Pelvic organ prolapse occurs when the pelvic organs such as the womb, rectum and bladder slip out of their normal position and into the vagina. This happens because the supporting tissues and ligaments have weakened. Stretching and slackening is a normal result of childbirth and prolapse often occurs in later life following protracted labour, large babies or the use of forceps and vacuum extraction.
Occasionally prolapse may occur if there is an inherited weakness of the pelvic floor muscles or as a result of heavy lifting, chronic coughing and constipation. Obesity can add additional stresses to an already weak system of support as the extra weight presses on the bladder.
Finally, it can happen as a natural result of menopause as the muscles thin and become weaker.
It is estimated that up to 50% of women who have had children are affected by some degree of prolapse. It happens more frequently as women age and go through menopause and it’s rare in women who haven’t had children. It is also the most common reason for women to have a hysterectomy when they are over 50 years of age.
The types of prolapse that can occur are:
- Uterine prolapse involving the womb
- Rectocele involving the rectum
- Cystocele involving the bladder
- Enterocele involving a hernia of the small bowel
- Vaginal vault where the top of the vagina sags after a hysterectomy.
They can occur separately or together and will occur to differing degrees.
Symptoms of pelvic organ prolapse
- lump or bulge inside or outside the vagina
- the feeling of pressure in the vagina
- recurring bladder infections
- backache in the lower back
- disturbance of bowel movements
- need to urinate more frequently
- incontinence to a varying degree
- stress incontinence
- sexual discomfort
- urge incontinence
- overflow incontinence
- total incontinence
All prolapses have different stages or degrees. Each of these requires a different type of intervention or treatment.
- stage 1: the prolapse is more than 1cm above the opening of the vagina
- stage 2: the prolapse is 1cm or less from the opening of the vagina
- stage 3: the prolapse sticks out of the vagina opening more than 1cm, but not fully
- stage 4: the full length of the prolapse bulges out of the vagina
In most cases of stage 1 and some stage 2 prolapses treatment will be things like weight loss and kegel exercises (pelvic floor exercises). It is also possible that HRT may be prescribed as this could have a beneficial effect on the pelvic floor muscles and surrounding tissues and ligaments
Many stage 2 and some stage 3 prolapses may require the insertion of a device called a vaginal ring pessary which can help to hold the prolapsed organ in its proper place
For most stage 3 and 4 prolapses, it is likely that surgery will become necessary. This may involve insertion of a mesh to support the womb or even a hysterectomy. It is possible that women who have been treated may also need surgery to support the vaginal walls as well. There is no guarantee that surgery will solve all the symptoms of prolapse and in some cases, it can make them worse.
What Treatment is Available?
The most common Drug Treatment is the use of hormone replacement therapy which is used to help restore the strength in the ligaments and muscles.
Surgical Treatment (Alternatives to Hysterectomy)
Surgical treatments are used to repair and restructure the ligaments and muscles and will depend on the type and amount of prolapse that has occurred. It includes vaginal repairs which involve the vagina being cut and folded over to create additional support. However, such repairs may impact sexual activity, particularly where the vagina is narrowed or shortened.
The vaginal suspension (uterocolposacropexy) uses netting or leather to attach the top of the cervix or vagina to the top of the pelvis.
A Manchester procedure partially amputates the elongated cervix and shortens the ligaments which support the uterus in its normal position.