Pelvic organ prolapse

Also called vaginal prolapse or genitourinary prolapse

Pelvic organ prolapse is a condition in women where the organs that are usually housed in the pelvis (womb, bladder and rectum) slip down from their usual position, into the vagina.

Mild pelvic organ prolapse often causes no symptoms and treatment is not always necessary. But sometimes a prolapse may be large enough to cause a bulge in the vagina.

Why does pelvic organ prolapse happen?

The pelvic organs are held in place by ligaments and pelvic floor muscles. If the ligaments are torn or stretched for any reason, and if your pelvic floor muscles are weak, then your pelvic organs might not be held in their right place and they may bulge or sag down into the vagina.

What causes pelvic organ prolapse?

Pelvic organ prolapse is caused by either a weakness in the supports of the pelvis or by an increase in the pressure inside the abdominal cavity.

The most common causes of weakness of the supports are:

  • Pregnancy and childbirth
  • Aging and menopause
  • Hysterectomy
  • A genetic tendency

The most common causes of an increase in abdominal pressure are:

  • Being overweight
  • Constipation
  • Excessive coughing

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

Being pregnant and giving birth

This is the most common cause of weakening of the pelvic floor support muscles, especially if your baby was large, you had an assisted birth (forceps/ventouse) or your labour was very long.

The more births a woman has, the more likely she is to develop a prolapse in later life; however, you can still get a prolapse even if you haven’t given birth.

Performing pelvic floor exercises is very important after childbirth but may not prevent prolapse from occurring and will not restore a large prolapse. 

Ageing and menopause

Prolapse is more common as women get older, particularly after menopause.

A decrease in the female hormone oestrogen, that occurs after the menopause affects the pelvic floor muscles and structures around the vagina, making them less springy and supportive.

What are the different types of pelvic organ prolapse?

There are different types of prolapse depending on which pelvic organ might have dropped down into the vagina.

  • Cystocele – this is the name often used if the prolapse involves the urethra (the tube through which urine passes from the bladder to the outside). This is the most common type of prolapse.
  • Uterine prolapse – this is the second most common type and is the name if there is prolapse of the womb (uterus) into the vagina. 
  • Rectocele – name used if the prolapse involves the rectum (the back passage or bottom).

What are the signs of pelvic organ prolapse?

There are a number of signs that you may have a prolapse. These signs depend on the type of prolapse and how much pelvic organ support has been lost.

If the prolapse is mild, you may not know you have a prolapse as there will be no symptoms, but your doctor or nurse might be able to see your prolapse when you have your routine cervical smear test.

When a prolapse is larger, you may notice things such as:

  • a heavy sensation or dragging in the vagina
  • something ‘coming down' or a lump in the vagina
  • a lump bulging out of your vagina, which you see or feel when you are in the shower or having a bath
  • sexual problems of pain or less sensation
  • your bladder might not empty as it should or your urine stream might be weak
  • urinary tract infections might be reoccurring
  • it might be hard for you to empty your bowel.

These signs can be worse at the end of the day and may feel better after lying down. If the prolapse bulges right outside your body, you may feel sore and bleed as the prolapse rubs on your underwear. 

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.

How is pelvic organ prolapse treated?

If you only have a mild prolapse or have no symptoms from your prolapse, you may choose or be advised to take a ‘wait and see’ approach. However, the following may ease your symptoms and stop your prolapse from becoming worse:

  • Lifestyle changes:
    • losing weight if you are overweight
    • managing a chronic cough if you have one; stopping smoking will help
    • avoid constipation and straining when passing poos; talk to your doctor about ways of helping and treating constipation
    • avoid heavy lifting; you may wish to talk to your employer if your job involves heavy lifting
    • avoid physical activity such as trampolining or high-impact exercise.
  • Pelvic floor exercises may help to strengthen your pelvic floor muscles.
  • Vaginal hormone treatment (oestrogen) – if you have a mild prolapse and you have gone through the menopause, your doctor may recommend oestrogen cream applied to your vagina for 4 to 6 weeks. This may help any feelings of discomfort that you may have. However, sometimes symptoms may return once the cream is stopped.

If your symptoms are more severe, your doctor will discuss the following treatment options with you:

  • Ring pessary – having a pessary (a plastic or rubber device that fits into your vagina) carefully measured and placed into the vagina to provide inside support for your pelvic organs. This is called a ring pessary. Read more about ring pessaries.
  • Surgery – an operation can be done to repair the torn or stretched ligaments. This can be done through the vagina or the tummy. Sometimes special mesh is used to strengthen it where it is weak or torn. Your doctor can talk you through the pros and cons of using mesh. 

Learn more

The following links provide further information on pelvic organ prolapse. Be aware that websites from other countries may contain information that differs from New Zealand recommendations.

Pelvic organ prolapse Continence NZ
Pelvic organ prolapse Royal College of Obstetricians & Gynaecologists (UK) 
Genitourinary prolapse Patient Info, UK 
Surgical mesh implants Medsafe NZ
Surgical mesh implants – what you need to know FDA USA

References

Pelvic organ prolapse American Family Physician, 2010
Vaginal prolapse The Royal Women's Hospital, Victoria Australia

Credits: Editorial team. Reviewed By: Dr J Tuohy, Obstetrician & researcher Last reviewed: 05 Dec 2016