What Is Pelvic Organ Prolapse?

Lifestyle modification, pessaries, and surgery are treatment options.

Close up of doctor writing on a medical chart.
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When a body part slips out of position or falls from place, this drop is called a prolapse. Pelvic organ prolapse refers to prolapse of the pelvic organs. Put another way, pelvic organ prolapse is a hernia of the pelvic organs—most commonly the bladder—through the vaginal opening. The most specific symptom of pelvic organ prolapse is feeling a bulge in—“something coming out of”—the vagina.

Understandably, having a hernia in one’s vagina can be quite distressing and affect body image, sexual function, and quality of life.

Fortunately, although some degree of prolapse is present in between 41 percent and 50 percent of all women, only three percent report symptoms, and many of these women don’t require treatment. For women who do require treatment, pelvic floor exercises, pessaries, and surgery are all available options.

Anatomy

The vagina lies horizontally atop the levator ani muscles. The levator ani muscles in part comprise the pelvic floor muscles, which form a sling or hammock across the pelvis. In women, this sling holds the uterus, bladder, bowel, and other pelvic organs in place so that everything functions as it should. Injury or weakness in the pelvic floor muscles can “drop” pelvic organs into the vagina.

It should be noted that the cause of pelvic organ prolapse is usually due to many factors, with injury to the pelvic floor being the most salient. In one MRI study, it was demonstrated that women who had a pelvic organ prolapse within one centimeter of the level of the hymen were 7.3 times more likely to have injured the levator ani muscles as compared to women without a prolapse.

There are different types of vaginal hernias:

  • Prolapse located in the anterior vaginal wall (front wall of the vagina) is a cystocele, or herniation of the bladder into the vagina. This distinction makes sense because the bladder lies in front of the vagina.
  • A cystocele can be accompanied by a urethrocele, which is a sagging of the urethra, a duct through which urine is expelled from the bladder.
  • Herniation in the posterior vaginal wall (back wall of the vagina) is usually a rectocele, or herniation of the rectum into the vagina. This distinction makes sense, too, because the rectum is located behind the vagina.
  • Loss of pelvic support at the apex, or top, of the vagina (close to the cervix) may result in an enterocele, or hernia of the small bowel into the vagina. Technically, enteroceles are the only “true” hernia among the different iterations of pelvic organ prolapse.
  • Loss of support in the major ligaments of the uterus (i.e., cardinal or uterosacral ligaments) can lead to uterine prolapse, or hernia of the uterus into the vagina. The major ligaments of the uterus hold the uterus in place.

Importantly, two or three types of prolapse can occur together in women with pelvic organ prolapse. Additionally, pelvic organ prolapse often co-occurs with other pelvic floor disorders. For instance, 37 percent of women with this condition also have overactive bladder, 40 percent of these women have stress urinary incontinence, and 50 percent of these women have fecal incontinence.

Symptoms

Most women with pelvic organ prolapse experience no symptoms at all.

In addition to a bulge in the vagina, other common symptoms of pelvic organ prolapse include the following:

  • Heaviness, fullness, aching, or pulling in the vagina (worsening at the end of the day or during a bowel movement)
  • Difficulty urinating
  • Difficulty voiding the bladder completely
  • Pain on urination
  • Sexual difficulties
  • Frequent urinary tract infections
  • Leaking urine while coughing, exercising, or laughing
  • Constipation
  • Leaking stool
  • Trouble controlling gas

Of note, the specific symptoms experienced depend on which pelvic organs herniated through the vagina. For instance, cystoceles, which are herniations of the bladder, result in urinary symptoms.

In a 2017 article titled “Pelvic Organ Prolapse,” Iglesia and Smithling state the following:

Pelvic organ prolapse is dynamic, and symptoms and examination findings may vary day to day, or within a day depending on the level of activity and the fullness of the bladder and rectum. Standing, lifting, coughing, and physical exertion, although not causal factors, may increase bulging and discomfort.

Large prolapses, or herniations that extend outside the vaginal canal, can lead to erosion or ulceration of the vaginal mucosa.

Severe cases of prolapse are uncommon. According to Hazzard’s Geriatric Medicine and Gerontology:

In some cases, women with large cystoceles may report having to put their fingers in the vagina to elevate the tissue in order to straighten out the urethra to urinate. Despite this, high-grade obstruction in women is rare, and development of upper tract deterioration with hydronephrosis and renal insufficiency is uncommon.

Physical Exam

A physical exam is essential to properly diagnose pelvic organ prolapse. Visual inspection of the vagina by a physician is usually not enough to diagnose this condition. Instead, an OB-GYN will use a single-blade speculum to either lift the anterior wall of the vagina or depress the posterior wall of the vagina to ascertain pathology. During the exam, your physician may ask that you cough or strain (Valsalva) to better visualize the prolapse. Furthermore, you may also be asked to stand during the examination for better visualization of certain types of prolapse.

Here are some things that an OB-GYN evaluates during the physical exam for pelvic organ prolapse:

  • Vaginal bulge
  • Mucosal abrasions or ulcerations
  • Degree of descent (for example, beyond the midpoint of the vagina or beyond the entrance of the vagina)
  • Support and mobility of the cervix and uterus
  • Support and mobility of the urethra and bladder neck
  • Urine studies (e.g., postvoid residual volume and urinalysis)

Risk Factors and Frequency

During delivery, the levator ani muscles can stretch 200 percent greater than the threshold for stretch injuries, making vaginal birth the biggest risk factor for the development of pelvic organ prolapse. Women with this condition often have delivered more than one baby. Other risk factors include the following:

  • Genetic predisposition
  • Prior pelvic surgery
  • Obesity
  • Chronic straining (i.e., increased intra-abdominal pressure) secondary to constipation or coughing
  • Hysterectomy
  • Smoking
  • Poor tissue quality

Although women at any age can develop pelvic organ prolapse, this condition usually affects older women. In women aged between 60 and 69 years old, the prevalence of this condition is five percent.

On a related note, limited data suggest that pelvic organ prolapse progresses until menopause, and after menopause this condition neither progresses or regresses. Moreover, results from one study suggest that women who are obese are likely to experience hastened progression, and weight loss doesn’t reverse this prolapse.

Treatment

Treatment of pelvic organ prolapse depends on several factors, including age, desire for pregnancy, menstruation, and sex.

For milder cases of this condition, lifestyle modification can help with symptoms, including weight reduction, pelvic muscle training (I.e., Kegel exercises), high-fiber diet, and limited straining or lifting activities.

Pessaries are devices placed within the vagina to re-establish normal pelvic anatomy. They help alleviate the symptoms attributable to pelvic organ prolapse. About 67 percent of women will initially choose the pessary as a treatment option, with 77 percent continuing to use this device after one year.

Pessaries work for women with different degrees of pelvic organ prolapse—from those with mild illness to more serious presentations. These devices can slow the progression of this condition and delay or eliminate the need for surgery.

Pessaries are usually made of medical-grade silicone. Pessaries can be either supportive or space occupying. In the United States, the ring pessary, a type of supportive pessary, is the most popular followed by space-occupying pessaries like the donut pessary or Gellhorn pessary. Space-occupying pessaries are required for more advanced illness.

To date, in women with pelvic organ prolapse, there’s only been one randomized controlled trial comparing the ring pessary with the Gellhorn pessary (a type of space-occupying pessary) and both types of pessary were shown to be comparable.

Pessaries can stay in place for days or weeks at a time. Support pessaries are usually inserted and removed by the patient, and some pessaries even allow for vaginal intercourse. The use of pessaries in women with dementia may not be a good idea because, if not maintained and followed up with properly, a pessary can result in serious adverse effects such as erosion into the bladder or rectum.

Over 85 percent of women who desire a pessary can be fitted with one. Factors that make it harder to be fit with a pessary include short vaginal length, history of hysterectomy, or a wide vaginal opening.

Depending on goals and desires of the patient, surgery for pelvic organ prolapse can be either reconstructive or obliterative. Decision between these procedures depends on your desire to have sexual intercourse and personal perspectives on body image. Hysterectomy or uterine conservation (i.e., hysteropexy) are two available options. In women who no longer desire vaginal intercourse, the best surgical treatment option is colpocleisis, or vaginal obliteration.

According to Iglesia and Smithling:

For women who prefer to maintain coital function, reconstructive surgery should be performed and the vaginal apex can be suspended using the woman’s own tissues and sutures native tissue repair), or mesh can be placed abdominally, to suspend the top of the vagina to the sacrum (sacrocol­popexy), or transvaginally (transvaginal mesh).

According to the FDA:

Surgery to repair POP [pelvic organ prolapse] can be done through either the vagina or abdomen, using stitches (sutures) alone or with the addition of surgical mesh. Surgical options include restoring the normal position of the vagina, repairing the tissue around the vagina, permanently closing the vaginal canal with or without removing the uterus (colpocleiesis).

Finally, the use of transvaginal mesh is controversial and has been dissected by experts. Experts suggest that the use of transvaginal mesh should be limited to those with complex presentations, such as advanced or recurrent prolapse or those with medical conditions that make more invasive surgery risky.

Sources:

Iglesia CB and Smithling KB. Pelvic Organ Prolapse. American Family Physician. 2017;96(3):179-185.

Miller KL, Griebling TL. Gynecologic Disorders. In: Halter JB, Ouslander JG, Studenski S, High KP, Asthana S, Supiano MA, Ritchie C. eds. Hazzard's Geriatric Medicine and Gerontology, 7e New York, NY: McGraw-Hill.

Pelvic Organ Prolapse (POP). FDA.

Woo J. Gynecologic Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical Diagnosis & Treatment 2018 New York, NY: McGraw-Hill.

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