Pelvic organ prolapse

Mild cases of pelvic organ prolapse often don’t cause any symptoms. But if the organs drop down further, the following problems may arise:

• feeling like something is pushing down
• feeling like there’s a foreign object in your abdomen
• a weak bladder, needing to urinate (pee) often, or difficulties urinating
• a “dragging” pain in the abdomen
• pain during sex
• problems with bowel movements
• low back pain
• pressure sores and bleeding in the vagina

Pain, pressure and the feeling that there’s something inside you mainly occur when walking, standing or during bowel movements. They often go away when you lie down.

Sometimes these organs slip down so far that the vagina is pushed outward or the womb bulges out of the vaginal opening. This type of prolapse can be especially distressing – both physically and emotionally. Many women feel ashamed, and it can greatly affect their sex life as well.

Pelvic organs drop down if the muscles and connective tissue that hold them in place are no longer firm enough. This is referred to as a weak pelvic floor. Some women are more likely to have weak connective tissue because of their genes. Other risk factors include the following:

• Vaginal birth: Giving birth in this way can damage and weaken the pelvic floor. Having a Cesarean section doesn't increase the risk of vaginal or uterine prolapse.
• Age: Muscles and connective tissue become weaker over time. This can destabilize the support structures in the pelvic floor.
• Weight: Vaginal or uterine prolapse is more common in women who are very overweight.

It is also thought that the pelvic floor can become weaker due to things like lifting and carrying heavy objects, a chronic cough or frequent constipation. But there isn’t much research in this area, so it’s not clear what role these factors play. It is also not clear whether surgery to remove the womb (a hysterectomy) increases the risk of prolapse. The bladder and bowel are thought to have less support following a hysterectomy, and to be more likely to slip down as a result.

In about half of all women, the pelvic floor weakens a little in the course of their life. It is estimated that about 3% of women have a prolapse that causes symptoms.

There are four general stages of severity, defined by how far the bladder, womb or bowel have dropped down:

• First-degree prolapse: The organs have only slipped down a little.
• Second-degree prolapse: The organs have slipped down to the level of the vaginal opening.
• Third-degree prolapse: The vagina or womb has dropped down so much that up to 1 cm of it is bulging out of the vaginal opening.
• Fourth-degree prolapse: More than 1 cm of the vagina or womb is bulging out of the vaginal opening.

Most women only have a mild prolapse that may even go away again after a few months or years. But it might gradually get worse over time.

About half of all women who have a mild (first-grade or second-grade) pelvic organ prolapse also leak urine sometimes. This kind of unintentional loss of urine is known as stress incontinence because it happens when the woman’s bladder is exposed to pressure (“stress”) – for instance when she sneezes, coughs or does sports. Women with a third-grade or fourth-grade prolapse are likely to have a different problem: it tends to be difficult for them to empty their bladder because the prolapsed organs may cause the urethra (urine tube) to bend, blocking the flow of urine.

Women who have a pelvic organ prolapse often go to see their doctor because they have general abdominal pain or bladder problems. Severe cases can already be diagnosed by examining the vagina. In order to be able to diagnose milder cases, the doctor feels the abdominal organs with their hands – both from the outside (belly) and from inside the vagina – and examines the vagina with an instrument known as a speculum. The position of the organs in the back part of the pelvis can be felt through the anus. These examinations are usually enough to diagnose a prolapse and determine how severe it is.

Stress incontinence can be diagnosed using the cough stress test, which tests whether urine comes out when you cough hard.

If you have problems urinating, you can do a post-void residual urine test to try to find out why. This test involves going to the toilet to empty your bladder as much as possible. The doctor then checks whether you still have urine in your bladder. This is usually done using ultrasound.

Regularly doing pelvic floor exercises (sometimes called Kegel exercises) can strengthen the pelvic floor muscles and the pelvic floor. Special postnatal exercises can help your pelvic floor to recover after giving birth. Doctors sometimes recommend that you avoid lifting or carrying heavy objects, in order to rest the pelvic floor. If someone has a chronic cough or regular constipation, treating that condition is also thought to help reduce pelvic floor problems. But there isn’t enough good research in this area to know whether these measures or losing weight can actually prevent prolapse.

The choice of treatment will mainly be based on the severity of symptoms rather than how far the organs have slipped down. The most suitable treatment will depend on things like

• which symptoms you would like to improve and how distressing they are,
• how old the woman is,
• whether she still wants to have children,
• whether she would like to keep her womb,
• which organ has dropped down, and how much,
• how effective non-surgical treatments are, and
• whether she has urinary incontinence or other medical conditions.

The treatment options are:

• Pelvic floor exercises to strengthen the muscles
• Vaginal pessaries: small cubes, rings or saucer-shaped devices made of rubber or silicone (not to be confused with contraceptive pessaries or caps). These pessaries are inserted into the vagina with the aim of supporting the organs in the pelvis. They are available in different sizes.
• Surgery: Prolapse surgery involves lifting and stabilizing the organs in the pelvis. A hysterectomy is sometimes recommended too.

Some women can relieve their symptoms enough through pelvic floor exercises or by using a vaginal pessary. If neither of these help, if the symptoms get worse or if a lot of the womb is bulging out of the vaginal opening, surgery may be an alternative option. Surgery usually doesn’t involve removing the womb.

Our decision aid may help when deciding whether or not to have surgery. It summarizes the main advantages and disadvantages of the various treatment options.

When people have gynecological diseases or health problems, they usually go to see their gynecologist first. Read about how to find the right doctor, how to prepare for the appointment and what to remember.