into the vagina because of a weakened lower vaginal wall and perineum (area of the pelvic floor between the vagina and the anus).
  • Uterine Prolapse: The supports to the uterus and upper vagina weaken, allowing the uterus to slide down into the vaginal canal or beyond the vaginal opening.
  • Vaginal Vault Prolapse: Upper support of the vagina weakens in a woman who has had a hysterectomy, allowing the vaginal walls to sag into the vaginal canal or beyond the vaginal opening.

Pelvic organ prolapse is quite common and isn’t necessarily dangerous. Women with pelvic organ prolapse who aren’t experiencing any discomfort may choose to monitor their symptoms over time, as POP may stay the same for years. If a woman is bothered by her symptoms, POP should not be considered “a part of aging”—a there are many treatments that can be helpful to reduce or eliminate symptoms.
Behavior:
  • Do not strain with bowel movements. If constipated, loosen stools with a natural laxative, such as apple juice or prune juice. Hot water and coffee may also help stimulate bowel movements. Eat plenty of fiber, and exercise regularly. For moderate to severe constipation, consult your health care provider for options for treatment.
  • As long as sex isn’t causing pain, you don’t need to avoid sex due to prolapse. Sex won’t cause prolapse to become more severe. On the contrary, some forms of sexual activity can exercise the pelvic floor muscles and replace prolapsed organs to their appropriate position.

Diet:
  • Prevent constipation by eating a healthy, balanced diet high in fiber. Fruits, vegetables and whole grains are all good sources of dietary fiber. If constipation is still a problem, consider adding a fiber supplement to your daily regime.
  • Drink plenty of water. Aim for 60-80 ounces a day.

Exercise:
  • Avoid extreme weight lifting and repeated heavy lifting.
  • Kegel exercises, which consist of repeatedly contracting (squeezing) and releasing pelvic floor muscles, can help with mild POP symptoms and sometimes can help prevent prolapse from occurring in the first place.

Lifestyle Factors:
  • Maintain a healthy weight. If you’re overweight, try to get down to a healthy weight with diet and exercise.
  • If you’re a smoker, please quit. This is one of the most positive steps you can take to improve your overall health. Smoking doubles your risk for pelvic floor disorders, including POP.
  • Pelvic Floor Physical Therapy: A pelvic floor physical therapist will use a variety of specialized techniques to improve the symptoms caused by POP and the bladder and/or bowel problems caused by POP.

  • Vaginal Devices (Pessary): A pessary is a silicone device inserted into the vagina. Pessaries lift the bladder, uterus, or vaginal walls and prevent the bulge from coming down. Pessaries come in various sizes and shapes and are individually fitted to ensure that they are comfortable and supportive for the type of prolapse that is diagnosed.

  • Surgery: Several different types of POP surgeries can improve pelvic floor anatomy:
    • Apical suspension: This procedure restores the support of the top of the vagina. If you have a uterus, this surgery can be done at the same time as a hysterectomy or in some circumstances the uterus and/or cervix can be left in place. Sexual function is possible after this surgery. There are many types apical suspension, including:
    • Sacral colpopexy: Performed through an abdominal incision, laparoscopically or robotically. The surgeon attaches a strip of mesh material from the vagina to a strong ligament on the sacrum (the back bone between the hips).
    • Uterosacral or sacrospinous ligament suspension: Performed through the vagina with no abdominal incisions and no mesh. The surgeon stitches the top of the vagina to ligaments in the pelvis.
    • Anterior vaginal prolapse repair: This surgery uses an incision in the wall of the vagina underneath the bladder to fix a cystocele. Sutures are used for the repair to fix defects in the supporting tissue beneath the bladder.

  • Posterior vaginal prolapse repair: This surgery uses an incision in the wall of the vagina over the rectum to fix a rectocele. It rebuilds the wall between the vagina and rectum using sutures in the supporting tissue and muscles.

  • Obliterative procedures (colpocleisis and colpectomy): These surgeries close and shorten the vagina by removing the skin of the vagina and sewing the inside vaginal walls together. This type of surgery is less invasive and has a higher success rate than pelvic reconstruction. After this procedure you will no longer be able to have anything placed inside the vagina including during sexual activities or for medical procedures like ultrasound.
What causes pelvic organ prolapse?
Causes of prolapse include pregnancy and childbirth, loss of estrogen during menopause, repeated heavy lifting, genetics, and certain health conditions that involve repeated straining of the pelvic muscles, including obesity, chronic cough and constipation.

How common is pelvic organ prolapse?
Pelvic organ prolapse is a very common problem. About 1 in 3 women who have given birth vaginally have prolapse, and about 200,000 surgeries are done each year in the U.S. to correct POP. Prolapse is particularly common among women who have had a large baby, needed forceps to deliver or have had many vaginal births.

What are the risk factors for pelvic organ prolapse?
Genes do play a role in prolapse, so if your mother, grandmother, aunts or sisters had POP, you may be at increased risk of prolapse. Additional risk factors include aging, obesity, a history of extreme weight lifting or jobs that require heavy lifting. Having a hysterectomy may also increase your risk of POP, depending on how the surgery was performed. In most cases, women with POP have two or more risk factors.

How is pelvic organ prolapse diagnosed?
A urogynecologist will first review your medical history and then perform a pelvic exam to look for any lesions, masses or ulcers, and to identify any prolapsed organs. They will likely then also perform a rectal exam to look for any abnormalities in that region. Depending on what they find, they may recommend more tests, including UTI screening, urodynamic testing or an ultrasound.

Are some types of pelvic organ prolapse worse than others?
POP refers to a displacement of one or more of the pelvic organs, and these displacements are typically staged on a scale of 0 to 4, with 0 being no prolapse and 4 being total prolapse (also called procidentia). So, a stage 4 prolapse is “worse,” or more pronounced, than a stage 0 prolapse, but prolapse that is causing distressing symptoms that negatively impact your quality of life or overall health is prolapse worth treating.

What happens if pelvic organ prolapse is left untreated?
Left untreated, prolapse almost always gets worse over time, but usually gradually—over years or decades, not months. The exception is “new” prolapse, or prolapse that is noticed right after the birth of a baby. This will often get better within the first year after delivery.

In the vast majority of cases, the decision to treat rests with the woman experiencing symptoms and depends on how her prolapse is affecting her quality of life. In rare cases severe POP can cause urinary retention, in which urine backs up into the kidneys, resulting in kidney damage or infection. In these cases, treating POP is considered mandatory.

What is surgical mesh?

Surgical mesh is a medical device that is generally used to repair weakened or damaged tissue. In gynecological procedures to repair POP, surgical mesh is permanently implanted to reinforce the weakened vaginal wall. If you decide on surgery, your surgeon will discuss if surgical mesh is appropriate for you.

What is the success rate of surgery for pelvic organ prolapse?
Many factors can affect the outcome of any particular surgery, including decreased muscle and nerve function, the condition of the connective tissues due to age, genetics, prior trauma and medical conditions that affect healing. However, in general, procedures to correct POP are successful 80%-95% of the time. It is important to discuss with your surgeon the symptoms that bother you the most, and whether prolapse surgery will improve or eliminate these symptoms.