Pelvic organ prolapse

How common is pelvic organ prolapse?

It is difficult to estimate how many women are affected by pelvic organ prolapse because many women do not visit their doctor for help. It is thought that around half of all women who have had children have some degree of GU prolapse but that most do not seek medical advice.

Types of pelvic organ prolapse

Different types of pelvic organ prolapse can occur, depending on which pelvic organ, or organs, might have dropped down into the vagina. Generally, pelvic organ prolapse can be divided into the following, depending on which part of the pelvis it affects. However, pelvic organ prolapse may affect more than one part of the pelvis at the same time.

Prolapse affecting the front part of the pelvis (anterior prolapse)

• There can be prolapse of the urethra (the tube along which urine passes from the bladder to the outside) into the vagina. The medical term for this is a urethrocele.

• There can be prolapse of the bladder into the vagina. The medical term for this is a cystocele.

• Or, both the urethra and the bladder can prolapse into the vagina at the same time. The medical term for this is a cystourethrocele. This is the most common type of pelvic organ prolapse.

Prolapse affecting the rear part of the pelvis (posterior prolapse)

• There can be prolapse of the back passage (rectum) into the vagina. The medical term for this is a rectocele. This is the third most common type of pelvic organ prolapse.

Cystocele and rectocele

Prolapse affecting the middle part of the pelvis

Uterine prolapse

• There can be prolapse of the womb (uterus) into the vagina. This is called a uterine prolapse. It is the second most common type of pelvic organ prolapse.

• If a woman has had her womb removed (a hysterectomy), the end of the vagina that would normally attach to the neck of the womb (cervix) is closed up during the operation. This now blind end of the vagina is referred to as the vaginal vault. The vaginal vault can prolapse into the vagina. This is known as a vault prolapse.

• There can be prolapse of the space between the rectum and the womb, known as the pouch of Douglas, into the vagina. The medical term for this is an enterocele. Loops of bowel may be present in the prolapse.

Pelvic organ prolapse symptoms

You can have a pelvic organ prolapse and not have any symptoms from it. It may just be noticed by a doctor when you are examined for another reason - for example, when you have a cervical smear test.

However, it is common for women to have some symptoms. There are certain symptoms that women with all types of prolapse can have. Symptoms include:

• Feeling of a lump in your vagina or having a feeling of something 'dragging' or 'coming down'. You may actually be able to feel a lump or protrusion.

• You may experience pain in your vagina, back or tummy (abdomen).

• Sometimes, you may also notice a discharge from your vagina, which may be blood-stained or smelly.

• Sex may be uncomfortable or painful.

• Symptoms are usually worse after long periods of standing and they improve after lying down.

Other symptoms that you may experience can depend on the type of prolapse that you have. They can include the following:

Urinary symptoms

You may have urinary symptoms if your prolapse affects the front (anterior) part of your pelvis (your urethra and bladder). Symptoms may include:

• The need to pass urine often, both during the day and at night.

• Leaking of urine on coughing, sneezing, laughing, straining or lifting.

• Feeling a sudden urge to pass urine, and also sometimes leaking urine before getting to the toilet.

• A flow of urine that stops and starts.

• A feeling that your bladder has not emptied properly and the need to pass urine again soon afterwards.

• The need to change position whilst sitting on the toilet or the need to use your finger to push back the prolapse to enable urine to pass.

Also, complications may occur. These include:

• Urine infections.

• Loss of control of urine (incontinence).

• Not being able to pass urine at all (retention of urine), which may need treatment by inserting a small, flexible tube (a catheter) into your bladder to drain the urine.

Bowel symptoms

You may have bowel symptoms if your prolapse affects the rear (posterior) part of your pelvis (your rectum). Symptoms may include:

• Difficulty passing stools (faeces) and having to strain to pass stools.

• Feeling a sudden urge to pass stools.

• A feeling that your bowels have not emptied fully.

• Incontinence of stools.

• Passing lots of wind.

• A feeling of a blockage or an obstruction whilst you are passing stools.

• The need to push on, or around, your vagina or perineum to enable stools to pass.

Sexual difficulties

Most women can have sex without problems with a prolapse but in some it may cause problems. It may be difficult to have sex, or it may be uncomfortable. The prolapse can affect arousal. For some women the prolapse is embarrassing so they may avoid having sex. There is no need to feel embarrassed about this and it is important to consult your doctor if a prolapse is causing you problems.

Other symptoms

If the prolapse is large enough to protrude from your vagina, this can lead to ulceration of the neck of your womb (your cervix) or skin. It may sometimes cause bleeding and infection.

Note: you may have a combination of these symptoms if prolapse affects the organs in different parts of your pelvis at the same time.

Causes of pelvic organ prolapse

It is not known for sure why pelvic organ prolapse happens to some women but not to others. It is thought that a number of things may increase the risk of developing pelvic organ prolapse. They include the following:

Childbirth

Pelvic organ prolapse does not affect everyone who gives birth. It may be more likely after a difficult, prolonged labour, a forceps or suction delivery, or if a woman gives birth to a large baby. It also becomes more likely the more times a woman has given birth. Prolapse is more common in women who have had vaginal births than those who have had caesarean sections.

Increasing age

The chance of having a prolapse increases as a woman becomes older. The lack of oestrogen hormone that occurs after the menopause affects the pelvic floor muscles and structures around the vagina, making them less springy and supportive.

Increased pressure inside the tummy (abdomen)

Anything that causes an increase in the pressure inside a woman's abdomen and pelvis can also be a risk factor for the development of pelvic organ prolapse. This can occur because of the strain put on the supporting ligaments and muscles. The most common reason for this increased pressure is during pregnancy and childbirth. However, the same increase in pressure can also occur in:

• Women who are overweight.

• Women who have persistent (chronic) lung problems, such as a chronic cough.

• Women who frequently strain due to constipation.

• Women who do heavy lifting as part of their job.

Gynaecological surgery

If a woman has had her womb (uterus) removed (a hysterectomy), or other gynaecological surgery, she may be more likely to develop pelvic organ prolapse. This is because the surgery may have weakened the ligaments, pelvic floor muscles and other support structures for the pelvic organs. However, with new advances in surgical techniques, including keyhole (laparoscopic) surgery, this is becoming less of a problem.

Other risk factors

Very rarely, pelvic organ prolapse can occur because of a congenital problem (a problem that someone is born with) that causes deficiency, in the body, of a substance called collagen. Collagen is needed to help form the ligaments that normally support the pelvic organs. Also, it is thought that having a mother or a sister who has pelvic organ prolapse may increase a woman's risk.

How is pelvic organ prolapse diagnosed?

Pelvic organ prolapse is usually diagnosed by your doctor performing a simple examination of your vagina. They will usually ask you to lie on your left side with your knees bent slightly towards your chest. Your doctor may also ask to examine you whilst you are standing, or lying on your back, similar to when you have a smear test.

When they examine you, your doctor will usually insert an instrument called a speculum into your vagina. This may be a similar instrument to that used during cervical screening, or a differently shaped speculum. The doctor will usually move the speculum to the front and back walls of your vagina, allowing them to look for prolapse. Your doctor may ask you to cough or strain. These examinations are not usually painful. If you have bowel symptoms, your doctor may suggest that they examine your back passage (rectum).

Will I need any investigations for pelvic organ prolapse?

For most women, examination alone is enough to make a diagnosis. If you have any urinary symptoms, as described above, your doctor may ask you to collect a specimen of urine to be sent off to the laboratory to check for signs of infection. They may also suggest that you have a blood test to check your kidney function. They may refer you to a specialist for some more detailed tests on your urine and bladder - for example, some tests known as urodynamic studies. These are tests of your urine flow and they are usually done in a hospital unit. If you have bowel symptoms, a specialist may suggest some special tests to look into these. Occasionally further tests, such as an ultrasound scan, are used.

Pelvic organ prolapse treatment

The aims of treatment for pelvic organ prolapse are to ensure that you:

• Are comfortable and pain-free.

• Are able to pass urine and stools (faeces) adequately and have no problems with urinary or faecal loss of control (incontinence).

• Are able to have sex comfortably.

• Do not experience any complications relating to the prolapse, such as urine infections or ulceration of the prolapse.

• Are able to continue to have children if you so desire.

As we will see below, some women will need surgery for their prolapse. However current guidance is that non-surgical methods should always be tried first.

Watchful waiting

If you have little in the way of symptoms, after discussion with your doctor, you may choose to wait to see how your symptoms develop. In some women, symptoms do not become any worse over time, and they may even improve. However, if you develop any new symptoms, you should see your doctor.

Lifestyle changes

During this period of watchful waiting, however, there are a number of things that you may be able to do to help prevent the pelvic organ prolapse from becoming any worse. As discussed above, there are a number of things that can cause a rise in the pressure inside your tummy (abdomen), increasing risk of pelvic organ prolapse, or making it worse. There is no evidence currently that making these changes helps; however, it makes sense to give them a try. For example:

• If you have pelvic organ prolapse and are overweight, it may help if you lose weight. See the separate leaflet called Weight Loss (Weight Reduction) for more details.

• If you are constipated you should discuss this with your GP to ensure that you are receiving adequate treatment. See the separate leaflet called Constipation for more details.

• Coughing can make prolapse worse. If you smoke, you should try to give up. See the separate leaflet called How to Quit Smoking for more details.

• You should try to avoid heavy lifting, as this may make prolapse worse.

Pelvic floor exercises

All women with pelvic organ prolapse, whether they have symptoms or not, should do pelvic floor exercises. The exercises may stop mild degrees of prolapse from becoming any worse. They may also relieve symptoms such as backache and abdominal discomfort. See the separate leaflet called Pelvic floor exercises. Your GP may refer you to a physiotherapist with specialised skills in this type of exercise, as it is now recommended that these are done with supervision by an appropriately qualified healthcare professional, rather than on your own. Pelvic floor exercises do not work overnight and you should use them consistently for at least four months.

A vaginal pessary

A vaginal pessary can be a very good way to manage pelvic organ prolapse. It may be used by:

• Women who do not wish to have surgery.

• Women who are still of child-bearing age.

• Women who are waiting for surgery.

• Women who have other illnesses that may make surgery more risky.

Pessaries can come in a variety of shapes but are usually in the shape of a ring. They are usually made of silicone or plastic.

Vaginal pessaries

Various vaginal pessaries, by Huckfinne, via Wikimedia Commons

Vaginal ring pessary

Vaginal ring pessary

Vaginal pessary placement

Positioning of a type of vaginal pessary

The ring is inserted into your vagina. It is left in place and helps to lift up the walls of your vagina and any prolapse of your womb (uterus). Vaginal pessaries are easily inserted and many GPs are able to insert them. They should be changed every 6-12 months. If no GP in your practice is able to insert them then you can be referred to a specialist, or a GP with a particular interest in this area. This may be at a hospital-based clinic, or one in the community.

Having a vaginal ring pessary does not prevent you from having sex. It can either be left in during sex, or removed before sex and replaced afterwards. Discuss this with your GP.

If you have pain or difficulty passing urine after you have a vaginal pessary inserted, you should speak to your GP as soon as possible. You may need the pessary changing for a different size.

Vaginal pessaries do not usually cause any problems but (very rarely) they may affect the skin inside your vagina which can become ulcerated. Some women notice some discomfort during sex.

Vaginal oestrogen creams

If the prolapse is mild, your doctor may suggest that you apply some oestrogen cream to your vagina for 4-6 weeks. This may help any feelings of discomfort that you may have. However, sometimes symptoms may return once the cream is stopped. This cream is a type of hormonal replacement therapy (HRT), although it is not thought to have many of the risks which may be associated with HRT.

Surgery for pelvic organ prolapse

The aim of surgery is to provide a permanent treatment for pelvic organ prolapse. There are various operations that can be performed, depending on the type of prolapse that you have. Keyhole surgery may be possible for some of these operations. Your surgeon will be able to advise which operation is best for you. Operations can include the following:

• A vaginal repair operation: in this procedure, the walls of your vagina are reinforced, and tightened up. This is usually done by making a tuck in the wall of your vagina and using stitches to hold the tuck in place. The operation is usually done through your vagina and so you do not need a cut in your tummy (abdomen).

• Removal of the uterus (a hysterectomy): this is a common treatment for uterine prolapse. In fact, pelvic organ prolapse is the most common reason why women over 50 years of age have a hysterectomy. Sometimes a hysterectomy is suggested at the same time as a vaginal repair operation.

• An operation to lift up your uterus or vagina: there are various different types.

• An operation to seal up the vagina (a colpocleisis). This is rarely done as it is not possible to have sex after this operation. However, it is a safe and effective operation for some women. Obviously the implications would be discussed before choosing to go ahead with this operation.

You may need to stay in hospital for a few days after your operation. Full recovery may take up to 6-8 weeks and your surgeon should give you a fit note if needed, to cover the entire duration that you will need to be off work. They should not ask you to see your GP for a fit note. You should avoid heavy lifting and sexual intercourse during this time. There is a chance that a prolapse can return after surgery.

Why has surgery for prolapse been in the news recently?

In 2020, Baroness Cumberledge published a report which looked at three areas where there was concern that patients might have been harmed. One of these was the use of pelvic mesh in surgery for prolapse. Pelvic mesh was used to support prolapsed organs, but led to significant complications in many women. These included pain, recurrent infections, incontinence and recurrence of their prolapse. In 2018, while the report was being written, a pause in the use of pelvic mesh was recommended and implemented. Current advice is that mesh procedures should only be carried out as part of research.

All women who have surgery for pelvic organ prolapse should be recorded in a national registry which is being kept so that we can be alerted to complications earlier in the future than has happened in the past. Follow-up data must be recorded for at least five years.

As always, any surgeon who is proposing an operation should make sure that your consent is fully informed. This includes making you aware of the risks and benefits of the proposed surgery, and the likelihood of each, and giving you the right to make your own decision as to the type of surgery that will be carried out (whilst helping you with this decision if needed), as well as if you want to have surgery at all.

All patients having surgery for prolapse should be discussed with a multidisciplinary team which may involve a variety of professionals including surgeons, pain specialists and physiotherapists.

What is the outlook (prognosis) for pelvic organ prolapse?

Left untreated, pelvic organ prolapse will usually gradually become worse. However, this is not always the case. Sometimes it can improve with no treatment. The outlook is best for younger women who are of a normal weight and are in good health. The outlook is worst for older women, those in poor physical health and those who are overweight. Pelvic organ prolapse can return after an operation. About 29 in 100 women need another operation at some point. For 13 in 100 women this occurs within five years of the original operation.

Can pelvic organ prolapse be prevented?

There are a number of things that may possibly help to the risk of pelvic organ prolapse. However, not all of these have been proven. Simple things that you can do are:

• Regular pelvic floor exercises, especially if you are planning to become pregnant, are pregnant, or have given birth.

• If you are overweight, try to lose weight.

• Eat a high-fibre diet (plenty of fruit and vegetables and wholegrain bread and cereal) and drink plenty of water to avoid constipation.

• If you smoke, try to stop smoking.

• Avoid occupations that involve heavy lifting.