Pelvic organ prolapse

Pelvic organ prolapse is when one or more pelvic organs drop from their position. This makes a bulge in the vagina, called a prolapse.

The muscles and connective tissues of the pelvic floor typically hold the pelvic organs in place. Pelvic organs include the vagina, bladder, uterus, urethra and rectum. Pelvic organ prolapse happens when the muscles and tissues of the pelvic floor weaken. This may be due to pregnancy, childbirth or menopause.

Pelvic organ prolapse can be treated. Often, nonsurgical treatment helps. Sometimes, surgery might be needed to put the pelvic organs back in place.

Sometimes, pelvic organ prolapse has no symptoms. When symptoms happen, they might include:

• Seeing or feeling a bulge of tissue at or beyond the opening of the vagina.
• Pelvic pressure, heaviness or pain.
• Lower back pain.
• Not being able to keep in a tampon.
• Urinary changes. These might include urinating more, feeling an urgent need to urinate, not being able to empty the bladder all the way or having a weak urine stream.
• Bowel changes, such as not emptying stool all the way or having to put fingers in the vagina to support the bulge to be able to pass stool. This is called splinting.
• Sexual issues, such as pain with sex.

Weakness of the pelvic floor often affects more than one area. For instance, if one of your pelvic organs is prolapsed, you're more likely to have another type of pelvic organ prolapse.

The cause of pelvic organ prolapse is the weakening of the tissues and the muscles that support the pelvic organs. The most common cause is having a baby vaginally.

Risk factors for pelvic organ prolapse include:

• Having more than one baby, vaginal delivery, high birth weight babies and deliveries using tools.
• Being older.
• Being obese.
• Having had pelvic surgery.
• Straining from an ongoing cough, such as from chronic obstructive pulmonary disease, ongoing constipation or ongoing heavy lifting.
• Having a family history of pelvic organ prolapse or connective tissue conditions.

Diagnosis of pelvic organ prolapse begins with a medical history and an exam of the pelvic organs. This can help your healthcare professional find the type of prolapse you may have.

Some tests also might be needed. Tests for pelvic organ prolapse can include:

• Pelvic floor strength tests. A healthcare professional tests the strength of the pelvic floor and sphincter muscles during a pelvic exam. This tests the strength of the muscles and ligaments that support the vaginal walls, uterus, rectum, urethra and bladder.
• Bladder function tests. Some tests show whether the bladder leaks when it's held in place during the pelvic exam. Other tests might measure how well the bladder empties.

Imaging, such as MRI or ultrasound, might be used for people whose pelvic organ prolapse is complex.

Treatment depends on your symptoms and how much they bother you. If your pelvic organ prolapse doesn't bother you, your healthcare professional might suggest no treatment or treating the prolapse without surgery. If symptoms get worse and affect your quality of life, you might need surgery.

The prolapse might not be the cause of urinary and bowel symptoms, although they can be linked. If those symptoms are not linked to the prolapse, then treatment for the prolapse might not improve them.

Medications

Many people with prolapse also are in menopause. Menopause lowers estrogen levels. Too little estrogen can weaken vaginal tissue and lead to vaginal dryness. Talk with your healthcare professional about whether treatment with estrogen is right for you. The use of vaginal estrogen might be an option.

Physical therapy

Your healthcare professional may suggest pelvic floor exercises using biofeedback to strengthen muscles of the pelvic floor. Biofeedback involves the use of monitoring devices with sensors that are placed in the vagina and rectum or on the skin. As you do an exercise, a computer screen shows whether you're using the right muscles. It also shows the strength of each squeeze, called a contraction. This helps you learn how to do the exercises correctly. Over time, making pelvic floor muscles stronger might help ease symptoms.

Pessaries

Using a pessary is a nonsurgical way to support prolapsed pelvic organs. These silicone devices come in various shapes and sizes. They're put in the vagina to hold the pelvic organs in place.

Some people who use pessaries can learn to take them out at night, clean them and replace them in the morning. Others might need to visit their healthcare professional every three months to replace the pessary.

Surgery

If your pelvic organ prolapse bothers you, surgery might help. The goals of surgery are to get rid of the vaginal bulge and improve some symptoms.

Most often, the surgery corrects the prolapse and aims to put the pelvic organs back in place. This is called reconstructive surgery. The approach to surgery depends on where the prolapse is and whether there's more than one area of prolapse.

• Anterior prolapse. The most common site of prolapse is the front, also called anterior, vaginal wall. An anterior prolapse most often involves the bladder. This type of prolapse is called a cystocele.

  Anterior prolapse repair is done through a cut, called in incision, in the wall of the vagina. A surgeon pushes the bladder up and secures the connective tissue between the bladder and the vagina to keep the bladder in place. This is called a colporrhaphy.

  The surgeon also removes extra tissue. If you have urinary incontinence, the surgeon might suggest a bladder neck suspension or sling to support your urethra.

• Posterior prolapse. This type of prolapse involves the rear, also called posterior, vaginal wall. A posterior prolapse involves the rectum. This type of prolapse is called a rectocele.

  A surgeon secures the connective tissue between the vagina and rectum to make the bulge smaller. The surgeon also removes extra tissue.

• Uterine prolapse. If you don't plan to have children, the surgeon might suggest surgery to remove the uterus. This is called a hysterectomy.

• Vaginal vault prolapse. In people who have had a hysterectomy, the top of the vagina can lose its support and drop. This type of prolapse might involve the bladder and rectum. The small bowel is often involved. When it is, the bulge is called an enterocele.

  The surgeon might do the surgery through the vagina or abdomen. In a vaginal approach, the surgeon uses the ligaments that support the uterus to correct the problem.

  An abdominal approach might be done laparoscopically, robotically or as an open procedure. The surgeon attaches the vagina to the tailbone. Small pieces of mesh might be used to help support vaginal tissues.

  If you're concerned about the use of mesh materials, talk with the surgeon about the benefits and possible risks.

Prolapse surgery only repairs the tissue bulge. If the bulge doesn't bother you, surgery isn't needed. Surgery doesn't repair the weakened tissues. So the prolapse might come back.

Pelvic organ prolapse is the result of weakened pelvic floor tissues that make a bulge. There are things you can do to help stop weakness in these tissues. These steps can help keep your condition from getting worse. They also may help keep symptoms from coming back after a surgical repair. Try the following:

• Quit smoking.
• Treat conditions that might put strain on the pelvic floor, such as long-term cough or constipation.
• Lose weight.
• Strengthen your core and your pelvic floor.
• Don't lift heavy objects.
• Don't strain during bowel movements.

For uterine prolapse, you may see a specialist in conditions affecting the female reproductive system. This type of doctor is called a gynecologist. Or you may see a specialist in pelvic floor problems and reconstructive surgery. This type of doctor is called a urogynecologist.

Here's some information to help you get ready for your appointment.

What you can do

When you make the appointment, ask if there's anything you need to do before the appointment, such as not drinking or eating before having certain tests. This is called fasting.

Make a list of:

• Your symptoms, including any that seem unrelated to the reason for your appointment, and when they began.
• Key personal information, including major stresses, recent life changes and family medical history.
• All medicines, vitamins or other supplements you take, including doses.
• Questions to ask your healthcare team.

Take a family member or friend along, if possible, to help you remember the information you're given.

For pelvic organ prolapse, some basic questions to ask your healthcare professional include:

• What's likely causing my symptoms?
• What are other possible causes for my symptoms?
• What tests do I need?
• Is my condition likely to go away or be long-lasting?
• What are my treatment choices?
• I have other health conditions. How can I best manage them together?
• Are there restrictions I need to follow?
• Should I see a specialist?
• Are there brochures or other printed material I can have? What websites do you think might be helpful?

Be sure to ask all the questions you have.

What to expect from your doctor

Your healthcare professional is likely to ask you questions, such as:

• Do your symptoms come and go or do you have them all the time?
• How severe are your symptoms?
• What, if anything, seems to make your symptoms better?
• What, if anything, seems to make your symptoms worse?