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 something in your belly (abdomen)
• A weak bladder, needing to urinate (pee) often, or difficulties urinating
• A “dragging” pain in your belly
• Pain or other problems during sex
• Problems with bowel movements (pooping)
• Back pain
• Pressure sores and bleeding in the vagina

The pain, "pushing-down" sensation, and the feeling that there's something inside you are most noticeable when walking, standing or going to the toilet (pooping). They often get better when you're in a lying position.

Sometimes the organs slip down so far that the vagina bulges outward or part of the womb (uterus) visibly comes out of the vaginal opening. This type of vaginal or uterine prolapse is usually especially distressing – both physically and emotionally. Many women feel ashamed if this happens, and it can greatly affect their sex life as well.

The pelvic floor closes the pelvic cavity from below. Made up of muscles and connective tissue, it helps to keep the pelvic organs in place. If the pelvic floor is no longer firm enough (a weak pelvic floor), the organs can drop down. Some women are more likely to have weak connective tissue because of their genes. Other risk factors include the following:

• Vaginal births: Giving birth in this way can damage and weaken the pelvic floor. If the second ("pushing") stage of labor takes a long time, pelvic floor damage is more likely. The risk also increases if the child weighs more than 4,000 grams at birth or was delivered using forceps or a suction cup. 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. There isn’t much research in this area, though, 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 other organs dropping down. But it's assumed that the bladder and bowel have less support following a hysterectomy, so they're more likely to slip down.

About half of all women develop mild pelvic floor weakness over the course of their life, but that usually doesn't cause any major problems. It is estimated that about 5% of women have a prolapse that causes distressing symptoms.

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

• Stage 1: The organs have only slipped down a little.
• Stage 2: The organs have slipped down to the level of the vaginal opening.
• Stage 3: Up to 1 cm of the vagina or womb is bulging out of the vaginal opening.
• Stage 4: A large part of the vagina or womb is bulging out of the vaginal opening.

In most women with a mild prolapse, it doesn't get worse. The prolapse may even improve after a few months or years – for example, if it happened while giving birth. But it might gradually get worse over time.

About half of all women who have a mild (stage 1 or 2) pelvic organ prolapse also leak urine sometimes. This 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 stage 3 or 4 prolapse are more likely to have trouble emptying their bladder. This is because the prolapsed organs may cause the urethra (urine tube) to bend, blocking the flow of urine.

Women who have a mild pelvic organ prolapse often only find out about it when they go to see their doctor due to general abdominal pain or bladder problems. To diagnose milder cases, the doctor feels the pelvic 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. They can assess the position of the organs in the back part of the pelvis by gently inserting fingers into the anus and feeling the organs through the bowel. 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 (pee) comes out when you cough hard.

If you have problems peeing, 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 (also called Kegel exercises) can help to strengthen the muscles in the pelvis and stabilize 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 go easy on your 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 whether symptoms occur 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 you are,
• whether you still want to have children,
• whether you would like to keep your womb,
• which organ has dropped down, and how much,
• how effective non-surgical treatments are, and
• whether you have urinary incontinence or other medical conditions.

The non-surgical treatment options are:

• Pelvic floor exercises (also called Kegel exercises): Specific exercises to strengthen the muscles in the pelvis and the pelvic floor.
• Therapeutic pessaries: Small cubes, rings or saucer-shaped devices made of rubber or silicone. They are placed inside the vagina to support the pelvic organs. Pessaries are available in different sizes. They should be individually fitted.

Some women can relieve their symptoms enough through pelvic floor exercises or by using a pessary. Hormone treatment is sometimes recommended too – for example, a cream that you apply to your vagina. But there is no evidence that hormone treatments help reduce pelvic organ prolapse. They can protect the lining of the vagina when using a pessary, though, and also make it easier to insert the pessary.

If these things don't help, the symptoms get worse or if part of the womb is bulging out of the vagina, surgery may be considered. The aim is to lift the pelvic organs up, stabilize them, and strengthen the connective tissue. Surgery usually doesn’t involve removing the womb. Doctors sometimes recommend removing the womb (having a hysterectomy), though. Surgery can usually correct the prolapse and reduce the associated symptoms. But organs may drop down again after a while.

Sometimes pelvic floor exercises or pessaries do not reduce prolapse symptoms enough. Then surgery is the only treatment that will help. You can use our decision aid to see which treatment options you would consider.

In Germany, doctors who recommend a hysterectomy must inform you of your right to a second medical opinion. That means that you can have an appointment with a different specialist to help you decide whether or not to have the surgery. You will not have to pay for the appointment.

When women in Germany have gynecological health problems, they usually go to their gynecologist first. It is a good idea to see a specialist for the diagnosis and treatment of pelvic organ prolapse – for example, in a pelvic floor center (Beckenbodenzentrum). You will find a list of specialized centers here (in German).

Information about health care in Germany can help you to navigate the healthcare system and find a suitable doctor. You can use this list of questions to prepare for your appointment.