What to do about pelvic organ prolapse

Content provided by the Faculty of the Harvard Medical School

What to do about pelvic organ prolapse

Relaxation is usually a good thing, but not when it involves the muscles and tissues holding pelvic organs in place.

Pelvic relaxation is a weakness or laxity in the supporting structures of the pelvic region. Bladder, rectal, or uterine tissue may then bulge into the vagina. This is called pelvic organ prolapse. The term refers to a number of conditions that can dramatically affect a woman's quality of life, causing discomfort and embarrassment and limiting sexual and physical activity.

Once rarely discussed or recognized, this problem has now become a priority in women's health because we're living longer and want to stay active well past menopause. Today, many primary care physicians and gynecologists routinely screen patients for the symptoms, and the new surgical specialty of urogynecology has arisen to correct prolapse conditions and the urinary incontinence that often results. By age 80, more than 1 in every 10 women will have undergone surgery for prolapse.

Fortunately, the medical understanding of pelvic support anatomy has increased dramatically in recent years, so we have a much clearer picture of what causes these conditions and how best to treat them.

Types of pelvic organ prolapse

Different types of pelvic organ prolapse affect different parts of the vagina (see illustrations). Once the pelvic floor is weakened, it's prone to further problems, so it's not uncommon to have more than one type of prolapse at a time:

Cystocele and urethrocele. A cystocele occurs when the bladder protrudes into the front wall of the vagina. A similar defect, known as a urethrocele, develops when the urethra presses into the front vaginal wall. A cystocele and a urethrocele may occur together, a condition called a cystourethrocele.

Rectocele. Part of the rectum bulges into the back wall of the vagina, sometimes causing difficulty with defecation.

Uterine prolapse. The uterus drops down into the vagina, and, in severe cases, may bulge through the vaginal opening. In women who have undergone a hysterectomy, a similar condition known as vaginal vault prolapse can occur: the top of the vagina protrudes into the lower vagina.

Pelvic organ prolapse conditions Depending on where weak spots occur, the bladder, urethra, rectum, or uterus may protrude into the vagina. In a cystocele, the bladder bulges into the vagina at a weak spot in the tissues separating the bladder from the front of the vagina. A urethrocele forms where the urethra prolapses into the vagina. A rectocele occurs where the rectum protrudes through a weak spot at the back of the vagina. Weakness at the top of the vagina can result in uterine prolapse.

What causes pelvic organ prolapse?

Pelvic support comes from pelvic floor muscles, connecting tissue (fascia), and thickened pieces of fascia that serve as ligaments. The levator ani, the primary pelvic floor muscle, provides the main support for the uterus and bladder. The fascia and support ligaments help hold the pelvic organs in place, much in the same way that a mooring line secures a boat. When pelvic floor muscles are weakened, the fascia and ligaments have to bear the brunt of the weight. Eventually, they may stretch and fail, allowing pelvic organs to drop and press into the vaginal wall, which stretches to cover the prolapsed organ.

Women who have had multiple vaginal births are at greatest risk for pelvic organ prolapse. The problem may occur immediately after birth, or turn up only years later — particularly after menopause, when women tend to lose muscle tone as well as estrogen, which helps maintain vaginal tissue. Other risk factors include surgery to the pelvic floor, connective tissue disorders, obesity, and anything that increases intra-abdominal pressure, such as coughing, chronic lung disease, heavy lifting, or intense physical activity. Older women with pelvic organ prolapse usually have more than one of these contributing factors, although the condition may also occasionally occur in a young woman with no obvious risk factors.

What are the symptoms?

Women with mild prolapse discovered during a routine pelvic exam may have no symptoms at all. But others experience considerable discomfort and a range of symptoms, including:

Pressure and pain. The most common complaints are a feeling of pelvic pressure, or bearing down, leg fatigue, and low back pain. Some women feel as though they're sitting on a lump. These symptoms are most noticeable at the end of the day or after a long period of standing.

Urinary symptoms. Cystocele, urethrocele, and uterine prolapse can cause stress incontinence and difficulty in starting to urinate.

Bowel symptoms. A rectocele may cause problems with defecation by forming a pocket just above the anal sphincter (see illustration below). Stool can become trapped, causing pain, pressure, and constipation. In severe cases, a woman may need to push back the protrusion in the vaginal wall to empty her bowels (this is called splinting).

Sexual problems. Any type of prolapse can cause sexual difficulties for a variety of reasons, including physical pressure from the prolapse, irritated vaginal tissues, and psychological factors. Intercourse may be painful, and the prolapse a source of embarrassment. Even in the absence of prolapse, pelvic muscle relaxation can make intercourse less pleasurable for both partners by loosening the vaginal opening.

Getting a diagnosis

If you think you have a pelvic prolapse condition, see your primary care provider or gynecologist. A traditional pelvic examination is the only way to diagnose it; lab tests and imaging studies are not particularly helpful. You'll be asked to lie on your back and bear down forcefully while your clinician checks the vaginal walls for weak spots. The exam will then be repeated while you're standing, because the effects of gravity can make a defect in the pelvic support system more obvious. Depending on your symptoms, you may be referred to a urogynecologist.

Physicians sometimes grade prolapses numerically to indicate severity. In a stage-1 prolapse, only a small amount of tissue has descended into the vagina, and symptoms are usually mild. In a stage-4 prolapse, the most severe kind, the prolapsed organ extends outside the vagina; surgery is usually required.

Treating prolapse

Women with no or very mild symptoms don't need treatment, although they should avoid anything that might worsen the prolapse. For example, they should lose weight if necessary and avoid anything that increases pressure within the abdomen, such as lifting heavy objects, constipation, or chronic cough. If they smoke, they should stop, because smoking causes coughing. Vaginal estrogen may also be recommended to minimize vaginal atrophy.

Prolapse doesn't necessarily worsen over time, so there's no need to seek aggressive treatments, unless your symptoms are really bothersome. For example, in a 412-woman study undertaken as part of the Women's Health Initiative, one-third of the women had signs of prolapse. In about half of those with mild prolapse, the condition resolved spontaneously. Cystocele was the most common problem.

If you're experiencing major discomfort or inconvenience, surgery is the only definitive way to relieve symptoms and improve your quality of life (see "Surgical treatment," below). But if your symptoms are mild or you want to delay or avoid surgery, less invasive treatments can help:

Kegel exercises. Contracting and releasing the pelvic floor muscles (see "How to perform Kegel exercises," below) may help relieve mild cystocele, urethrocele, and rectocele. A woman with prolapse but no symptoms may be urged to practice Kegel exercises to reduce the chance that her condition will progress.

Pessary. For women who aren't good surgical candidates or want to delay surgery, one alternative is a vaginal pessary — a device similar to a diaphragm or cervical cap that's inserted in the vagina to help support the pelvic area (see illustration). A pessary may completely relieve symptoms in a woman with only moderate prolapse. Women who need to delay surgery may use a pessary temporarily — as may younger women who plan to have more children. (Vaginal deliveries usually reverse the effect of any corrective surgery.) Older women with multiple illnesses who would be high-risk surgical patients (or who prefer to avoid surgery) may also opt for a pessary.

The type and size of pessary will depend on individual anatomy; sometimes a woman must try several before finding one that works. You need to know how to remove, clean, and reinsert the pessary. If you can't, you'll need to visit your gynecologist regularly for removal and cleaning, as serious complications can occur if a pessary is neglected. Vaginal estrogen should be used in conjunction with a pessary to protect the vaginal mucosa from irritation.

Surgical treatment

Before undergoing surgical repair of a prolapse, you'll need to have a thorough pelvic exam, to ensure that all problems have been identified. Symptoms of urinary incontinence should be evaluated, and your clinician should also check for potential "occult incontinence" that doesn't become evident until after the prolapse is corrected. (For example, incontinence could result from corrective surgery if it straightened a kink in the urethra that had prevented incontinence during prolapse.)

Be sure your surgeon has expertise in the field of pelvic reconstruction, as new procedures and anatomical knowledge have led to better results. In the past, recurrence was common after cystocele and rectocele procedures, because the standard methods paid little attention to a woman's individual anatomy. Today, surgery is more tailored to the individual woman.

Surgical techniques. Pelvic reconstruction surgery may be performed through the vagina or abdominally; both procedures are equally effective. A newer option is laparoscopic surgery, in which repairs are made with instruments, including a camera, inserted through a few tiny abdominal incisions. The approach your surgeon recommends will depend on the procedures required and his or her experience.

The prolapsed organ will be repositioned (a prolapsed uterus may be removed or repositioned) and secured with stitches to the surrounding tissues and ligaments. The vaginal defect will be repaired, sometimes using a piece of synthetic material, called a graft.

Recovery. After laparoscopic surgery, women can usually leave the hospital within 24 hours. Vaginal or abdominal surgery generally requires a two-to-three day stay. After any kind of surgery, women should expect to take six to eight weeks for complete recovery, including at least four weeks of vaginal rest (nothing in the vagina). They should avoid lifting anything heavy (over 10 pounds) for at least three months.

Complications. Possible complications of pelvic reconstructive surgery include urinary tract infection, temporary or permanent incontinence, infection, bleeding, and — rarely — damage to the urinary tract that requires additional corrective surgery. Some women may develop chronic irritation or pain during intercourse from a suture or scar tissue, which may also need surgical repair. There's also a risk of recurrence, which seems to be highest for cystocele and lowest for rectocele. Sometimes prolapse of a different organ will occur following surgery, especially if all defects weren't initially identified and repaired.

Fortunately, recurrence rates are dropping as surgical techniques and preoperative planning improve. The chance of recurrence will also be reduced if a woman avoids stress, such as heavy lifting or straining during a bowel movement, and performs Kegel exercises regularly before and after surgery. Clinicians may also suggest using vaginal estrogen.

Last updated:	November 08, 2006