Pelvic Organ Prolapse

What is Pelvic Organ Prolapse?

Pelvic organ prolapse (POP) occurs when the tissue and muscles of the pelvic floor no longer support the pelvic organs resulting in the drop (prolapse) of the pelvic organs from their normal position. The pelvic organs include the vagina, cervix, uterus, bladder, urethra, and rectum. The bladder is the most commonly involved organ in pelvic organ prolapse.

Symptoms of Prolapse

Many women with Pelvic Organ Prolapse have no symptoms at all, however some women may experience one or more of the following:

• Discomfort (usually pressure or fullness)
• Bleeding from the exposed skin that rubs on pads or underwear
• Urinary symptoms of leakage, difficulty starting the stream of urine, or frequent urinary tract infections
• Difficult bowel movements—the need to strain or push on the vagina to have a bowel movement
• A bulge near the opening of the vagina or a sensation of pressure in their pelvic region and/or lower abdomen

Symptoms often progress very gradually. And you may make changes in physical or social activities that go unnoticed by others until they become extreme. More rarely symptoms of prolapse can present suddenly.

As POP worsens, you may notice:

• A bulging, pressure or heavy sensation in the vagina that worsens by the end of the day or during bowel movements
• The feeling of "sitting on a ball"
• Needing to push stool out of the rectum by placing fingers into or around the vagina during a bowel movement
• Difficulty starting to urinate or a weak or spraying stream of urine
• Urinary frequency or the sensation that you are unable to empty the bladder well
• Lower back discomfort
• The need to lift up the bulging vagina or uterus to start urination
• Urinary leakage with intercourse. Though unusual, severe prolapse can block the flow of urine and cause recurrent urinary tract infections or even kidney damage.

Types of Prolapse

Anterior Vaginal Wall Prolapse (Cystocele or Urethrocele)

Anterior vaginal wall prolapse often occurs at the top of the vagina where the uterus used to be in women who have had a hysterectomy. This type of prolapse occurs when the bladder's supportive tissue, called fascia, stretch or detach from the attachments securing it to the pelvic bones. With this loss of support, the bladder falls down into the vagina. As this condition worsens, the prolapsed pelvic organs may bulge outside the opening of the vagina causing pressure, discomfort or pain. Other symptoms MAY include:

• Urinary frequency, nighttime voiding, loss of bladder control and recurrent bladder infections—usually due to the bladder not emptying well
• Stress urinary incontinence (SUI) with activity such as laughing, coughing, sneezing, or exercise) cause by weakened support for the urethra

Posterior Wall Prolapse (Rectocele or Enterocele)

This type of prolapse occurs when the support tissue or fascia between the vagina and rectum stretches or detaches from its attachment to the pelvic bones. With this loss of support, the rectum or intestines fall (prolapse) into the vagina causing it to bulge or protrude outward. Symptoms typically include:

• A bulge sensation
• Problems having a bowel movement such as straining more with bowel movements and the feeling of not completely emptying the bowels
• The need to put your finger in or around the vagina or rectum to help empty bowels

Uterine Prolapse

Uterine prolapse is a condition that occurs when the muscles and tissue in your pelvis weaken. Your uterus drops down into your vagina. Sometimes, it comes out through your vaginal opening. Nearly half of all women between ages 50 and 79 have uterine prolapse, or some other form of pelvic organ prolapse

Symptoms

Many women with uterine prolapse have no symptoms. However, if symptoms start, they may include:

• Leakage of urine
• Feeling of heaviness or fullness in your pelvis
• Bulging in your vagina
• Lower-back pain
• Aching, or the feeling of pressure, in your lower abdomen or pelvis

Apical Prolapse (Vaginal Vault Prolapse) or Uterine Prolapse

If a woman has had a hysterectomy, the top part of the vagina (vault) can become detached from the ligaments and muscles of the pelvic floor. Often, uterine or vault prolapse is associated with loss of anterior or posterior vaginal wall support. When the cervix protrudes outside the vagina, it can develop ulcers from rubbing on underwear. Sometimes these ulcers will bleed if they become irritated. Most women experience symptoms of bulge or pressure sensation in the pelvis.

Rectal Prolapse

Like the vagina and uterus, ligaments and muscles securely attach the rectum to the pelvis. Infrequently, the supporting structures stretch or detach from the rectal wall and the rectum falls out through the anus. Early on, women may notice a soft, red tissue protruding from the anus after a bowel movement. It can be confused with a large hemorrhoid. Other symptoms may include:

• Pain during bowel movements
• Mucus or blood discharge from the protruding tissue
• Loss of bowel control

Risk factors for rectal prolapse include conditions associated with straining such as chronic constipation or diarrhea, nerve and muscle weakness (paralysis or multiple sclerosis), and advancing age are risk.

Who's at risk?

If you have given birth, you have the highest risk for uterine prolapse. If you've had a vaginal delivery, you are more likely to develop uterine prolapse than if you've had a C-section. If you are menopausal, Caucasian, overweight, or obese, you are also more likely to experience uterine prolapse. Smoking is another factor that increases your risk.

Diagnosis

If your doctor suspects that you have a prolapse in one or more pelvic organs, he or she will probably perform a physical examination to check for irregularities in your pelvis. If you're also having problems like urinary incontinence or a feeling of incomplete emptying of your bladder, your doctor may perform a procedure called a cystoscopy to examine your bladder and urethra.

Your physician might also order imaging of the pelvic organs such as an ultrasound (sonogram) or an MRI (magnetic resonance imaging). This will allow your doctor to assess your kidneys and other pelvic organs when indicated.

Treatment

If your prolapse symptoms bother you or keep you from feeling comfortable during everyday activities, talk with your doctor about treatment options. Lifestyle changes like losing weight coupled with routine Kegel exercises can also be helpful. These strengthen your pelvic floor muscles. To perform a Kegel exercise, you squeeze the muscles you use to control the flow of urine, and hold for up to 10 seconds before releasing. Aim for 50 repetitions a day.

A pessary can provide relief from the symptoms of uterine prolapse. This is a device your doctor inserts into your vagina to support your pelvic organs.

When symptoms are more bothersome surgery can be considered. There are many types of surgeries that can be performed depending on which organs are prolapsed. Options depending on your condition and other factors include minimally invasive approaches like vaginal, robotic or laparoscopic surgery and sometimes open abdominal surgery. The goal of surgery is to restore pelvic organ support. In some cases of uterine prolapse hysterectomy or uterine suspension procedure may be recommended. These procedures can be done in a minimally invasive fashion. For example, with a vaginal hysterectomy your doctor removes your uterus through your vagina. The healing time is faster. There also are fewer complications than with traditional hysterectomy, which requires an abdominal incision. In some cases of uterine prolapse uterine sparing surgery may be appropriate.

Complications

Surgery for pelvic organ prolapse carries the risks that all surgery has. This includes the chance of bleeding, infection, injury to the body area involved (in this case, the urinary tract), and problems related to anesthesia.

Prevention

There is no surefire way to prevent pelvic organ prolapse. However, you can lower your risk by:

• Losing weight if you're overweight
• Following a diet rich in fiber and fluids to prevent constipation and straining
• Avoiding heavy lifting
• Quitting smoking
• Seeking prompt treatment for a chronic cough, which can place extra pressure on your pelvic organs
• Regularly performing Kegel exercises to strengthen your pelvic floor muscles

These strategies may also help if you have already developed uterine prolapse.

Consult your doctor when pelvic organ prolapse symptoms first start to bother you. Don't wait until your discomfort becomes severe. Regular pelvic exams can help detect uterine prolapse in its early stages.

Surgery is an option, but not always necessary. Medical devices, exercises, and lifestyle changes can sometimes provide relief from bothersome symptoms.

Download: Robotic Surgery for Pelvic Organ Prolapse

Download: Treating Prolapse with Surgery

Download: Uterine Prolapse without Hysterectomy