Pelvic organ prolapse is bulging of one or more of the pelvic organs into the vagina.
These organs are the uterus, vagina, bowel and bladder.
Symptoms may include:
- a sensation of a bulge or something coming down or out of the vagina, which sometimes needs to be pushed back
- discomfort during sex
- problems passing urine – such as slow stream, a feeling of not emptying the bladder fully, needing to urinate more often and leaking a small amount of urine when you cough, sneeze or exercise (stress incontinence)
Some women with a pelvic organ prolapse don't have any symptoms and the condition is only discovered during an internal examination for another reason, such as a cervical screening.
When to see your GP
Pelvic organ prolapse isn't life-threatening, but it can affect your quality of life.
See your GP if you have any of the symptoms of a prolapse, or if you notice a lump in or around your vagina.
Internal pelvic examination
Your doctor will need to carry out an internal pelvic examination. They'll ask you to undress from the waist down and lie back on the examination bed, while they feel for any lumps in your pelvic area.
Some women may put off going to their GP if they're embarrassed or worried about what the doctor may find. However, the examination is important, only takes a few minutes and is similar to having a smear test.
If you have bladder symptoms, such as needing to rush to the toilet or leaking when you cough and sneeze, further tests may need to be carried out in hospital.
For example, a small tube (catheter) may be inserted into your bladder to examine your bladder function and identify any leakage problems. This test is known as urodynamics.
Your doctor will decide if further tests are needed before treating the prolapse.
Types of prolapse
If pelvic organ prolapse is confirmed, it will usually be staged to indicate how severe it is. Most often, a number system is used, ranging from one to four, with four indicating a severe prolapse.
Pelvic organ prolapse can affect the front, top or back of the vagina. The main types of prolapse are:
- anterior prolapse (cystocele) –where the bladder bulges into the front wall of the vagina
- prolapse of the uterus and cervix or top of the vagina –which can be the result of previous treatment to remove the womb (hysterectomy)
- posterior wall prolapse (rectocoele or enterocoele) –when the bowel bulges forward into the back wall of the vagina
It's possible to have more than one of these types of prolapse at the same time.
Why does prolapse happen?
Prolapse is caused by weakening of tissues that support the pelvic organs. Although there's rarely a single cause, the risk of developing pelvic organ prolapse can be increased by:
- your age – prolapse is more common as you get older
- childbirth, particularly if you had a long or difficult labour, or gave birth to multiple babies or a large baby – up to half of all women who have had children are affected by some degree of prolapse
- changes caused by the menopause – such as weakening of tissue and low levels of the hormone oestrogen
- being overweight, obese or having large fibroids (non-cancerous tumours in or around the womb) or pelvic cysts – which creates extra pressure in the pelvic area
- previous pelvic surgery – such as a hysterectomy or bladder repair
- repeated heavy lifting and manual work
- long-term coughing or sneezing – for example, if you smoke, have a lung condition or allergy
- excessive straining when going to the toilet because of long-term constipation.
Certain conditions can also cause the tissues in your body to become weak, making a prolapse more likely, including:
- Joint hypermobility syndrome - where your joints are very loose
- Marfan syndrome- an inherited condition that affects the blood vessels, eyes and skeleton
- Ehlers Danlos Syndrome - a group of inherited conditions that affect collagen proteins in the body
Can a prolapse be prevented?
There are several things you can do to reduce your risk of prolapse, including:
- doing regular pelvic floor exercises
- maintaining a healthy weight by losing weight if you're overweight
- eating a high-fibre diet with plenty of fresh fruit, vegetables, and wholegrain bread and cereal to avoid constipation and straining when going to the toilet
- avoiding heavy lifting
If you smoke, stopping smoking may also help to reduce your risk of a prolapse.
How is prolapse treated?
Many women with prolapse don't need treatment, as the problem doesn't seriously interfere with their normal activities.
Lifestyle changes such as weight loss and pelvic floor exercises are usually recommended in mild cases.
If the symptoms require treatment, a prolapse may be treated effectively using a device inserted into the vagina, called a vaginal pessary. This helps to hold the prolapsed organ in place.
Surgery may also be an option for some women. This usually involves giving support to the prolapsed organ. In some cases, complete removal of the womb (hysterectomy) is required, especially if the womb has prolapsed out.
Most women experience a better quality of life after surgery, but there's a risk of problems remaining or even getting worse.
Treating a pelvic organ prolapse
There are several treatment options available for a pelvic organ prolapse, depending on your circumstances.
The treatment most suitable for you depends on:
- the severity of your symptoms
- the severity of the prolapse
- your age and health
- whether you're planning to have children in the future
You may not need any treatment if your prolapse is mild to moderate and not causing any pain or discomfort.
Self care advice
If your prolapse is mild, there are some steps you can take that may help improve it or reduce the risk of it getting worse.
This may include:
- doing regular pelvic floor exercises
- losing weight if you're overweight, or maintaining a healthy weight for your build
- eating a high-fibre diet with plenty of fresh fruit, vegetables and wholegrain bread and cereal to avoid constipation and straining when going to the toilet
- avoiding heavy lifting and standing up for long periods of time
If you smoke, giving up will help, because coughing can make a prolapse worse.
Pelvic floor exercises
The pelvic floor muscles are a group of muscles that wrap around the underside of the bladder and rectum.
Having weak or damaged pelvic floor muscles can make a prolapse more likely. Recent evidence suggests that pelvic floor exercises may help to improve a mild prolapse or reduce the risk of it getting worse.
Pelvic floor exercises are also used to treat urinary incontinence (when you leak urine), so may be useful if this is one of your symptoms.
To help strengthen your pelvic floor muscles, sit comfortably on a chair with your knees slightly apart. Squeeze the muscles eight times in a row and perform these contractions three times a day. Don't hold your breath or tighten your stomach, buttock, or thigh muscles at the same time.
When you get used to doing this, you can try holding each squeeze for a few seconds (up to 10 seconds). Every week, you can add more squeezes, but be careful not to overdo it and always have a rest in between sets of squeezes.
Your doctor may refer you to a physiotherapist who can teach you how to do pelvic floor exercises. It usually takes at least three months before you notice any improvement.
A vaginal ring pessary is a device inserted into the vagina to hold the prolapse back. It works by holding the vaginal walls in place. Ring pessaries are usually made of latex (rubber) or silicone and come in different shapes and sizes. The most commonly used type is a ring pessary.
Ring pessaries may be an option if your prolapse is more severe, but you would prefer not to have surgery or are thinking about having children in the future or have a medical condition that
makes surgery more risky. A gynaecologist (a specialist in treating conditions of the female reproductive system) or a specialist nurse usually fits a pessary.
Pessaries are more likely to help a uterine prolapse or an anterior wall
prolapse, and are less likely to help a posterior wall prolapse.
Fitting the correct size of pessary is important and may take more than one attempt.
Pessaries should be changed or removed, cleaned and reinserted regularly. This can be done by
your doctor, nurse or sometimes by yourself. Estrogen cream is sometimes used when changing
the pessary, particularly if you have any soreness.
Pessaries do not usually cause any problems but may on occasion cause inflammation. If you have any unexpected bleeding, you should see your doctor.
Ring pessaries can occasionally cause vaginal discharge, some irritation and possibly bleeding and sores inside your vagina. Other side effects include:
- passing a small amount of urine when you cough, sneeze or exercise
- difficulty with bowel movements
- interference with having sex, although most women can have intercourse without any problems
- an imbalance of the usual bacteria found in your vagina (bacterial vaginosis)
These side effects can usually be treated.
Surgery may be an option for treating a prolapse if it's felt the possible benefits outweigh the risks.
Surgery for pelvic organ prolapse is relatively common. It's estimated that 1 in 10 women will have surgery for prolapse by the time they're 80 years old.
Pelvic floor repair
One of the main surgical treatments for pelvic organ prolapse involves improving support for the pelvic organs.This may involve stitching prolapsed organs back into place and supporting the existing tissues to make them stronger. Pelvic organ repair may be done through cuts (incisions) in the vagina. It's usually carried out under general anaesthetic, so you'll be asleep during the operation and won't feel any pain.
If you're planning to have children and have a prolapse, your doctors may suggest delaying surgery until you're sure you no longer want to have any more children. This is because pregnancy can cause the prolapse to recur.
In recent years a number of new operations have been developed where mesh (supporting
material) is sewn into the vaginal walls. The risks and benefits of mesh are unclear and it is
currently recommended that operations using mesh are only performed as part of an audit.
Sacrocolpopexy/ Sacrospinous fixation
Operations that aim to lift up and attach your uterus or vagina to a bone towards the bottom of
your spine or a ligament within your pelvis (sacrocolpopexy or sacrospinous fixation). These
may be done by keyhole surgery.
If the womb (uterus) is prolapsed, then removing it during an operation called a hysterectomy often helps the surgeon to give better support to the rest of the vagina and reduce the chance of a prolapse returning.
A hysterectomy will usually only be considered in women who don't wish to have any more children, as you can't get pregnant after having a hysterectomy.
Closing off your vagina (colpocleisis) may be considered but only if you are in very poor medical health or if you have had several operations previously that have been unsuccessful. Vaginal intercourse is no longer possible after this operation.
It may be possible to treat urinary incontinence at the same time as surgery for prolapse and your doctor will discuss this with you if relevant. Sometimes when you are relaxed under the anaesthetic, other areas of prolapse can become obvious. Your surgeon may request your consent to operate on those areas of prolapse as well. This should be fully discussed with you before your operation.
Complications from surgery
All types of surgery carry some risks. Your surgeon will explain these in more detail, but possible complications could include:
- risks associated with anaesthesia
- bleeding, which may require a blood transfusion
- damage to the surrounding organs, such as your bladder or bowel
- an infection – you may be given antibiotics to take during and after surgery to reduce the risk of infection
- pain during sex, usually caused by narrowing of the vagina
- vaginal discharge and bleeding
- experiencing more prolapse symptoms, which may require further surgery
- a blood clot forming in one of your veins (for example, in your leg) – you may be given medication to help reduce this risk after surgery
Recovering from surgery
Most prolapse operations require an overnight stay in hospital. More major operations, such as a hysterectomy, may require a few nights in hospital.
If you need to stay in hospital, you may have a drip in your arm to provide fluids and a thin plastic tube called a catheter to drain urine from your bladder. Some gauze may be placed inside your vagina to act as a bandage for the first 24 hours. This may be slightly uncomfortable. Your stitches will usually dissolve on their own after a few weeks.
For the first few days or weeks after your operation, you may have some vaginal bleeding similar to a period. You may also have some vaginal discharge. This may last three or four weeks. During this time, you should use sanitary towels rather than tampons.
There may still be some activities you need to avoid while you recover from surgery. Your care team can advise about activities you may need to avoid, such as heavy lifting and strenuous exercise, and for how long.
Generally, most people are advised to move around as soon as possible, with good rests every few hours.
You can usually shower and bathe as normal after leaving hospital, but you may need to avoid swimming for a few weeks.
It's best to avoid having sex for around four to six weeks, until you've healed completely.
Your care team will advise about when you can return to work.
Problems with recovery
Contact your doctor if you experience:
- a high temperature (fever) of 38C (100.4F) or over
- severe pain low in your tummy
- heavy vaginal bleeding
- a stinging or burning sensation when you pass urine
- abnormal vaginal discharge, as this may be an infection
How successful is surgery for pelvic organ prolapse?
No operation can be guaranteed to cure your prolapse, but most offer a good chance of improving your symptoms. The benefits of some last longer than others. About 25–30 out of 100 women having surgery for prolapse will develop another prolapse in the future. There is a higher chance of the prolapse returning if you are overweight, constipated, have a chronic cough or undertake heavy physical activities. Prolapse may occur in another part of the vagina and may need repair at a later date.
What might happen if I don’t have an operation?
Your problems may remain the same or get worse, or sometimes even improve over time. There is no way of confidently predicting this but an advanced prolapse cannot be expected to improve without a pessary or surgery. Prolapse is not life-threatening although it may affect the quality of your life. You can reconsider your options at any time.