The organs inside a woman's pelvis include the womb (uterus), the bladder and the back passage (rectum). Normally, these are supported and held in position by certain structures including ligaments and the muscles at the bottom of the pelvis (pelvic floor muscles).
Genitourinary prolapse occurs when these normal support structures are weakened and are no longer effective. The result is that one (or more) of the organs inside the pelvis drops down (prolapses). The space available for the organ(s) to drop down into is the vagina. There can be different degrees of prolapse, depending on how much, or how far, the organ(s) might have dropped down into the vagina. Sometimes, the prolapse can be so much that it causes the walls of the vagina, or the uterus, or both, to protrude outside the opening of the vagina.
It is difficult to estimate how many women are affected by genitourinary (GU) 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 genitourinary prolapse
Different types of GU prolapse can occur, depending on which pelvic organ, or organs, might have dropped down into the vagina. Generally, GU prolapse can be divided into the following, depending on which part of the pelvis it affects. However, GU prolapse may affect different parts of the pelvis at the same time.
Prolapse affecting the front (anterior) part of the pelvis
- 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 GU prolapse.
Prolapse affecting the rear (posterior) part of the pelvis
- 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 GU 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 GU 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, enclosed within the prolapse.
You can have a GU 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. These include a 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:
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.
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.
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.
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.
It is not known for sure why GU prolapse happens to some women but not to others. It is thought that a number of things may increase the risk of developing GU prolapse. They include the following:
GU prolapse does not affect everyone who gives birth. It may be more likely after a difficult, prolonged labour, a forceps 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.
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 GU 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.
If a woman has had her womb (uterus) removed (a hysterectomy), or other gynaecological surgery, she may be more likely to develop GU 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, GU 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 GU prolapse may increase a woman's risk.
How is genitourinary prolapse diagnosed?
GU 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.
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 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.
The aims of treatment for GU 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.
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.
During this period of watchful waiting, however, there are a number of things that you may be able to do to help prevent the GU 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 GU prolapse, or making GU prolapse 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 GU 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 GU 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. One-to-one supervised training may be more effective than doing the exercises on your own.
A vaginal pessary
A vaginal pessary can be a very good way to manage GU 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.
Various vaginal pessaries, by Huckfinne, via Wikimedia Commons
Vaginal ring 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.
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 you have mild prolapse, 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. There is not yet convincing evidence that it helps for prolapse.
Editor's comments (April 2019) from Dr Sarah Jarvis
The National Institute for Health and Care Excellence (NICE) has now produced full guidance on the treatment options for prolapse and urinary incontinence. They stress that non-surgical treatments such as those above should always be tried before surgical treatments. You should only be referred for surgery if non-surgical treatments have not been successful.
In particular, they recommend that 'first-line' options should include:
- Advice on avoiding constipation and heavy lifting.
- Advice to help you lose weight, if your body mass index is over 30.
- At least four months of pelvic floor training.
- Topical oestrogen cream if you are postmenopausal.
- Referral to a specialist service if fitting of vaginal pessaries is not available in your area.
If your doctor does discuss mesh surgery with you, they should:
- Always give you the right to choose what type of surgery you have. If your surgeon cannot carry out that type of operation, they should refer you to a surgeon who can.
- Give you full details of the possible short- and long-term complications.
- Get your permission to enter your details in a national registry, so that all complications that do occur are logged.
- Give you details of the type of mesh and whether it is permanent.
- Give you details of written information about the implant, including its name, manufacturer, date of insertion, and the implanting surgeon's name and contact details.
- Discuss your case with a Regional Multidisciplinary Team, including urogynaecologists, a specialist physiotherapist, a pain specialist and a bowel surgeon with expertise in pelvic floor problems.
Clinical Editor's comments (October 2017)
Dr Hayley Willacy recommends the Further Reading documents (below) from NICE, dealing with the use of mesh for prolapse repair. Mesh repairs work well enough for use in the NHS, but have serious, well-known risks. Your health professional should explain that there is a risk of the prolapse happening again.
Also, they should tell you about the possibility of serious complications, including mesh erosion. This occurs when the mesh breaks down or penetrates the vagina or other organs nearby, causing damage. You should also be told how to find more information about the procedure. All of this should happen before you decide whether you want to have this procedure or not.
The aim of surgery is to provide a permanent treatment (a cure) for GU 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). In some cases, a mesh or special tape may be sewn into the vaginal walls. Note: there are a number of different types of vaginal repair operations. There is some uncertainty about the long-term results when using mesh for some of these types of operations. Also, there may be a risk of complications, such as the mesh eroding through the wall of your vagina. This may mean that you need further surgery and may also have some discomfort and sexual difficulties. You should discuss the pros and cons of any operation in detail with your surgeon before going ahead.
- Removal of the uterus (a hysterectomy): this is a common treatment for uterine prolapse. In fact, GU 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 which include:
- Sacrohysteropexy: a special mesh is used that acts like a kind of sling to help to support your uterus and hold it in place. One end of the mesh is attached to the neck of the womb (your cervix) and the other to the bone at the back of your pelvis, called your sacrum. This operation is usually done through a cut in your abdomen.
- Sacrocolpopexy: during this operation, your vagina is hitched up and held in place by fixing it to your sacrum. A mesh or another material is usually used to hold your vagina in place. A hysterectomy may be suggested at the same time. This operation is usually done through a cut in your abdomen.
- Sacrospinous fixation: during this operation, your vagina is hitched up and stitched to a ligament inside your pelvis, called your sacrospinous ligament. It is usually carried out through your vagina and so no cut in your abdomen is needed.
- 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. You should avoid heavy lifting and sexual intercourse during this time. There is a chance that a prolapse can return after surgery.
What is the outlook (prognosis) for genitourinary prolapse?
Left untreated, GU 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. GU 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 genitourinary prolapse be prevented?
There are a number of things that may possibly help to prevent genitourinary (GU) 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.
Further reading and references
Hagen S, Stark D; Conservative prevention and management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2011 Dec 7(12):CD003882. doi: 10.1002/14651858.CD003882.pub4.
Sacrocolpopexy using mesh to repair vaginal vault prolapse; NICE Interventional procedure guidance, June 2017
Uterine suspension using mesh (including sacrohysteropexy) to repair uterine prolapse; NICE Interventional procedure guidance, June 2017
Hagen S, Stark D, Glazener C, et al; Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. Lancet. 2013 Nov 27. pii: S0140-6736(13)61977-7. doi: 10.1016/S0140-6736(13)61977-7.
Maher C, Feiner B, Baessler K, et al; Surgery for women with anterior compartment prolapse. Cochrane Database Syst Rev. 2016 Nov 3011:CD004014.
Post-Hysterectomy Vaginal Vault Prolapse; Royal College of Obstetricians and Gynaecologists (July 2015)
Ismail SI, Bain C, Hagen S; Oestrogens for treatment or prevention of pelvic organ prolapse in postmenopausal women. Cochrane Database Syst Rev. 2010 Sep 8(9):CD007063. doi: 10.1002/14651858.CD007063.pub2.
Bugge C, Adams EJ, Gopinath D, et al; Pessaries (mechanical devices) for pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013 Feb 282:CD004010. doi: 10.1002/14651858.CD004010.pub3.
Urinary incontinence and pelvic organ prolapse in women: management; NICE (April 2019)