Pelvic organ prolapse

By , 21 August 2013

Pelvic organ prolapse

 

What is prolapse?

Pelvic organ prolapse, or simply “prolapse”, is a condition unique to women.  It occurs when the tissues that support and hold the pelvic organs (the uterus, bowel, and bladder) in their normal positions become damaged and weakened.(1)  As a result, one or more of these organs prolapse (or “drop”) into the vagina.  Sometimes, doctors give prolapse a more specific name, depending on which organ is prolapsing, or which vaginal “wall” or “compartment” is protruding (anterior, posterior, or uterine/apical compartments).
 

How common is prolapse?

Precise rates of prolapse are not known because many women with symptoms do not seek medical attention.  However, prolapse probably affects around 40% of all women, and at least one in ten women will undergo surgery for prolapse at some time in their lives, making it a very common condition.(2)
 

What causes prolapse?

The supporting tissues may have an inherited weakness or, more usually, become torn, stretched, and/or weakened, through life events and lifestyle factors.  Pregnancy and childbirth are the most important factors, and prolapse may affect up to one third of all women who have had one or more children.(3)  The tissues may also become weakened in association with obesity, longstanding constipation or coughing, straining and heavy lifting, and smoking.  Advancing age, and especially the reduction of oestrogen after menopause, leads to further weakening.
 

What are the symptoms of prolapse?

Not all women have symptoms.  When present, symptoms vary from minimal to quite distressing, and depend upon which organ is prolapsing and how severely.  Symptoms are often worse after exercise, prolonged standing, or at the end of the day, and may include:

  • Sensation of a “lump” or “bulge” in the vagina, perhaps even protruding from the vagina
  • A pressure or dragging sensation in the lower pelvic area or lower back
  • Discomfort with sexual intercourse
  • Urinary and bowel problems: repeated bladder infections, difficulty emptying your bladder or bowel, bladder leakage with laughing, coughing, or sneezing (see incontinence).  Some women may need to press on the bulge in the vagina with a finger in order to empty their bladder or bowel
  • Bleeding may occur due to irritation and trauma to the prolapsed tissue from clothing
  • Unfortunately, embarrassment and loss of self-esteem are also common symptoms
     

How is prolapse diagnosed?

Prolapse is diagnosed during pelvic examination by your doctor.  Small degrees of prolapse may be noticed at the time of a Pap test.  A thorough assessment of prolapse by a gynaecologist may include examining the bulge of the vaginal walls in different positions, and you may be asked to strain or “bear down” do allow determination of the maximum extent of the prolapse.
 

Can prolapse be prevented?

The chance of getting prolapse can be reduced by:

  • Losing weight if you are overweight
  • Avoiding constipation by dietary changes or medications
  • Avoiding heavy lifting or straining
  • Ceasing cigarette smoking
     

How is prolapse treated?

Treatment of prolapse is generally only indicated for women with bothersome symptoms.  In such cases, treatment options include physiotherapy, pessaries, surgery, or a combination of these.  The choice of treatment will depend upon the extent of your prolapse, the severity of your symptoms, and the acceptability to you of the treatment methods.
 

Pelvic floor rehabilitation exercises (also called “Kegel” exercises) may be recommended by your doctor.  These aim to strengthen the muscles of your pelvic floor, and may reduce the severity of your prolapse, even to the point of eliminating your symptoms.  They may also reduce the rate at which your prolapse symptoms worsen, and may reduce the risk of prolapse symptoms returning after corrective surgery.  Although instructive aids can easily be found on the internet or in pamphlets, many gynaecologists (including Dr Moore) would suggest that best results are seen when these exercises are taught and monitored by a qualified physiotherapist with special training in women’s pelvic floor rehabilitation.  Dr Moore has established professional relationships with, and can recommend, particular physiotherapists who excel in this area.
 

Vaginal pessaries are small devices (often made of silicone) that are inserted inside a woman’s vagina to support the walls and reduce the symptoms of prolapse.  They come in different shapes and sizes, and are fitted largely by trial and error.  Pessaries are useful alternatives for women who do not want surgery, or who may be unfit for surgery due to other medical conditions.  They can also be used for women who are planning further pregnancies, as pregnancy after surgical repair can cause prolapse symptoms to return.  Finally, pessaries are useful for women who need to delay their surgery, to control symptoms in the meantime.  Importantly, pessaries need to be removed and cleaned regularly, and some types require removal before sexual intercourse.(4)
 

Surgery aims to reconstruct the pelvic floor by resuspending and strengthening the walls of the vagina, returning the pelvic organs to their natural position.  The particular surgical procedure undertaken depends on the type of prolapse and whether the woman has had previous prolapse surgery.  Additionally, the choice of procedure also depends on the presence of faecal or urinary incontinence, and a woman’s preference after discussion of the various options.  Importantly, hysterectomy (removal of the uterus) is not a prolapse procedure; while it may be performed at the same time as a prolapse repair for other reasons, it is not necessary in all cases, and the need for hysterectomy will be discussed in each woman’s case.  As many women with prolapse also have symptoms of urinary stress incontinence, a surgical procedure to treat incontinence may be combined with a prolapse repair.(5)  Dr Moore will fully discuss with you all planned aspects of your surgical treatment, including the risks and benefits in your particular case.
 

Pelvic organ prolapse

References

  1. Patient information: pelvic organ prolapse (The Basics). In: Basow DS, (Ed). UpToDate. Waltham, MA, 2013.
  2. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence.  Obstet Gynecol.  1997; 89(4):501-6.
  3. RANZCOG. Surgical treatment of pelvic organ prolapse: a guide for women. 2nd ed. Melbourne: Mi-tec Medical Publishing; 2005.
  4. Clemons JL. Vaginal pessary treatment of prolapse and incontinence. In: Basow DS, (Ed). UpToDate. Waltham, MA, 2013.
  5. Jelovsek JE. Pelvic organ prolapse in women: choosing a primary surgical procedure. In: Basow DS, (Ed). UpToDate. Waltham, MA, 2013.
     

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About Dr David Moore

Pelvic organ prolapse

David is a Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and undertook his specialist training in Queensland.  He is highly skilled in the management of complex and high-risk pregnancies, and has special training in minimally-invasive surgery, endometriosis, pelvic floor and incontinence surgery.  David has completed a Master of Reproductive Medicine and is skilled in the assessment and management of fertility problems, and can offer the full range of assisted reproductive treatments.  He is a Senior Lecturer with The University of Queensland Medical School, and has published both medical journal and textbook contributions.

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