What is Uterine/Pelvic Organ Prolapse?

Urinary incontinence, constipation, a feeling of heaviness and pain in the vagina, the sensation of holding a ball inside—all are symptoms of a complaint that many women are too embarrassed to so much as a whisper. Pelvic organ prolapse.

Time lost to silence, however, is time lost to treatment. Speaking up early will give you better odds of needing less invasive treatments and a better chance of being back to your usual self.

With these modern approaches to female reproductive health, there’s no shame in experiencing what we used to call “women’s troubles”!

What is Pelvic Organ Prolapse?

Pelvic organ prolapse develops when the natural scaffolding that supports internal organs becomes weakened. This weakening causes the uterus, bladder, vagina, and rectum to slump into the vaginal cavity. In more advanced cases, this can cause a protrusion from the vagina.¹

This ailment most often occurs in women after pregnancy or with the onset of menopause, but it can also occur in patients who have never given birth.¹ In fact, half of all women aged 50 to 79 suffer from pelvic organ prolapse.

Experts divide pelvic organ prolapse into three large groups depending on the prolapsed structure:

• Uterine prolapse: slipping of the cervix down the vaginal canal;
• Cystocele: part of the bladder descends into the vaginal cavity;
• Rectocele: occurs when the back wall between the rectum and vagina weakens, causing both organs to dip into the vagina.¹

Does Utrerine/Pelvic Organ Prolapse Progress?

Pelvic organ prolapse is a progressive disease, but initially, it occurs rather slowly and without pronounced symptoms, so a patient might only notice something wrong in later stages.²

The stages of pelvic organ prolapse are:

Stage 1 – the cervix descends to half of the vagina;
Stage 2 – the genitals descend to the vaginal opening;
Stage 3 – the body of the uterus is still in the vagina and the cervix and vaginal walls are already protruding;
Stage 4 – at this stage there is a prolapse of the uterus and vaginal walls protrude outside the vagina.²

What Causes Pelvic Organ Prolapse?

Any activity that causes systemic or severe tension in the pelvic floor muscles can lead to pelvic organ prolapse. The most common risk factors are:

• traumatic and long labor;
• weak connective tissue (e.g., Ehlers Danlos syndrome, Marfan syndrome);
• estrogen deficiency (often related to menopause);
• chronic diseases with increased intra-abdominal pressure (bronchitis, asthma, constipation, etc.);
• obesity.³
  

What are the Symptoms?

Common signs that you may be experiencing a prolapse include:

• feeling of vaginal bloating;
• feeling of heaviness and protrusion in the vagina;
• nagging and aching pain in the lower back;
• repeated need to urinate during the day, urinary incontinence;
• constipation, loss of bowel control, flatulence.^{1, 3}

How Is Pelvic Organ Prolapse Diagnosed?

A doctor will use a physical examination to make a diagnosis. They will examine the pelvis to determine which organs are affected and to what extent. To confirm their diagnosis they will use:

• Bladder function tests to evaluate how well the bladder stores and empties urine;
• Pelvic floor strength tests to evaluate the strength and function of muscles and ligaments that support pelvic organs;
• Imaging tests (MRI/ultrasound) to produce detailed images of pelvic organs.^{1, 3}

What Treatments Are Available?

There are two main types of treatment for treating pelvic organ prolapse: conservative and surgical.⁴

Conservative treatments are recommended for the initial stages of pelvic organ prolapse. They are non-surgical and aim to ‘conserve’ the reproductive organs. Treatments can consist of specific physical exercises with biofeedback, hormone supplements, and implanted support devices.⁴

Fitness for intimate muscles 

Physiotherapy and exercises such as kegels or pilates routines can strengthen the pelvic floor. A sensor-based device, placed in the patient’s vagina, rectum, or skin, monitors muscle activity in the pelvic area and provides real-time feedback to help the patient relax and strengthen her muscles.⁴

Extra Estrogen

As previously mentioned, lack of estrogen is an important risk factor for weakened pelvic floor muscles. Women transitioning through menopause will gradually produce less estrogen. Using estrogen suppositories or a special cream can help to keep the pelvic floor muscles toned.

Positioning pessary

Conservative therapy can also involve the installation of a urogynecological pessary – a silicone product that fixes the ligaments, bladder, and uterus in the correct position. The pessary supports the vaginal walls and cervix, prevents spontaneous urination when sneezing and coughing, and eliminates discomfort caused by prolapse of the pelvic organs.⁴

Surgical Treatment

Surgery is prescribed for stages 3 and 4. Specialists will select a treatment based on the degree of prolapse, the condition of the genital organs, and the characteristics of the woman’s body amongst other factors. Treatments include:

• Surgical repair: These procedures involve making small incisions in the wall of the vagina and using specialized instruments to repair the weakened or damaged pelvic structures.
• Vaginal mesh surgery: The surgeon places a plastic net inside the vagina to help support and stabilize the pelvic organs. This practice is controversial and these days rarely used as it causes complications in some women.
• Hysterectomy: Removing the uterus reduces pressure on the vagina and therefore reduces the likelihood of prolapse. This operation is recommended for women who are going through menopause or do not plan to have more children.
• Closing the vagina: The vagina may be surgically closed in women who have not responded to other treatments and who accept to avoid having sexual intercourse in the future.⁴ 

Even with surgical correction, prolapse may return. The surgery fixes the tissue but does not treat the main cause of the pathology – the weakening of the muscles. Therefore, it is critical for both pre-symptomatic and treated individuals to carry out preventive measures.

How Do I Prevent Pelvic Organ Prolapse?

An ounce of prevention is better than a pound of cure. Thankfully, there are steps you can take to reduce your chances of developing a prolapse.

• follow a diet to get rid of excess weight, and prevent constipation and bloating;
• regularly perform Kegel exercises to maintain muscle tone in the pelvic area;
• have a go at pilates or similar pelvic floor strengthening exercise regimes;⁵
• consider hormone replacement therapy when menopause kicks in;
• quit smoking;
• treating respiratory diseases promptly (bronchitis, pneumonia), to avoid increased abdominal pressure from coughing;
• avoid lifting heavy objects.^{1, 4}

It is important to note that early diagnosis and intervention are key in managing pelvic organ prolapse. It can significantly improve the quality of life and reduce the risk of complications.

Don’t be afraid to talk to your doctor, there are treatments!

References

1. Pelvic Organ Prolapse – Urogynecology & Pelvic Health | UCLA Health. www.uclahealth.org. Accessed October 16, 2023. https://www.uclahealth.org/medical-services/womens-pelvic-health/conditions-treated/pelvic-organ-prolapse
2. Services D of H & H. Prolapsed uterus. www.betterhealth.vic.gov.au. Accessed October 16, 2023. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/prolapsed-uterus#prevention-techniques
3. Services D of H & H. Pelvic organ prolapse. www.betterhealth.vic.gov.au. Accessed October 16, 2023.  https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/bladder-prolapse
4. Pelvic organ prolapse – Treatment. nhs.uk. Published October 20, 2017. Accessed October 30, 2023. https://www.nhs.uk/conditions/pelvic-organ-prolapse/treatment/
5. Hagen S, Glazener C, McClurg D, et al. Pelvic floor muscle training for secondary prevention of pelvic organ prolapse (PREVPROL): a multicentre randomised controlled trial. Lancet. 2017;389(10067):393-402. doi:10.1016/S0140-6736(16)32109-2