Pelvic Organ Prolapse

Pelvic organ prolapse is common, affecting 1 in 10 women over the age of 50 years. Mild

prolapse often causes no symptoms and treatment is not always necessary. Prolapse can affect quality of life by causing discomfort. You may also experience a feeling of

heaviness or a dragging sensation in the pelvis which may get worse as the day progresses.

It can also cause bladder and bowel symptoms, and having sex may feel different.

Prolapse symptoms can be reduced with lifestyle changes, including stopping smoking, weight loss, avoiding constipation where possible and heavy lifting. Treatment choices for prolapse include physiotherapy, support pessaries or surgery. Your choice of treatment will depend on how the prolapse affects your quality of life. Not everyone with prolapse needs surgery or any other form of treatment. 

Treatment for prolapse aims to support the pelvic organs and helps to ease your symptoms. It does not always cure the problem completely and prolapse may return. 

What is 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 are weakened, the pelvic organs can bulge (prolapse) from their natural position down into the vagina and this is known as pelvic organ prolapse. 

What are the different types of prolapse? 

There are different types of prolapse depending on which pelvic organ is bulging into the vagina. It is common to have more than one type of prolapse at the same time. The prolapse can be of various degrees (grades or stages) depending on how far down the prolapse is coming. It is important to distinguish between the different types and degree of pelvic organ prolapse as their symptoms and treatment may differ.

The most common types of pelvic organ prolapse are: 

-Anterior vaginal wall prolapse: when the bladder and/or urethra bulges into the front wall of the vagina. This is also called a cystocele or cystourethrocele. 

-Posterior vaginal wall prolapse: when the rectum (lower part of the large bowel) bulges into the back wall of the vagina, also called a rectocele. The small bowel may also bulge into the back wall of the vagina, this is called an enterocele. 

-Uterine prolapse: when the uterus drops or sags down into the vagina. Eventually, the uterus may protrude outside the body and if the whole uterus is completely outside the vagina this is called a procidentia. 

-Vault prolapse: when the top of the vagina (or vault) bulges down. This can happen if you have had a hysterectomy and may develop in up to 1 in 10 women. 

How common is pelvic organ prolapse? 

It is difficult to know exactly how many women are affected by prolapse since many do not see their doctor for it. However, it appears to be very common, especially in the older age group. In women over the age of 50 years, 1 in 10 will have some symptoms of pelvic organ prolapse. 

Why does pelvic organ prolapse happen? 

Pelvic organ prolapse can happen when the pelvic floor weakens. A weak pelvic floor can be due to the following: 

• pregnancy and childbirth
• ageing – prolapse is more common as you get older, particularly after your menopause
• being overweight
• persistent constipation, coughing or heavy lifting
• a natural tendency to develop prolapse 

Often it is a combination of these factors that result in you having a prolapse. 

What are the symptoms of pelvic organ prolapse? 

Your symptoms will depend on the type and degree of your prolapse. The following is a list of possible symptoms: 

-You may not have any symptoms at all. 

-You may feel a bulge or a dragging sensation in the vagina. You may also have backache, heaviness or discomfort inside your vagina. These symptoms are often worse if you have been standing for a long time and may improve on lying down. 

-You may be able to feel or see a bulge in your vagina. 

-You may need to pass urine more frequently and urgently. Also, you may have difficulty in passing urine or a sensation that your bladder is not emptying properly. 

-You may leak urine when coughing, laughing; lifting heavy objects or you may have frequent bladder infections (cystitis).

-You may notice constipation or incomplete bowel emptying. You may sometimes need to press on the bulge with your fingers to help open your bowels. 

-You may be anxious about sex, find it uncomfortable or notice a lack of sensation during intercourse. 

Some of the above symptoms may not be directly related to your prolapse. 

How is prolapse diagnosed? 

Prolapse is diagnosed by performing an internal examination. Your healthcare professional will examine your vagina using a speculum to see exactly which organ(s) is bulging. You may be asked to lie on your side with your knees drawn up towards your chest for this examination or you may be examined standing up. Prolapse is staged from 1 to 4 depending on the degree of the prolapse. Women with Stage 1 usually have mild or no symptoms and rarely need treatment. 

Will I need any tests? 

You will be offered a urine test to check for infection. If you have bladder symptoms, like leaking urine or being unable to empty your bladder fully, your doctor may advise a bladder scan and may check how your bladder is working using tests known as urodynamics. 

Do I have to have treatment? 

No. You may choose not to have any treatment or be advised to take a ‘wait and see’ approach. Prolapse is not life threatening, but it may affect the quality of your life.

Your symptoms may stay the same, get worse or sometimes even improve over time. 

What are my options for treatment? 

Your options for treatment will depend on the type and degree of prolapse you have and your individual circumstances, such as age, general health, whether you are sexually active and whether you have completed your family. Your options include: 

-Lifestyle changes: 

• losing weight if you are overweight
• managing a long-standing cough if you have one
• stopping smoking
• avoiding constipation
• avoiding heavy lifting
• avoiding physical activity that impacts on the pelvic floor, like running or trampolining. 

Pelvic floor muscle exercises: to strengthen your pelvic floor muscles you may be referred to a specialist women’s health physiotherapist for a course of physiotherapy treatment (3–6 months). Pelvic floor exercises may not get rid of your prolapse, but are likely to improve your symptoms. Even if you are considering surgical treatment, it is advisable to continue with pelvic floor muscle training to improve your overall chances of successful treatment.

Even if you do not currently have any symptoms, you may wish to consider pelvic floor exercises and lifestyle changes to prevent your prolapse getting worse. 

Vaginal hormone treatment (estrogen): if you have gone through the menopause, your doctor may recommend vaginal estrogen treatment in the form of tablets, cream or a ring that is inserted into your vagina. Estrogen treatment can help to reduce the discomfort you may experience from having a prolapse. 

Vaginal support pessary: a pessary is a plastic or silicone device which fits into your vagina to help support the pelvic organs. This can be an effective way of helping your symptoms. A pessary is suitable for most people. You may choose this option if you are thinking about having children in the future, you do not wish to have surgery or you have a medical condition that makes surgery more risky. You may also choose to use a pessary while you are waiting to have surgery. 

There are different types and sizes of pessaries, and your doctor or specialist nurse will advise which one will suit you best. Ring pessaries are most commonly used. 

Identifying the correct pessary may take more than one attempt as there are many different sizes and shapes. Pessaries should be changed or removed, cleaned and reinserted every 4–6 months. This can be done by your doctor. 

Pessaries do not usually cause any problems but can sometimes cause infection, discharge, bleeding or ulceration. Very rarely, the pessary may get stuck. If you have any concerns, you should see your doctor. It is possible to have sex with certain types of pessaries in place, but you and your partner may occasionally be aware of it. Some women may choose to remove it before having sex and reinsert it afterwards. 

Surgery: 

Whether you choose to have surgery will depend on how severe your symptoms are and how your prolapse affects your daily life. You may want to consider surgery if other options have not helped. 

There are risks with any surgery. These risks are higher if you are overweight, smoke or have medical problems. Your doctor will discuss this with you so you can decide whether you wish to go ahead with your surgery. 

If you plan to have children, you may be advised to delay surgery until your family is complete. This is because another pregnancy and birth may increase the chance of your prolapse happening again. 

What are the different types of surgery? 

There are many different types of surgery for prolapse. Your gynaecologist can advise which surgery is best for you. This will depend on your type of prolapse and symptoms, as well as your age, general health, your wish to have sexual intercourse and whether or not you have completed your family. If there is more than one choice, your gynaecologist will explain the pros and cons of each.

Surgery for prolapse is usually performed through the vagina but may involve keyhole surgery or a cut in your abdomen (tummy). You may occasionally be referred to a specialist unit. 

Hope you found this information helpful.