Pelvic organ prolapse
Pelvic organ prolapse is when the bladder, the bowel or the womb slips downwards and pushes against the wall of the vagina, and sometimes appears outside it.
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Pelvic organ prolapse is when the bladder, the bowel or the womb slips downwards and pushes against the wall of the vagina, and sometimes appears outside it. What holds them up from below is the pelvic floor, a sheet of muscle and ligament slung like a hammock between the pubic bone and the tailbone. When that hammock stretches, the support goes. It is not a tumour and not a threat to life, but it affects daily life a good deal and does not put itself right with time. Past the age of fifty, signs of prolapse are found in a great many women, though only some of them have symptoms.
What exactly is coming down
Which wall of the vagina has given way determines both the symptoms and the treatment. A report will name one of these, and often several at once, since they frequently occur together.
- Front wall and bladder. The commonest kind. The bulge is felt at the front and usually comes with problems passing urine.
- Back wall and bowel. The bulge is at the back, and the main complaint is difficulty emptying the bowel.
- Womb. The cervix comes down the vagina and, in severe cases, outside it.
- Vaginal vault. This follows removal of the womb: the top of the vagina drops, having lost its anchor.
- Loops of bowel between the vagina and the rectum — less common, and also usually after surgery.
Severity is described in grades from one to four: at grade one the descent is barely noticeable and is found by chance; at grade four the organ comes fully outside. Grade and symptoms do not always match — a small prolapse can be miserable and a marked one barely felt.
What it feels like
Symptoms are rarely sharp. They usually build through the day and with exertion, and ease after lying down. Typically:
- heaviness, pressure, a sense of "something being in the way" low down or in the vagina;
- a bulge that can be felt or seen inside the vagina and, at higher grades, outside it;
- leaking urine when coughing, laughing or running; or the opposite — a weak stream, a bladder that does not empty, and having to go back to the toilet;
- difficulty opening the bowels: a feeling of incomplete emptying, needing to strain or to press with a finger;
- discomfort or reduced sensation during sex;
- a dragging feeling in the lower back that goes when you lie down.
Quite often prolapse causes no symptoms at all and is found by chance, for instance at a cervical screening appointment. One point is worth separating out: severe pain is not typical of prolapse. If something genuinely hurts, the cause is looked for elsewhere.
When it cannot wait
In most cases an ordinary appointment is enough. But some situations need help urgently:
- you cannot pass urine and the bladder is full and painful — this is acute urinary retention; go to an emergency department at once or call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine, 112);
- the part that has come down will not go back, has swollen, has turned dusky or has become sharply painful;
- an ulcer has appeared on the protruding tissue, it is bleeding, or there is offensive, purulent discharge;
- you cannot empty your bowels at all, the abdomen is distended, and there is nausea and vomiting;
- a fever appears along with loin pain and burning on passing urine — a kidney infection on the back of urine that is not draining.
Without urgency, but without putting it off for years, see a doctor if a bulge has appeared in the vagina, if urine leaks continuously, or if there is any bleeding after the menopause: that last one has nothing to do with prolapse and needs investigating in its own right.
Why the pelvic floor stops holding
The cause is almost always cumulative: one event stretched the muscle, and everything else stopped it recovering over the years.
- Vaginal births, particularly long labours, large babies, forceps or ventouse deliveries, and several births in succession.
- The menopause. As oestrogen falls the tissues thin and hold their shape less well, which is why prolapse so often first declares itself in those years.
- Constant pressure from above: extra weight, chronic constipation with straining, a smoker's persistent cough, work involving heavy lifting.
- Pelvic surgery, above all removal of the womb: the top of the vagina loses its usual anchor.
- Connective tissue differences — joint hypermobility, Ehlers-Danlos and Marfan syndromes. With these, prolapse also occurs in young women and in those who have never given birth.
Family history counts too: if a mother or sister had prolapse, the likelihood is higher. That is not a sentence, though — weight, constipation and cough can all be acted on, and doing so works.
What happens at the appointment
The diagnosis is made by examination; complicated tests are not usually needed. The doctor will ask what is troubling you, how things are with passing urine and opening the bowels, and how many births there were and how they went.
For the examination you undress from the waist down. You can ask for a chaperone, ask to be seen by a woman doctor, and stop the examination at any point. It is usually done lying on your side with the knees drawn up; to see the prolapse at its fullest you may be asked to bear down or cough, and sometimes you are examined standing. The doctor passes a speculum — a smooth instrument that holds the vaginal walls apart — and sees which one is descending and how far.
Further tests are not for everyone. They are arranged when there are urinary symptoms: a bladder diary, measuring how much urine is left after passing water, a urine test and sometimes a study of bladder function. For an ordinary prolapse neither a scan nor an MRI is needed.
What else a lump can be
A "lump" in the vagina is not always a prolapse, and it is a doctor who sorts that out, not a search engine:
- a cyst of the vaginal wall or of the Bartholin's gland — firm, with clear edges, unchanged when you bear down;
- a polyp or a submucous fibroid coming through the cervix — usually with bleeding as well;
- a urethral diverticulum — a swelling by the front wall, with urine dribbling after you have finished;
- piles and rectal prolapse — the bulge comes from the back passage, not from the vagina;
- a tumour of the vagina or cervix — rare, and precisely for that reason any lump is examined rather than judged from a description;
- urinary incontinence without prolapse — that is treated differently, and one does not imply the other.
Pain is a trap of its own. If pain is the main complaint, what usually lies behind it is endometriosis, chronic pelvic pain or spasm of the pelvic floor muscles, and a small prolapse found along the way is beside the point: surgery will not take that pain away.
What you can do yourself
This is almost always where treatment starts, and at grades one and two it is often enough on its own. The result does not come in a week but over two to three months.
Pelvic floor exercises. The single most effective thing you can do without help. But they are done wrongly more often than rightly: instead of the pelvic floor, people tighten the abdomen and buttocks. So the first session is best done with a pelvic health physiotherapist, who will check that the right muscles are working. They need doing daily: the benefit builds over months and fades if you stop.
Take the pressure off from above. Get to a healthy weight; treat constipation with fibre, fluids and gentle laxatives rather than straining; stop smoking so that the chronic cough settles; avoid heavy lifting and, when it is unavoidable, lift breathing out and with a straight back. Jumping, running and heavy weights in the gym are unwise with a marked prolapse, but there is no need to give up movement: walking, swimming and cycling do no harm.
Pessaries and local oestrogen
A pessary is a silicone ring or cup placed in the vagina to support the organs mechanically. It is not a stopgap before surgery but a full alternative to it, particularly if an operation is unwelcome or a pregnancy is planned. It is fitted by size, you are taught to take it out and put it in, and it must be checked every few months: without those checks it rubs the vaginal lining. If pain, bleeding or offensive discharge appear, take it out and see a doctor.
Local oestrogen is prescribed after the menopause as a cream, pessary or ring for the vagina itself. It makes the tissue firmer and more elastic, reduces soreness and makes a support pessary much easier to wear. It acts locally, and its effect on the body is different from that of hormone tablets.
When surgery is offered
Surgery is discussed when symptoms are getting in the way of life and exercises and a pessary have not helped or have not suited. The point of the operation is to put the organ back and reinforce the support: repair of the front or back wall with your own tissue, suspension of the womb or its removal, fixing the top of the vagina to the pelvic ligaments or to the sacrum. The approach may be through the vagina or through the abdomen, including by keyhole surgery.
Worth discussing beforehand:
- plans for children. A birth afterwards undoes the result, so surgery is usually deferred until the family is complete;
- recurrence. It is possible, and the more so the higher the original grade and the greater the strain afterwards;
- mesh implants. Placing synthetic mesh through the vagina is restricted or suspended in many countries because of serious complications: pain, erosion through the vaginal wall, injury to the bladder. If mesh is proposed, ask precisely which operation is meant, because for some abdominal procedures mesh is still in use. If you have had mesh for some time and develop pain or bleeding, seek advice, preferably from the centre that placed it;
- what will actually improve. Surgery deals well with the bulge, but does not guarantee that leaking urine or difficulty emptying the bowel will go: those are managed separately.
Pelvic floor exercises are not dropped after an operation — on the contrary, they are what helps the result last.
Online consultation
An online appointment works well as a first step, particularly when going to see someone feels awkward — and with this subject people put it off for years for exactly that reason. The doctor will ask about the symptoms, the births, passing urine and opening the bowels, explain what is happening to the pelvic floor, and say whether urgent care is needed.
Online you can also go through a report you already have: what the grade means, how a bladder prolapse differs from a bowel one, why with the same findings one woman is offered a pessary and another an operation. Practical questions suit it too: how to do the exercises, how to manage constipation, what to ask the surgeon.
What cannot be done online: examining you, grading the prolapse and fitting a pessary — that needs a face-to-face appointment. And if any of the signs in the urgent section appear, do not send a message — get help straight away.
This material is for information only and does not replace medical advice.
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