A woman’s guide to pelvic organ prolapse

Pelvic organ prolapse, also known as vaginal prolapse, is a very common condition; so common in fact that experts estimate that around half of all women over the age of 50 experience some degree of the condition. Additionally, many people believe it only affects older women, however, some young women have to deal with these symptoms too.

Mr Ian Currie is a leading consultant obstetrician and gynaecologist with over 20 years of experience in treating women with pelvic organ prolapse. In this article, he explains what the condition is, the symptoms and causes and what treatments are available.

What is a pelvic organ prolapse?

Pelvic organ prolapse refers to a weakness of the genital area, particularly in women, when one or more of the organs in the pelvis drops down and begins to bulge outwards. In women, this typically happens through the vagina.

Are there different types of pelvic organ prolapse?

There are different types of pelvic organ prolapse depending on which part of the pelvic organ is affected.

• Anterior prolapse (cystocele) — this is when the bladder slips down from its usual position as the tissue on the front wall of the vagina weakens.
• Posterior prolapse (rectocele) — when the tissue between the rectum and the vagina weakens, it also can allow the vaginal wall to bulge.
• Uterine prolapse — the uterus and cervix are held up by the pelvic floor muscles and ligaments. If these stretch and weaken, the cervix and uterus can start to fall down and protrude out of the vagina.
• Vaginal vault prolapse — if a woman has undergone a hysterectomy and therefore does not have a uterus, then the top part of the vagina can lose its normal shape and drop down outside of the vagina.

Vagina wall prolapse is very much like a hernia: It is generally caused by a weakness in the tissues in the front wall of the vagina and bladder and cause the wall to bulge out. The same can happen at the back, where the tissue thins and the back wall of the vagina starts to drop down and bulge.

Pelvic organ prolapse can also be graded from mild to severe and is based on the level of protrusion:

• Grade 0 - no prolapse
• Grade 1 - the prolapse occurs within the vagina
• Grade 2 - the prolapse appears at the entrance of the vagina
• Grade 3 - the prolapse drops down and comes right out of the vagina

What are the symptoms of vaginal prolapse?

Symptoms of pelvic organ prolapse depend on where the prolapse is and how severe it is. The commonest symptom is the appearance of a lump or the sensation of fullness in the vagina. Often after straining or showering, a woman might notice the sensation of a lump.

If the prolapse isn't that big, the vaginal might feel crowded or full and you might have difficulty retaining tampons. You may also experience a mild pulling or dragging sensation when you are walking or standing, and when you are lying down you will notice that the feeling eases.

If the prolapse is on the front wall of the vagina, it can be associated with bladder symptoms which can be varied. They can range from stress incontinence ( leakage with coughing and sneezing ) or leakage of urine due to irritation of the bladder, thereby causing frequency and urgency. It can also cause obstructive symptoms, making it difficult for you to pass urine.

If the prolapse occurs on the back wall, you may find it difficult to empty the bowel, with a feeling of straining more and being unable to empty it completely. Some women may need to splint the perineum (supporting the vagina to empty the bowl) or push their fingers inside the vagina to evacuate the bowel. I often find that women don’t freely inform their doctor of this symptom unless asked, due to the embarrassing nature of it, however it is important to explain all your symptoms to your doctor so they can provide an accurate diagnosis and the most suitable treatment.

Risk factors: Is pelvic organ prolapse a normal part of ageing?

There are certain risk factors that predispose a woman to pelvic organ prolapse:

• Genetics – the natural makeup of your own tissues — some tissues are naturally more prone to prolapse. There are even some rare genetic disorders that can weaken your tissues.
• Childbirth — this is the most common cause of vaginal and uterine prolapse due to stretching and straining the pelvic floor.
• Menopause — the tissues begin to weaken and thin due to the loss of the female hormone oestrogen.
• Age - tissues weaken as you get older.
• High BMI — being overweight is another risk factor. It not only adds to prolapse but reduces the success of surgery to fix it.
• Pressure on your abdomen — chronic coughing and chronic constipation can be a risk factor too, as it puts longterm pressure on your pelvic region.

Contrary to popular belief, exercise is not a risk factor. In fact, certain pelvic floor exercises can actually strengthen your pelvic floor muscles and may well relieve your symptoms.

What treatments are available for vaginal prolapse?

There are many treatments for vaginal prolapse which can be largely divided into three main groups:

• Conservative measures - pelvic floor exercises and seeing a physiotherapist. In my own experience, it only helps with mild prolapse and not with significant prolapse that is protruding out of the vagina.
• Supportive devices - there are many plastic and silicone devices that can be fitted to hold the vagina and uterus in place. These devices usually need to be worn every day.
• Surgery - this approach largely depends on where the prolapse is taking place (front, back or uterus or combination of those) and whether or not there is an effect on other parts of the pelvis, such as leakage with the bladder. Surgery ranges from vagina repairs to hysterectomy and also uterine preservation surgery. One of my areas of expertise is in post-hysterectomy prolapse and non-vaginal-mesh surgery.

It’s important to note that many women don’t necessarily want immediate treatment, but are instead seeking reassurance. Quite often there is a worry factor as the condition is not something you can see with your own eyes, so they seek professional advice and explanations as to what is happening to their body. From there, they may decide to wait and see how it progresses and opt for treatment later if necessary.

Many women also suffer psycho-sexual effects from pelvic organ prolapse. Although prolapse usually occurs in older women in the 5th or 6th decade in life, young women, who may be more sexually active, have to deal with significant symptoms too, and it can severely affect their sexual function.

If you are experiencing pelvic organ prolapse and would like to see a specialist, visit Mr Ian Currie’s Top Doctors profile and book a consultation to see him. He is also available to talk through our e-Consultation service which you can carry out from the comfort of your home.