Normally, the bladder, uterus, & rectum are supported inside the pelvis & away from the vagina. The muscles, ligaments, and connective tissues  in and around a woman’s vagina act as a complex support structure that holds pelvic organs, tissues, and structures in place. Various parts of this support system may eventually weaken or break, causing the bladder, uterus, upper vagina, &/or rectum to “drop” or “fall.” This is called prolapse. It is essentially a type of hernia where the organs bulge into the vagina. Without medical treatment or surgery, these structures may eventually prolapse farther and farther into the vagina or even through the vaginal opening & outside.

Significant pelvic organ prolapse may affect at least 1 in 3 women over their lifetime. Loss of support of the uterus, bladder, &/or rectum may result in a many clinical symptoms including incontinence,problems with sex, & disruption of social & exercise activities. The most important contributing factor is childbearing, but the inherent strength of the supporting tissues of the vagina & uterus is also important. Numerous studies have demonstrated that there are genetic factors which increase the risk & accelerate the course of prolapse. It is not uncommon for grandmothers, mothers, sisters, & daughters in a family to suffer from the same prolapse problems. With time these problems almost always slowly get worse.

 

 

 

 

 

 

 

 

What are the symptoms of prolapse?

Early stages of prolapse usually do not cause any symptoms. As the prolapse worsens the most common symptom is that you note a bulge coming to the vaginal opening. This is often felt in the shower or using the toilet.  As the bulge worsens is can cause pressure, lower back discomfort, discomfort or reduced sensation during sex, trouble emptying your bladder or bowels, or incontinence. Prolapse usually does not cause pain, even in advanced stages. When the prolapse comes outside it can rub on your clothing, become chapped & dry, & may even become abraded & bleed.

What types of prolapse can occur?

Like most things, prolapse occurs in different levels of severity. In mild forms of prolapse, no treatment is necessary & it is reasonable to see what will happen with time. In most women, their prolapse will slowly worsen with time. Exercise, straining, & sex will not significantly cause the condition to get worse; although the prolapse may make these activities uncomfortable. In severe forms of prolapse, the pelvic organs may be completely outside forming a large bulge.

1. Bladder prolapse, “cystocele”

Bladder prolapse is probably the most common type of prolapse. This is called a “cystocele.” When it is mild, no treatment is necessary. When it involves the opening which the  bladder empties through, or “urethra,” it can lead to urine leakage with coughing, straining, & exercise.

 

2. Rectum prolapse, “rectocele”

When the tissues between the vagina & rectum are weakened, the rectum can bulge into the vagina causing a “rectocele.”  This can progress to the point where it can be difficult to empty the bowels. Some women have to push the bulge back into the vagina to empty. This is called “splinting.” Childbirth can injure these tissues as well as the “perineum” between the vagina & anus. This leads to an increase in the size of the vaginal opening & can cause problems with intercourse. Chronic constipation & straining can worsen these problems.

3. Uterine prolapse

When the ligaments which support the uterus are damaged, the uterus can fall into the vagina or even outside.

The lower part of the uterus, or “cervix,” is very delicate & it is not uncommon for it to become abraded & bleed when it is outside.

4. Vaginal vault prolapse

When a hysterectomy is performed, the upper vaginal tissues are attached to the ligaments that support the uterus (the “uterosacral ligaments”). If these tissues are weak, the upper vagina (the vaginal “cuff” or “vault”) will drop into the vagina. This is essentially like turning a sock inside-out from the toe. The small bowel will fall into this space & form an “enterocele.”

As vault prolapse progresses to it’s worst extent, the vagina can become completely everted & form a bulge as large as a cantaloupe.

 

When does prolapse need to be treated?

It is reasonable to follow mild prolapse expectantly. Prolapse, even at its worst extent, rarely causes pain. It usually progresses slowly over time. When it is interfering with your activities or becoming uncomfortable, many treatment options exist. It is important to have clear goals for treatment of prolapse. Sometimes it is impossible to know whether a symptom, for example back pain, is due to prolapse or something else, & you may not know the answer until after the treatment. As a rule of thumb, once the tissue starts to come outside of the vaginal opening, it is time to start thinking about treatment. There are no medicines or exercise therapies for prolapse, & treatment options consist of using a mechanical device called a pessary or surgery.