Insights into Pelvic Prolapse, A Pelvic Support Dysfunction: Causes and Treatments
Pelvic Organ Prolapse (POP) is when one or more pelvic organs drop or lower from their position in the pelvis. Essentially it’s a hernia of either your uterus, bladder, and/or rectum where you can see or feel a bulge. Often people describe a feeling of the “vagina falling out."
Honestly, it kind of sounds like a problem that you would deal with when you are in your 80s or 90s. But let me tell you, it is not an “old person’s problem. At least 6% of women ages 20-29 experience symptomatic pelvic organ prolapse. And it has been estimated that by the year 2050, nearly 50% of women in the United States will suffer from symptomatic pelvic organ prolapse (POP).1 That is over 5 million women who will be affected.
Despite knowing how common pelvic organ prolapse is, there is often a lot of fear and embarrassment associated with your “bladder falling out”.2 We understand that it can be scary or frustrating to learn that you have prolapse or experience symptoms of prolapse. But we want you to know that there are ways to reduce your prolapse symptoms and possibly improve your prolapse. So we’re glad you’re here!
Understanding Pelvic Organ Prolapse
What does a prolapse feel like? Let’s start with the basics of anatomy. Your pelvic organs are supported by both connective tissue (fascia and ligaments) and your pelvic floor muscles. Unfortunately, you have little control over your connective tissue, but you can (mostly) control what happens with your pelvic floor muscles.
Prolapse can happen suddenly due to trauma or damage of the supporting connective tissues or gradually due to prolonged stretch of the connective tissue. Therefore, the connective tissues are unable to suspend or hold the organs in their normal resting place, so the organs start to descend in the pelvis.
And just because you have organ prolapse, doesn’t automatically mean that your pelvic floor muscles are weak either and that you can “kegel” your way out of a prolapse. There are many women with prolapse who have tight or uncoordinated pelvic floor muscles too.
The severity of prolapse is graded on a 0 to 4 scale in relation to position of the hymen, essentially the vaginal opening (there is some variation in grading systems).
Grade 0 is the normal position of the organ
Grade 1, the organ is at the mid-vaginal level
Grade 2, the organ is approaching the vaginal opening
Grade 3, the organ passes through the vaginal opening
Grade 4, the organ has passed further than grade 3
Types of Pelvic Organ Prolapse
Cystocele (Anterior Vaginal Wall Prolapse or Dropped Bladder): A compromise in the strength of the pelvic floor muscles situated above the vagina may lead to a displacement of the bladder, causing it to press against and bulge into the vaginal area. This condition, commonly referred to as cystocele, represents the most frequent form of Pelvic Organ Prolapse (POP).
Urethrocele: A weakening of the pelvic floor muscles may result in the descent of the urethra (the conduit through which urine exits the bladder and the body), often occurring concurrently with a cystocele.
Rectocele (Posterior Vaginal Wall Prolapse or Dropped Rectum): The diminution in the strength of the pelvic floor muscles located between the vagina and rectum can lead to the rectum protruding into the back wall of the vagina, a condition known as rectocele.
Enterocele: A laxity in the pelvic muscles can allow the small intestine to push against and bulge into either the rear wall or the apex of the vagina.
Uterine Prolapse (Dropped Uterus): A weakening in the pelvic floor muscles may permit the uterus to descend into the vaginal canal, a condition indicative of uterine prolapse.
Vaginal Vault Prolapse: The loss of integrity in the pelvic floor muscles can lead to the upper portion of the vagina (vaginal vault) sagging into the vaginal canal.
Symptoms and Signs of Prolapse
The most commonly reported symptom of vaginal prolapse is the sensation of pressure or heaviness in the vagina or a feeling of a bulge or a tampon coming out of the vagina. Often these symptoms worsen with prolonged activity such as standing or walking or at the end of the day.
Women may also experience a range of bladder, bowel, or sexual symptoms including:
Bladder:
Urinary Leakage either with activity or immediately after peeing
Need for position change to start or complete urination
Weak or prolonged urine stream, sensation of incomplete emptying
Bowel:
Fecal Leakage or urgency
Constipation including straining or feeling of incomplete emptying
Need to insert a finger to help with emptying your bowels
Need to apply pressure to the perineum to empty your bowels
Sexual:
Decreased lubrication, sensation, or arousal
Other:
Pelvic pressure or heaviness
Low pain or pelvic pain
Pelvic Prolapse Causes and Risk Factors
There have been a lot of proposed mechanisms that contribute to prolapse. Often it’s not just one thing, but a combination of factors creating “the perfect storm”. In general, women are more predisposed to prolapse due to the anatomy of the pelvis because simply there is just more space for an organ to move down. And of course pregnancy/childbirth can be a big contributor especially if you gave birth vaginally or required use of forceps during your delivery (don’t think you’re out of the woods if you had a c-section though, you are still at risk for prolapse!).
Other Pelvic Organ Prolapse risk factors include:
Connective tissue disorders due to genetic disorders
Chronic constipation resulting in straining
Chronic coughing such as someone who has asthma
Heavy lifting
Surgeries such as hysterectomies
Older age especially after menopause
Pelvic Organ Prolapse Treatment Options
There are three treatment options when it comes to prolapse management.
Pelvic Floor Physical Therapy (PFPT). PFPT is a low risk treatment option and should be your first option. This is where you get to the root cause of what is likely leading to your prolapse, such as muscle incoordination, chronic constipation, or breath holding with exercise. You will learn lifestyle changes to implement, how to strengthen your body and pelvis that is specific to your individualized needs. Most importantly, you’ll learn how to reduce the risk of your prolapse getting worse and possibly improve the position of your organs.
Pessary. A pessary is an orthotic device fit by a Urogynecologist. It is inserted into the vagina to provide support to the pelvic organs. This helps to take the load off of your connective tissue, but doesn’t necessarily get to the root cause of prolapse. It can be a very helpful tool especially when combined with PFPT. You do have to make sure to take it out regularly to clean it or see your doctor to have them clean it.
Surgery. In our opinion, this should be the last resort after you’ve exhausted all other options because surgery cannot be undone and often there is still the chance that surgery doesn’t work.
Navigating Life with Pelvic Organ Prolapse: Questions for Your Healthcare Partner
As you embark on this journey with Pelvic Organ Prolapse (POP), equipping yourself with knowledge is key to managing your health effectively. Consider the following essential questions to discuss with your healthcare provider, ensuring you make informed decisions together:
Identifying Your POP Type: "Can you specify the type of Pelvic Organ Prolapse I'm experiencing?"
Non-Surgical Management: "Is it possible for me to effectively manage my POP symptoms through non-surgical means?"
Exploring Surgical Solutions: "What surgical interventions are available for my specific type of POP, and how do they align with my health goals?"
Success Rates and Outcomes: "Could you share the success rates of the available options for POP and how they might apply to my situation?"
Comprehensive Symptom Relief: "What is the probability that Pelvic PT, a pessary, or surgery will address all my POP symptoms?"
Understanding Surgical Risks: "What are the potential side effects or risks associated with the recommended surgical approach?"
Impact on Sexual Health: "How might treatment, surgical or otherwise, affect my sexual well-being?"
At the end of the day, prolapse is a non-life threatening condition. While it can be extremely bothersome for many women, it is a condition that can easily be improved with non-invasive treatment. Still have questions or concerns? We’re happy to chat!
Written by CPHW’s very own,
References:
Weintraub, A. Y., Glinter, H., & Marcus-Braun, N. (2020). Narrative review of the epidemiology, diagnosis and pathophysiology of pelvic organ prolapse. International braz j urol : official journal of the Brazilian Society of Urology, 46(1), 5–14. https://doi.org/10.1590/S1677-5538.IBJU.2018.0581
Gonzalez, G., Vaculik, K., Khalil, C., Zektser, Y., Arnold, C., Almario, C. V., Spiegel, B. M. R., & Anger, J. T. (2021). Using Digital Ethnography to Understand the Experience of Women With Pelvic Organ Prolapse. Female pelvic medicine & reconstructive surgery, 27(2), e363–e367. https://doi.org/10.1097/SPV.0000000000000938
Zhu, Y. C., Deng, S. H., Jiang, Q., & Zhang, Y. (2018). Correlation Between Delivery Mode and Pelvic Organ Prolapse Evaluated by Four-Dimensional Pelvic Floor Ultrasonography. Medical science monitor : international medical journal of experimental and clinical research, 24, 7891–7897. https://doi.org/10.12659/MSM.911343