Muscles, ligaments and fibers that attach to bone support the bladder, uterus and rectum. When the muscles weaken because of childbirth or other factors, the pelvic organs can fall into the vagina. Pelvic organ prolapse is a type of hernia, which is a condition that occurs when an organ goes through an abdominal opening.
Pelvic organ prolapse is usually classified as asymptomatic (mild) or symptomatic (serious). Asymptomatic means the organs drop but do not extend beyond the vaginal opening. Symptomatic means the organs or tissue extend beyond the vaginal opening.
The type of pelvic organ prolapse is determined by which organs are affected:
- Cystocele — The bladder protrudes into the vagina.
- Rectocele — The rectum bumps into the back of the vagina.
- Uterine — The uterus drops into the vagina.
Mild cases can get better on their own. In serious cases, patients experience pressure, pain or the sensation of something falling out of their vagina or rectum. In extreme cases, people may see or feel their pelvic organs bulge out of their body. When prolapse causes pain, patients should see a doctor.
Treatment for symptomatic prolapse includes surgical and nonsurgical treatment. During surgery, a specialist uses a patient’s tissue to provide support for the prolapsed organ. Starting in the early 2000s, surgeons also began using transvaginal mesh implants to support prolapsed organs.
Drug companies claimed that vaginal mesh was superior for treating prolapse, but the U.S. Food and Drug Administration has said there is no evidence to support those claims.
Overall, treatment options for pelvic organ prolapse are limited and long-term success rates are inconsistent. Some doctors refer to pelvic organ prolapse as a chronic disease because many women experience a recurrence of symptoms after treatment.
Causes of Pelvic Organ Prolapse
Pelvic organ prolapse is caused by weakened or stretched pelvic muscles. Childbirth is the most common cause because it increases pressure on internal organs. That pressure can force the organs through the abdomen, leading to prolapse. Women who deliver babies heavier than nine pounds are at an increased risk.
- Half of women who deliver one or more babies through vaginal childbirth will experience prolapse
- A woman who has two vaginal births is eight times more likely to experience prolapse than a woman who hasn’t given birth vaginally
- After four vaginal births, a woman is 12 times more likely to suffer from prolapse
When women go through menopause, one side effect is a drop in their collagen levels. Collagen is a naturally occurring protein that helps connective tissue repair itself after stretching or tearing. Menopause, old age and other factors also contribute to weakened muscles.
- Multiple sclerosis
- Spinal cord injury and paralysis
- Muscular dystrophy
- Chronic cough
- Genetic weakness of connective tissue
Connective tissue in the pelvis can also weaken and cause prolapse when the uterus or cervix are removed during a hysterectomy. The risk of prolapse following a hysterectomy can be reduced if the doctor attaches the top of the vagina to ligaments in the pelvis during the procedure. This provides extra support to the pelvic organs.
A similar condition called rectal prolapse can occur in men as they age and their tissue loses its elasticity.
Symptoms of Pelvic Organ Prolapse
Lower back pain is one of the symptoms of pelvic organ prolapse
Symptoms of prolapse develop gradually as pelvic floor muscles weaken. Women will often feel pressure as the uterus, bladder or rectum press on the vaginal wall. Pain during sexual intercourse (dyspareunia) is a common symptom of prolapse in women. Recurring urinary tract infections may also indicate prolapse.
Women suffering from prolapse may experience pain during bowel movements or urination. Lifting objects, standing and jumping worsen prolapse symptoms. Lying down can help alleviate symptoms.
People who experience multiple symptoms should see their primary doctor or OB-GYN. Doctors can run several tests to diagnose pelvic organ prolapse.
Other symptoms of pelvic organ prolapse are:
- Pulling and stretching sensation in the groin
- Feeling bloated in the lower belly
- Lower back pain
- Spotting or bleeding
Diagnosing Pelvic Organ Prolapse
People usually seek medical attention for prolapse when it causes pain and discomfort. A doctor can diagnose prolapse with a cotton swab test, a bladder function test or a pelvic-floor strength test. Primary care doctors or OB-GYNs may refer patients to a pelvic floor specialist called a urogynecologist for diagnosis and treatment.
During a cotton swab test, a small cotton applicator is fed through a woman’s urethra. The patient is then asked to strain or cough, which indicates the position of the bladder.
A bladder function test uses a funnel to record a patient’s urine flow. If the bladder is under pressure from prolapse, the urine will flow at a certain rate. A catheter also may be inserted through the urethra to fill the bladder with sterile liquid. The pressure and volume of the bladder are recorded, allowing the doctor to diagnose the bladder’s condition.
In a pelvic floor strength test, potential muscle weakness is measured as the patient uses his or her pelvic floor and sphincter muscles.
If the prolapse is at an early stage, an MRI, X-ray, ultrasound, colonoscopy or cystoscopy can detect it. In cystoscopies and colonoscopies, a small camera is inserted through the urethra or the rectum.
Stages of Pelvic Organ Prolapse
The Pelvic Organ Prolapse Quantification system is the standard method for classifying how far organs have prolapsed in women.
There are five stages of prolapse:
- Stage 0: Organs are in their normal position
- Stage 1: An organ extends more than one centimeter above the hymen
- Stage 2: An organ is less than one centimeter from the hymen
- Stage 3: An organ extends more than one centimeter but less than two centimeters below the hymen
- Stage 4: The organ protrudes into the vagina
The POPQ measures six areas in the vagina to document how many centimeters the organs have fallen past the top of the vagina (the hymen). Doctors may use a long Q-tip as a ruler.
Centimeters above the hymen are negative points (less prolapse), and centimeters below are positive (more serious prolapse). Doctors total the points from each area to find the stage of the prolapse.
Treating Pelvic Organ Prolapse
After diagnosis, doctors recommend treatment that slows the descent of the organs, such as Kegel exercises. They’ll continue to monitor symptoms until prolapse causes pain or discomfort.
One study showed that 75 percent of doctors used conservative (nonsurgical) treatment as the first therapy for prolapse. Conservative treatment has the advantage of being safer, less expensive and less damaging to a patient’s body.
When the prolapse causes pain or discomfort, doctors may move to surgical methods. If advanced prolapse is left untreated, organs can eventually bulge into the vagina or hang out of the body when standing or walking.
Women can slow or prevent prolapse naturally by exercising their pelvic floor Kegel muscles. Kegel muscles control urination. Exercising them strengthens the pelvic area and supports the pelvic organs.
Doctors often prescribe low-dose estrogen cream to strengthen pelvic connective tissue and slow the movement of prolapsed organs. Estrogen creams are applied vaginally once a day for the first two weeks of treatment and three times a week thereafter.
Another conservative treatment involves a device called a pessary that is inserted into the vagina. This rubber ring provides support to organs. Estrogen cream can be used with this device to lower the risk of side effects such as odor, vaginal discharge, infection, ulcers, irritation and bleeding. The pessary must be cleaned regularly and removed before sexual intercourse.
Traditionally, doctors have turned to a surgical procedure known as a colporrhaphy to repair prolapse in women. In a colporrhaphy, doctors use stitches and the patient’s own tissues to repair weakened muscles and create more pelvic floor support. Doctors may perform a laparoscopic colporrhaphy, or they may cut the abdomen for the surgery.
Because prolapse can return after a colporrhaphy, doctors began using surgical mesh to reinforce the pelvic floor muscles in the early 2000s. A small piece of mesh — known as transvaginal mesh — was inserted through the vagina and sewn into pelvic floor ligaments and vaginal tissue.
More medical device manufacturers, such as Johnson & Johnson, Boston Scientific Corp., C.R. Bard and American Medical Systems, began making transvaginal mesh kits to assist surgeons in the operation.
Today, however, doctors are returning to colporrhaphy because complications with transvaginal mesh are increasingly common. The mesh can erode through vaginal walls and into other organs. It can also cause organ perforation. Many women have to undergo multiple revision surgeries to repair problems caused by transvaginal mesh.
Preventing Pelvic Organ Prolapse
Many causes of pelvic organ prolapse are unavoidable. It’s a genetic disorder that tends to run in families. Injury to the pelvic floor from traumatic experiences such as labor are unavoidable for women who choose to have children. Other traumatic experiences, such as auto accidents, are often unexpected. Menopause is also inevitable. However, women can take steps to avoid the certain factors that increase the risk of pelvic organ prolapse.
- Heavy lifting
- Intense activities, such as CrossFit
Pelvic organ prolapse can be a serious condition that lowers quality of life. Patients should talk to their doctors about all treatment options, including the benefits and risks of using transvaginal mesh during surgery. Conservative, non-surgical treatment options may provide relief from symptoms and help patients avoid surgery.