Pelvic organ prolapse

On this page, you can find the following information:

• Why does pelvic organ prolapse happen?
• What causes pelvic organ prolapse?
• What are the different types of pelvic organ prolapse?
• What are the signs of pelvic organ prolapse?
• How is a prolapse diagnosed?
• How is pelvic organ prolapse treated?

Key points about pelvic organ prolapse

1. Vaginal prolapse or genitourinary prolapse is a condition in women where the organs in your pelvis (uterus, bladder and rectum) slip down from their usual position into your vagina.
2. This is different from a rectal/bowel prolapse where the point of weakness starts in the bowel/rectum not your vagina.
3. Mild pelvic organ prolapse often causes no symptoms and treatment is not always needed.
4. But sometimes a prolapse may be concerning enough to need treatment from a health professional.
5. If you are worried please see your doctor.

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 your vagina.

Image: Canva

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
• ageing and menopause
• hysterectomy
• a genetic tendency.

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

• being overweight
• constipation
• excessive coughing
• excessive exercise or heavy lifting.

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. This makes them less springy and supportive.

What are the different types of pelvic organ prolapse?

The word ‘prolapse’ means a falling down or slipping of a body part from its usual position. There are different types of prolapse depending on which pelvic organ might have dropped down into the vagina.

• Cystocele – this is where there is prolapse of the bladder into the vagina. 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). 
• Enterocele (small bowel prolapse) – occurs when the small bowel presses against and moves the upper wall of the vagina. 
• Vault prolapse – where the top of the vagina comes down after the uterus has been removed via hysterectomy. 

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 weakened or 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. Not all woman undergo regular smear tests, for example if your cervix has been removed, so it is important to recognise these symptoms.

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
• pain during sex
• loss of sensation during sex
• your bladder might not empty as it should or your urine stream might be weak
• recurring urinary tract infections
• 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 a prolapse diagnosed?

To diagnose a prolapse your doctor will need to perform a vaginal examination. You can choose if this happens on your initial visit.  Some people may find this stressful especially for those who previously have had a traumatising experience, particularly a sexual assault. It can be helpful for your doctor to know if this is the case.

The examination will be done in a private and respectful way and you are welcome to bring a support person. A speculum, a plastic or metal instrument, may be inserted. This is used to separate the walls of the vagina so your doctor can see into your vaginal cavity to diagnose exactly which organ(s) are prolapsing.

How is pelvic organ prolapse treated?

You may be told you have a mild prolapse with little or no symptoms, meaning no treatment is needed at this stage. However, some degree of prolapse is quite common and if it doesn't trouble you there's no need to get it regularly checked. There are many self-care tips that you can follow to help prevent further prolapse, ease any symptoms you may have, or prevent the prolapse from becoming bothersome.

Things you can do to improve your symptoms

• If you are overweight losing weight can help.
• Managing a chronic cough if you have one.
• Getting support to quit smoking.
• 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 high-impact or excessive physical activity.
• Pelvic floor exercises may help to strengthen your pelvic floor muscles.
• Your doctor can put you in touch with a pelvic physiotherapist or you can find one here.
• Vaginal hormone treatment (oestrogen) – if you have a mild prolapse and you have gone through menopause, your doctor may recommend applying oestrogen cream to your vagina for 4–6 weeks. This may help any feelings of discomfort that you may have. However, sometimes symptoms 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, but this is not the only or preferred option as there are mesh free alternatives available, like native tissue repair. Your doctor can talk you through the pros and cons of having mesh or non-mesh surgery. It's best to wait until you have completed your family before having surgery. 

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 RANZCOG, NZ
Pelvic organ prolapse Patient Info, UK  
Surgical mesh implants Medsafe, NZ