Pelvic organ prolapse
Also known as: prolapse, cystocele, rectocele, uterine prolapse, vaginal vault prolapse, genital prolapse
Descent of one or more of the pelvic organs (the bladder, uterus, rectum, small bowel or, after hysterectomy, the top of the vagina) from their normal position so that they bulge into, and sometimes out of, the vagina, because the pelvic floor muscles and connective tissue that support them have weakened or stretched.
When to seek care
See a GP, or ask for a referral to a pelvic health physiotherapist or urogynaecology clinic, for a feeling of heaviness or a bulge in the vagina, a lump at the vaginal opening, difficulty passing urine or opening the bowels, urinary leakage or discomfort during sex; these problems are common and treatable and do not have to be accepted as part of ageing. Seek prompt care if a prolapse becomes stuck outside the body and cannot be pushed back, if it bleeds or is painful, if you cannot pass urine, or if you have fever, loin pain or repeated urinary infections.
Overview
The pelvic organs are held in place by the levator ani muscles of the pelvic floor, the endopelvic fascia and the ligaments that anchor the cervix and upper vagina to the pelvic walls. When these supports are torn or stretched, most often by childbirth, or weaken with age and the fall in oestrogen after the menopause, the organs sag under the pressure of the abdomen and the vaginal walls fold inwards. Prolapse is named for the compartment involved: an anterior wall prolapse (cystocele) carries the bladder, a posterior wall prolapse (rectocele) the rectum, an enterocele a loop of small bowel, a uterine prolapse brings the cervix down the vagina, and a vault prolapse is descent of the top of the vagina after hysterectomy. It is staged from 1, a slight descent within the vagina, to 4, in which the organ lies entirely outside the vaginal opening. Some degree of prolapse is found on examination in many women who have given birth, though far fewer have symptoms, and it is rarely dangerous: symptoms range from a mild sense of heaviness to a visible bulge that interferes with passing urine, opening the bowels and sex. It affects anyone with a vagina and pelvic floor, including trans men and non-binary people.
Causes
- Stretching and tearing of the pelvic floor muscles, fascia and nerves during pregnancy and vaginal birth, especially with a large baby, a long second stage of labour, a forceps or ventouse delivery or several births
- Weakening of the supporting tissues with age and after the menopause, when oestrogen levels fall
- A long-term rise in pressure inside the abdomen from obesity, a chronic cough, constipation and straining, or repeated heavy lifting
- Loss of the uterus and its ligaments after hysterectomy, which leaves the vaginal vault less well supported
- Inherited weakness of connective tissue, including joint hypermobility syndromes
Risk factors
- Vaginal births, particularly a large baby, an instrumental delivery or a long labour
- Increasing age and the menopause
- Being overweight or obese
- Chronic constipation, a long-term cough or heavy manual work
- Previous hysterectomy or pelvic surgery
- A family history of prolapse or a connective tissue disorder
Symptoms
What a clinician may find
- A bulge of the vaginal wall or the cervix seen at the vaginal opening on straining or standing, or protruding at rest in advanced prolapse
- Descent of the anterior or posterior vaginal wall on speculum examination, recorded by stage
- Weak pelvic floor muscle contraction on examination
- Ulceration, thickening or bleeding of the exposed vaginal skin in a prolapse that sits outside the body
- Leakage of urine on coughing, or a residual volume of urine after voiding
Complications
- Urinary problems: stress incontinence, difficulty emptying the bladder, recurrent urinary tract infections and, rarely, kinking of the ureters with back-pressure on the kidneys in severe prolapse
- Bowel problems: constipation and incomplete emptying, sometimes needing the vaginal wall to be pressed back to open the bowels
- Ulceration, discharge and bleeding of the exposed vaginal skin, and rarely a prolapse that cannot be pushed back
- Discomfort or loss of confidence during sex
- Pessary problems such as discharge, vaginal irritation or ulceration if it is not checked and changed regularly
- Recurrence of prolapse after surgery, or new stress incontinence once the bulge no longer kinks the urethra
Diagnosis
The history covers the sensation of a bulge or dragging, urinary and bowel symptoms, sexual function and how much the prolapse affects daily life; NICE recommends using a validated pelvic floor symptom questionnaire. Examination with a speculum, at rest and while straining and sometimes standing, shows which compartment is affected and how far it descends, and is recorded using a standard staging system such as the Pelvic Organ Prolapse Quantification (POP-Q) system. The strength of the pelvic floor muscles is assessed at the same time. A urine dipstick is done if there are urinary symptoms, and a bladder scan measures the residual volume if emptying seems incomplete. Imaging is not usually needed: ultrasound or MRI is reserved for unusual symptoms, suspected other pelvic disease or, in advanced prolapse, to check the kidneys for back-pressure. A prolapse found by chance in someone without symptoms does not need treatment.
Treatment
Treatment is chosen according to the symptoms, the stage of prolapse, wishes about future pregnancy and sexual activity, and general health; NICE NG123 sets out the options. Lifestyle measures come first: losing weight if overweight, treating constipation and cough, and avoiding heavy lifting. NICE advises considering a supervised programme of pelvic floor muscle training for at least 16 weeks as a first option for symptomatic POP-Q stage 1 or stage 2 prolapse, and it improves symptoms in many women. Vaginal oestrogen is considered when there are signs of vaginal atrophy after the menopause. A vaginal pessary, a silicone or plastic ring or shelf that holds the prolapse up, is an option for symptomatic prolapse at any stage, used on its own or alongside pelvic floor muscle training, and is often chosen by those who prefer to avoid surgery or are not fit for it; it is checked, cleaned or changed by a clinician at regular intervals agreed with the service. Surgery is considered when other measures have not helped: repair of the vaginal wall using the woman's own tissue, vaginal hysterectomy or a uterus-preserving operation such as sacrohysteropexy, and sacrocolpopexy or sacrospinous fixation for vault prolapse. NICE restricts synthetic mesh inserted through the vagina, and any mesh procedure needs a full discussion of risks and benefits and recording in a national registry. Continence surgery is sometimes combined with the repair when stress incontinence is also present.
Prevention
Pelvic floor muscle training during pregnancy and after childbirth, continued as a lifelong habit, is the main preventive measure and also reduces urinary incontinence. Keeping to a healthy weight, avoiding constipation with a high-fibre diet and enough fluid, treating a chronic cough, stopping smoking and lifting safely all lower the strain on the pelvic floor. Vaginal oestrogen does not prevent prolapse, but treating vaginal dryness and thinning after the menopause can ease symptoms and is offered alongside other measures.