Pelvic Organ Prolapse
What is Pelvic Organ Prolapse?
Pelvic organ prolapse occurs when one or more of the pelvic organs (bladder, uterus, vagina, and rectum) fall downward and bulge out through the opening of the vagina.
Prolapse is the bulging or dropping of the uterus (uterine prolapse), rectum (rectocele) or bladder (cystocele) into the vagina. There are several different types of pelvic organ prolapse. Pelvic organ prolapse occurs when the pelvic floor muscles become weak or damaged and can no longer support the pelvic organs.
The womb (uterus) is the only organ that actually falls into the vagina. When the bladder and bowel slip out of place, they push up against the walls of the vagina. While prolapse is not considered a life- threatening condition it may cause a great deal of discomfort and distress.
Types of Pelvic Prolapse
There are a number of different types of prolapse that can occur in a woman's pelvic area and these are divided into three categories according to the part of the vagina they affect: front wall, back wall or top of the vagina. It is not uncommon to have more than one type of prolapse.
- Cystocele (Fallen Bladder) - When the bladder falls down into the vagina it is referred to as a cystocele. When the bladder prolapses, it falls towards the vagina and creates a large bulge in the front vaginal wall which may cause discomfort and difficulty emptying the bladder.
- Uterine Prolapse (Fallen Uterus) - Uterine prolapse is when the womb drops down into the vagina. It is the second most common type of prolapse and is classified into three grades depending on how far the womb has fallen. This condition may cause discomfort and problems with difficulty having bowel movements.
- Vaginal vault prolapse
- Enterocele (Bulging of small bowels) - An entrocele occurs when a space between the vagina andrectum opens and small bowel bulges through.
- Rectocele (Bulging rectum)- If the rectum falls it is called a rectocele. This condition may cause discomfort and problems with difficulty having bowel movements.
What Causes Prolapse?
The pelvic organs rest on the muscular floor of the pelvis which is something like a trap door. If the door dropped down you would fall through unless you had something to hold onto. Similarly, when the pelvic floor opens due to muscle and nerve damage the organs begin to fall downward.
Ligaments catch the falling organs and hold them in place, but this puts a lot of stress on the ligaments and eventually the ligaments can fail as well. As a result, pelvic organ prolapse occurs and the organs fall or bulge out through the vaginal opening. Imagine the vagina is somewhat like a finger of a glove which is tucked inside the rest of the glove. In the same way, the vagina is surrounded by an enclosed area.
If the pressure in that area is increased, the vagina tends to be pushed downward. In women with normal support, the muscles and ligaments prevent the vagina from protruding outward. But in women with damaged support, the vagina is not held in place and the organs push downward causing the vagina to bulge or fall out through the opening. Because there are many different factors that can lead to pelvic organ prolapse, a different pelvic organ may fall down.
Does Childbirth Cause Prolapse?
It can. During vaginal delivery a woman's muscles have to stretch in order for the baby to come through the vagina. Vaginal delivery may cause a ligament to break as the baby's head comes through the pelvic floor. When this occurs the muscle does not contract as it normally would. (This is similar to a spinal cord injury when someone loses their ability to control the muscles that are not connected to the spinal cord and brain.) In most women the damage is minor, but in others enough muscle may be lost to the point that it can no longer hold the pelvic organs up.
Other Causes of Prolapse:
- Menopause: Decreased estrogen, such as during menopause, may also contribute to pelvic organ prolapse. During menopause, estrogen levels, collagen and certain connective tissue proteins decline.
- Obesity: Weight contributes to an increased pressure in the abdomen so women who are overweight often have a higher rate of pelvic organ prolapse.
- Chronic cough: Chronic coughing caused by smoking, asthma or chronic bronchitis puts increased pressure on the abdomen and pelvis. Smoking alone reduces collagen and can increase the chances of a connective tissue tear.
- Prior pelvic floor surgery: Prior surgery may cause damage to the support of the pelvic organs.
- Neurologic diseases: Diseases affecting the nervous system such as Parkinson’s, multiple sclerosis or a spinal cord injury also increase the chances of developing pelvic organ prolapse.
- Ethnicity/Race: Pelvic organ prolapse is found more often in women of Caucasian and Hispanic backgrounds.
Symptoms of Pelvic Prolapse
Physical symptoms can include:
- A bulge or lump on the outside of the vagina
- Feeling as though something is bulging out of the vagina, like a tampon is about to fall out
- Lower back pain or increased pelvic pressure that interferes with daily activities
- Irregular vaginal spotting or bleeding
- Frequent urinary incontinence, urinary tract infections, difficulty urinating, frequent urination or any of the above that interfere with a daily routine
- Sexual intercourse that is painful or difficult
- Difficult bowel movements, constipation, liquid stools
Women with pelvic organ prolapse can experience all, some or none of the above mentioned. Each woman’s experience with prolapse depends on the type, severity and the individual herself.
Emotional symptoms can include feeling alone, isolated, and depressed. You may feel embarrassed by this condition and because it is generally not discussed, fail to seek treatment. Women may feel embarrassed by their body and choose to hide their condition from their partners leading to reduced intimate contact.
If you have any concern at all about any condition with your body, you should always contact your doctor.
How We Diagnose Prolapse
An evaluation begins in your doctor’s office with questions about your health and health history. Some of the questions you may be asked include:
- What types of symptoms you are having?
- Do you have any type of chronic disease such as asthma, bronchitis, etc?
- Did you have any vaginal births?
- Do you smoke?
- Do you do heavy lifting or stand on your feet for long periods of time
To find out if you have pelvic organ prolapse, descent of any of the pelvic organs such as the bladder, cervix, vagina, or rectum, your doctor will do a pelvic exam. This is usually done while you lie on an exam table, or sometimes while standing. The doctor may ask you to push down or cough to see the full extent of the prolapse. A pelvic exam may be performed where a speculum in inserted into your vagina. A rectal exam might also be performed to check the strength of these muscles which can weaken with age or childbirth. The doctor will also likely as you do a Kegel (pelvic floor contraction- these are the muscles that you use to stop the flow of urine). If you do have pelvic organ prolapse the doctor will determine which organs are involved and how severe the prolapse is.
A post-void residual (PVR) is done to determine how much urine is left behind after you urinate. It is normal for the bladder to not completely empty itself of a small amount of urine. Even though you may have voided ten minutes earlier urine may still be collected from your bladder. The post-void residual test consists of you first emptying your bladder and then within 15 minutes a catheter is placed in your bladder to determine the amount of urine left behind. Most women have a post-void residual between 0-60cc. A PVR is done to determine if you have any urinary retention which can be a sign of an underlying condition. Most doctors will conduct follow up studies if the PVR is over 100cc.
Urinalysis is done to determine if you have an infection or other substances found in the urine. It is usually performed at the beginning of any type of bladder test. A clean catch of urine is obtained and then a test strip is dipped into the urine. Results are usually obtained within minutes. If you have a high white blood cells count it could indicate a bladder infection. For follow-up doctors may also send your urine out to be cultured which is a more sensitive test.
Types of Bladder Testing (Urodynamics):
- Urodynamic testing is a series of bladder tests that are done in order to observe how your lower urinary tract reacts under certain conditions. It is usually done to see if you have problems with loss of urine (urinary incontinence) or to figure out what type of incontinence you may have.
- Cystometry, also referred to by the general term urodynamics, consists of filling your bladder with sterile water, observing the pressure and how your bladder reacts under these conditions. When the test begins the physician inserts a small soft catheter in your bladder and a tube is hooked up to a bag of sterile water. Your bladder is then filled to around 250cc (approx. 1 cup) which most women can hold without needing to urinate. A second catheter which is connected to a machine or computer is also inserted. This catheter measures the pressures within your bladder.
Once the bladder is filled you will be asked to cough and strain in order to see how much urine you leak. Also, many women will leak if their bladder is full and they cannot get to the bathroom in time.
Stages of Pelvic Organ Prolapse:
- Stage 0 means that there is no prolapse. The pelvic organs like the vagina, bladder and rectum are perfectly supported by the ligaments in the pelvis.
- Stage 1 means that there is virtually no prolapse. The pelvic organs are very well-supported by the ligaments in the pelvis.
- Stage 2 prolapse means that the pelvic organs are not as well supported by the ligaments and have begun to fall down. In Stage 2 prolapse, the organs are still inside the vagina.
- Stage 3 prolapse means the pelvic organs are beginning to bulge to or beyond the opening of the vagina.
- Stage 4 prolapse means the pelvic organs are completely outside of the vagina.
Most women who have had children vaginally have Stage I or II pelvic organ prolapse and this is normal if they don't have any symptoms. On the other hand, women with Stage III or IV prolapse generally feel a bulging sensation and may have problems with urination or bowel movements.
Treating Pelvic Organ Prolapse
UVA offers a number of treatment options.
There are many simple things you can do to help with your prolapse or stop it from getting worse. Try not to stand on your feet for long periods of time. Heavy lifting can make a prolapse get worse, so try not to lift things that are heavier than 10-15 pounds. Straining to have a bowel movement can also make a prolapse worse. Try to keep your bowel movements soft (the consistency of toothpaste). This can be done with a high fiber diet, or with fiber supplements, such as Metamucil®. or Citrucel®.
Pessaries: A pessary is a small device made of plastic or silicone that is placed inside the vagina to hold the uterus or the walls of the vagina up, and inside of your body. Pessaries come in many shapes and sizes, and can be fitted for each individual woman to best suit her needs. Some are shaped like a ring, a dish, a donut, a mushroom or a cube. A woman can remove and replace her own pessary, or she can visit the doctor every few months to have it removed and cleaned. It is usually safe to keep a pessary in the vagina for 3-4 months at a time. Some women are sexually active with a pessary in place. Other women prefer to remove the pessary to have sex. A pessary can be an excellent choice for women who cannot or do not wish to have surgery to correct their prolapse. It is important to return to the doctor for scheduled visits to make sure that there are no pressure sores in the vagina as a result of the pessary.
- Pelvic floor muscle training (Kegels): There are muscles around the vagina that help with pelvic support. It is possible to train and exercise these muscles. There are tools that can be used for biofeedback, to show you how strong the muscles are, and to help you make them stronger. Pelvic floor muscle training can be used to stop a prolapse from getting bigger. It is usually more helpful in smaller prolapses. Once a prolapse is very large, with the uterus or vagina coming all the way outside of the vaginal opening, pelvic floor muscle training does not usually work as well.
There are many different types of surgeries to correct pelvic organ prolapse. Often, more than one of these surgeries will be performed at the same time.
We use three different approaches to surgery:
- Vaginal approach: the operation is performed through the vagina.
- Abdominal approach: an incision is made on the abdomen (belly), this may either be a transverse (side to side) incision, or a vertical (up and down) incision.
- Laparoscopic approach: Prolapse surgery may also be performed laparoscopically, through several small (about 1 cm) incisions on the abdomen.
There are some risks to any surgery. These risks include bleeding, infection, and damage to nearby organs. These risks should be discussed with your doctor before making the decision to have surgery.
In general, vaginal approach surgeries have a faster recovery time and cause less pain than abdominal surgeries.
A vaginal hysterectomy is the removal of the uterus through the vagina, without any incision on the abdomen. When the uterus is very low in the vagina, or coming outside of the vagina, then it is usually necessary to remove the uterus in order to correct the prolapse. Removal of the tubes and ovaries may be done at the same time. This is something that should be discussed with your doctor if you decide to have surgery.
Anterior Repair (Anterior Colporrhaphy)
An anterior repair is a vaginal surgery to correct a cystocele, when the "upper" wall of the vagina that is in contact with the bladder is sagging down, or coming outside of the vaginal opening. This is done by making a vertical incision in the skin of the vagina, and folding the strong tissues just underneath the vaginal skin. By folding these tissues, and stitching them together, the "upper" wall of the vagina is no longer sagging or ballooning, and should become stronger as well. This type of surgery can help with a feeling of a bulge or pressure in the vagina. It may also help with the problem of not being able to completely empty your bladder. Once things are back in proper alignment, it should be easier to urinate and empty the bladder. Sometimes it can become too easy to empty the bladder, and leakage of urine can occur after this type of surgery. Learn what to expect from the anterior repair procedure (PDF).
Posterior Repair (Posterior Colporrhaphy)
A posterior repair is a vaginal surgery to correct a rectocele, when the "lower" wall of the vagina that is in contact with the rectum is bulging into the vagina, or coming outside of the opening of the vagina. This is done by making a triangular or diamond-shaped incision, and removing some of the extra skin of the wall of the vagina. After this skin is removed, the strong tissues underneath are brought together with strong stitches. This type of surgery can help with a feeling of a bulge or pressure in the vagina. It sometimes helps a woman to empty her bowels more efficiently. One possible risk of this surgery is that the vaginal opening may become narrow with scar tissue, and there may be some discomfort with sexual activity. Find out about the posterior repair procedure (PDF).
Sacrospinous Ligament Suspension
A sacrospinous ligament suspension is a vaginal surgery that is used to re-attach the "top" or "apex" of the vagina when it has come down. Normally the vagina is held in place by the combined action of ligaments (sometimes called fascias) and muscles. The primary problem in women with vaginal prolapse occurs when the tissues that normally hold the top of the vagina up in place have failed. This operation attaches the vagina to the sacrospinous ligament through the vagina. There is not an abdominal incision. An incision is made at the top of the vagina. We then reach up to the ligament and put 4 stitches into it. We then use these stitches to tie the top of the vagina up. This gets the vagina pulled up to a normal position. Then, if the front wall is still dropped, an anterior repair is done. If the back wall is falling, a posterior repair is also done. During the operation we will correct any of the areas that are abnormal.
Uterosacral Ligament Suspension
A uterosacral ligament suspension is a vaginal surgery that is used to re-attach the "top" or "apex" of the vagina when it has come down. The "top" or "cuff" of the vagina is sewn to two strong ligaments deep in the pelvis, called the uterosacral ligaments. After the surgery, the top of the vagina should be deep inside of the body, instead of coming out as it was before. One possible risk of this surgery is the possibility of injuring the ureter, which is the tube that carries urine between the kidney and the bladder.
Colpocleisis (vaginal shortening)
A colpocleisis is one type of operation used to correct pelvic organ prolapse (“fallen womb, bladder”, etc.) for women who do not desire future vaginal intercourse and/or are in poor general health. Colpocleisis is a highly effective surgery (85-95% cure rate) with minimal to no complications. A study of older women (mean age 80) reported patient satisfaction of greater than 90%, similar to the rates seen with major reconstructive pelvic surgery.
The surgery takes place vaginally, that is, no incisions are made on the abdomen. The skin is removed from the vaginal bulge, and then the tissue is progressively sutured upon itself using many layers (see figure). If you have a uterus, it is not necessary to perform a hysterectomy, as channels are created within the closed tissue for drainage or bleeding to come out.
After the procedure, if you were to examine yourself, you would appear physically normal. However, because the purpose of surgery is to effectively shorten the vagina, it will no longer be deep enough to permit intercourse. Therefore, it is essential that you and/or your partner understand that vaginal intercourse will be impossible after this type of procedure. You will maintain other sexual function (e.g., responsiveness, orgasm, etc.) because those areas will not be altered as a result of the surgery.
The advantages of this type of surgery include: less invasiveness, short operative time (average one hour), an ability to have the surgery under regional anesthesia (epidural or spinal) if desired, short hospital stay (same day surgery or just overnight), less pain than reconstructive surgery, and quicker recovery time (average 2-3 weeks). The disadvantages include: an inability to have vaginal intercourse. Find out more about colpocleisis surgery (PDF).
In general, abdominal approach surgeries have a longer recovery time and generally cause more discomfort pain than vaginal surgeries.
Hysteropexy (Uterine Sparing)
A sacral hysteropexy is a uterine sparing surgery done to correct a prolapse/bulge of the uterus/womb. An incision is made on the abdomen (either transverse or vertical), and the uterus is supported by mesh with stitches that are attached to the front of the tail bone (sacrum). A possible risk from this type of surgery includes mesh erosion, when the foreign body (mesh) grows through or into the tissues, such as the vagina or the bowel. Sometimes a posterior repair will be done at the same time, if there is also a rectocele.
Supracervical Hysterectomy with Sacrocolpopexy
A supracervical hysterectomy with sacrocolpopexy is done to treat prolapse of the uterus (when the uterus is very low in the vagina, or coming outside of the vagina). The uterus is removed by making an incision on the abdomen. A supracervical hysterectomy is different from a total hysterectomy in that the lower part of the uterus, the cervix, is not removed. To prevent the cervix from coming out of the vagina in the future, the cervix is supported by mesh with stitches that are attached to the front of the tail bone (sacrum). Removal of the tubes and ovaries may be done at the same time. This is something that should be discussed with your doctor if you decide to have surgery. A possible risk from this type of surgery includes mesh erosion, when the foreign body (mesh) grows through or into the tissues, such as the vagina or the bowel.
An abdominal sacrocolpopexy is done to correct a prolapse when the "top" or "apex" of the vagina has come down. An incision is made on the abdomen (either transverse or vertical), and a mesh is used to attach the top of the vagina to a strong ligament that lies along the sacrum, which is part of the pelvic bone. A possible risk from this type of surgery includes mesh erosion, when the foreign body (mesh) grows through or into the tissues, such as the vagina or the bowel. Sometimes a posterior repair will be done at the same time, if there is also a rectocele. Find out more about how abdominal sacrocolpopexy works (PDF).
Laparoscopic Reconstructive Surgery
The abdominal surgeries can also be performed laparoscopically, through several very small (1 cm) incisions, with the use of a video camera. Abdominal sacrocolpopexy, paravaginal repair, and uterosacral ligament suspension can be done with the laparoscope. One advantage of laparoscopic surgery is that recovery time is faster than with abdominal surgery, and postoperative pain is usually less than abdominal approach surgeries.