Pelvic organ prolapse occurs when the normal support of the vagina is lost resulting in sagging or dropping of the bladder, urethra, cervix and rectum. As the prolapse of the vagina and uterus progresses, women can feel bulging tissue protruding through the opening of the vagina.
Causes and Risk Factors
By studying large numbers of women with and without prolapse, researchers have been able to identify certain risk factors that are believed to predispose, cause, promote or worsen prolapse. The strength of our bones, muscles and connective tissue are influenced by our genes and our race. Some women are born with weaker tissues and are therefore at risk to develop prolapse. Caucasian women are more likely than African American women to develop prolapse. Loss of pelvic support can occur when any part of the pelvic floor is injured during vaginal delivery, surgery, pelvic radiation or back and pelvic fractures during falls or motor vehicle accidents. Hysterectomy and other procedures done to treat prolapse are also associated with future development of prolapse. Some other conditions that promote prolapse include: constipation and chronic straining, smoking, chronic coughing, and heavy lifting. Obesity like smoking is one of the few modifiable risk factors. Women who are obese have a 40-75% increased risk of prolapse. Aging, menopause, debilitating nerve and muscle diseases contribute to the deterioration of pelvic floor strength and the development of prolapse.
We do not know exactly how common pelvic organ prolapse is because most of the research has been on women who come seeking health care. Nearly half of all women between the ages of 50 and 79 have some form of prolapse. The lifetime risk that a woman will have surgery for the correction of prolapse or urinary incontinence in the United States is about 11%. We also know that as many as one third of these women will undergo repeat corrective surgery for these conditions. Approximately 200,000 procedures for correction of pelvic prolapse are performed each year in the United States. We believe that is just the tip of the iceberg as many women mange their prolapse without surgery.
Some loss of support is a very common finding on physical exam in women, many of whom do not have bothersome symptoms. Those who are uncomfortable often describe the very first signs as subtle - such as an inability to keep a tampon inside the vagina, dampness in underwear, or discomfort due to dryness during intercourse. As the prolapse gets worse, some women complain of:
- A bulging, pressure or heavy sensation in the vagina that worsens by the end of the day or during bowel movements
- The feeling that they are sitting on a ball?
- Needing to push stool out of the rectum by placing their fingers into the vagina during bowel movement
- Difficulty starting to urinate, a weak or spraying stream of urine
- Urinary frequency or the sensation that they are not emptying their bladder well
- The need to lift up the bulging vagina or uterus to start urination
- Urine leakage with intercourse
Types of Prolapse
Anterior Vaginal Prolapse (also known as cystocele)
This type of prolapse occurs when the wall between the vagina and the bladder stretches or detaches from its attachment on the pelvic bones. This loss of support allows the bladder to prolapse or fall down into the vagina.
Most women do not have symptoms when the anterior vaginal prolapse is mild. As it progresses outside the opening of the vagina, the prolapsed bladder may not empty well which can lead to urinary frequency, night time voiding, loss of bladder control and recurrent bladder infections. Strengthening pelvic muscles may improve the support to the bladder and neighboring organs and reduce symptoms. In addition, women can get temporary support by wearing a device called a vaginal pessary. It works much like a knee or ankle brace would support a weak joint. When these efforts are inadequate surgery is available to elevate the bladder and other internal organs to their proper position.
Posterior Vaginal Prolapse (also known as rectocele)
Weakening and stretching of the back wall of the vagina allows the rectum to bulge into and out of the vagina. Most often, the damage to the back wall of the vagina occurs during vaginal childbirth, although not everyone who has delivered a child vaginally will develop a rectocele. Mild rectoceles rarely cause symptoms. However, straining with constipation puts significant pressure on the weak vaginal wall and can further thin it out. Avoiding constipation may prevent progression and also reduce symptoms from the rectocele. Some women may find benefit from pelvic floor muscle strengthening and vaginal pessaries. When these low risk interventions are insufficient to relieve symptoms, surgery is performed to reinforce the posterior vaginal wall.
When the supporting ligaments and muscles of the pelvic floor that keep the uterus in the pelvis are damaged, the cervix and uterus descend into and eventually out of the vagina. Often, uterine prolapse is associated with loss of vaginal wall support (cystocele, rectocele). When the cervix protrudes outside the vagina, it can develop ulcers from rubbing on underwear or protective pads. There is a risk that these ulcers will bleed and become infected. As with other forms of prolapse, it is not until the uterine descent is bothersome that treatment is necessary. Women who have uterine prolapse often report pelvic pressure, the need to sit or lay down to relieve the discomfort, a sensation that their insides are falling out, difficulty emptying their bladder and urine leakage. Strengthening the pelvic muscles with Kegel exercises, avoiding heavy lifting, constipation, and weight gain may reduce the risk of progression of uterine descent. Additional treatment options include pessary devices which provide support when worn or surgery, and/or use of estrogen vaginally.
Vaginal Prolapse after Hysterectomy
If a woman has already had a hysterectomy, the very top of the vagina (where the uterus used to be) can become detached from its supporting ligaments. This can results in the tube of the vagina turning inside out. This condition is also known as vaginal prolapse. Depending upon how extensively the top of the vagina is turning inside out, one or several pelvic organs (such as the bladder, small and large bowel) will prolapse into the protruding bulge. Symptoms depend on which organs are prolapsing. When the bladder is involved, women report difficulty in starting to urinate, and emptying their bladder well. If it is the bowel then many report the need to push up the vaginal bulge and strain to have a bowel movement. Skin sores may develop if the bulge is rubbing on pads or underwear. A pessary may provide support for the bulge, otherwise surgery is recommended.