Pelvic Organ Prolapse

What is pelvic organ prolapse?
Pelvic organ prolapse is a common condition that occurs in women in which the vaginal wall starts to protrude or bulge outside of the vagina. Usually a woman will start to feel a bulge that is soft and can be pushed back in place with her fingers. It is cause by a weakening in the pelvic floor similar to the weakening in the abdominal wall that can result in a hernia. As the vaginal walls weaken, other organs that are in close proximity to the vaginal walls, such as the bladder, uterus, rectum and small bowel, may become affected. Each type of prolapse has a different name, depending on which organs are affected:

• Uterine prolapse - occurs when the tissues that support the uterus and top of the vagina wall weaken allowing the vagina to turn (inside out) and to protrude. A small amount of uterine prolapse can be normal after a woman has vaginal deliveries. As this condition worsens the front and back of the vaginal wall along with the uterus can become affected. A bulge that can be felt outside of the vagina usually represents a prolapse that needs to be evaluated since the condition, like an abdominal wall hernia, can progress.
• Cystocele (SIS-toe-seal) or Anterior Vaginal Wall prolapse- occurs when the tissues that support the front of the vaginal wall and the top of the vagina and uterus weaken allowing the front of the vaginal wall to protrude and affect the bladder. Cystocele may cause discomfort and problems with emptying the bladder or there may be no symptoms other than a bulge. Women with this condition sometimes report that they have to push the bulge back in with their fingers when they want to empty their bladders.
• Rectocele (REC-toe-seal) or Posterior Vaginal Wall Prolapse - occurs when the tissues that support the posterior vaginal wall and the top of the vagina and uterus weaken allowing the posterior vaginal wall to protrude and affect the rectum. Women with this condition often report that they have to push the bulge back in when they are having a bowel movement.
• Enterocele (EN-ter-oh-seal) or Vaginal Vault Prolapse - occurs most often in women who have had a prior hysterectomy. The tissues that support the top of the vagina weaken allowing the vaginal wall to protrude. Usually the bulge that is produced has small bowel in it just like an abdominal wall hernia.

What causes pelvic organ prolapse?
The causes of pelvic organ prolapse are similar to those that also contribute to urinary incontinence. The principal cause is weakening of the pelvic floor muscles and connective tissues that support the uterus and vagina. Vaginal childbirth may cause the initial nerve injury to the pelvic floor muscles that result in pelvic floor weakening. Few women have symptoms of prolapse initially because other muscles around the pelvic floor can help to compensate. As women age, the muscles lose some of their strength and the prolapse becomes more noticeable. Other factors that have been linked to pelvic organ prolapse are:

• heavy lifting
• repeated straining during bowel movements and/or constipation
• smoking and chronic cough conditions
• family history
• hormones

Other conditions that may contribute to pelvic organ prolapse are obesity, respiratory problems and pelvic organ cancers.

What are the symptoms of pelvic organ prolapse?
Many symptoms have been attributed to pelvic organ prolapse but the most reliable is the presence of a bulge outside of the vagina. Other symptoms that have been attributed to prolapse include difficulty with urination or constipation and the sensation of (something falling) out of the vagina.

How is pelvic organ prolapse diagnosed?
Your doctor will want to begin with a complete medical history, including your symptoms and your surgical history. This would be followed by a pelvic examination. Often women are examined when standing and (bearing down) which allows the best assessment of the prolapse. Pelvic organ prolapse may also be discovered during a routine pelvic examination as part of your regular medical check-up. Radiological and laboratory tests are rarely used to make this diagnosis but may be ordered for other reasons prior to your being examined by a specialist.

How is pelvic organ prolapse treated?
Treatment for pelvic organ prolapse usually depends on the severity of the symptoms and how much these symptoms interfere with daily activities and general quality of life. Treatments may include:

• Kegel exercises - exercises that strengthen the pelvic muscles. These are most useful for women with urinary incontinence but may sometimes be recommended if you have prolapse.
• Mechanical devices (pessaries) - Silicone dishes that look similar to contraceptive diaphragms. They are inserted into the vagina to provide support for a drooping vagina or uterus and can reduce the bulge that often interferes with performing daily activities. Woman who choose to use these devices can insert and remove them on a daily or weekly basis. This can be a very viable alternative for women who may have to delay surgery or for women when surgery is not an option.
• Surgery - If other treatments fail to result in satisfactory improvement, your physician may suggest surgery. Various surgical procedures are available to correct pelvic organ prolapse. In developing a surgical plan, you and your physician will consider your level of activity, age, general health and your desire for sexual activity.

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