Pelvic Organ Prolapse (POP)

Pelvic Organ Prolapse

What is prolapse?

Pelvic organ prolapse is a very common condition, particularly among older women. It’s estimated that half of women who have children will experience some form of prolapse in later life, but because many women don’t seek help from their doctor the actual number of women affected by prolapse is unknown.

Prolapse may also be called uterine prolapse, genital prolapse, uterovaginal prolapse, pelvic relaxation, pelvic floor dysfunction, urogenital prolapse or vaginal wall prolapse

Types of prolapse

Pelvic organ prolapse occurs when the pelvic floor muscles become weak or damaged and can no longer support the pelvic organs. The womb (uterus) is the only organ that actually falls into the vagina. When the bladder and bowel slip out of place, they push up against the walls of the vagina. While prolapse is not considered a life threatening condition it may cause a great deal of discomfort and distress.

There are a number of different types of prolapse that can occur in a woman’s pelvic area and these are divided into three categories according to the part of the vagina they affect: front wall, back wall or top of the vagina. It is not uncommon to have more than one type of prolapse.

Prolapse of the anterior (front) vaginal wall

Cystocele (bladder prolapse)

When the bladder prolapses, it falls towards the vagina and creates a large bulge in the front vaginal wall. It’s common for both the bladder and the urethra (see below) to prolapse together. This is called a cystourethrocele and is the most common type of prolapse in women.

Urethrocele (prolapse of the urethra)

When the urethra (the tube that carries urine from the bladder) slips out of place, it also pushes against the front of the vaginal wall, but lower down, near the opening of the vagina. This usually happens together with a cystocele (see above)

Prolapse of the posterior (back) vaginal wall

Enterocele (prolapse of the small bowel)

Part of the small intestine that lies just behind the uterus (in a space called the pouch of Douglas) may slip down between the rectum and the back wall of the vagina. This often occurs at the same time as a rectocele or uterine prolapse (see below)

Rectocele (prolapse of the rectum or large bowel)

This occurs when the end of the large bowel (rectum) loses support and bulges into the back wall of the vagina. It is different from a rectal prolapse (when the rectum falls out of the anus).

Uterine prolapse

Uterine prolapse is when the womb drops down into the vagina. It is the second most common type of prolapse and is classified into three grades depending on how far the womb has fallen.

Grade 1: the uterus has dropped slightly. At this stage many women may not be aware they have a prolapse. It may not cause any symptoms and is usually diagnosed as a result of an examination for a separate health issue.

Grade 2: the uterus has dropped further into the vagina and the cervix (neck or tip of the womb) can be seen outside the vaginal opening.

Grade 3: most of the uterus has fallen through the vaginal opening. This is the most severe form of uterine prolapse and is also called procidentia.

Vaginal vault prolapse

The vaginal vault is the top of the vagina. It can only fall in on itself after a woman’s womb has been removed (hysterectomy). Vault prolapse occurs in about 15% of women who have had a hysterectomy for uterine prolapse, and in about 1% of women who have had a hysterectomy for other reasons.

Genital Prolapse

Genital prolapse occurs when pelvic organs (uterus, bladder, rectum) slip down from their normal anatomical position and either protrude into the vagina or press against the wall of the vagina. The pelvic organs are usually supported by ligaments and the muscles, connective tissue and fascia which are collectively known as the pelvic floor. Weakening of or damage to these support structures allows the pelvic organs to slip down.

The condition is most common in postmenopausal women who have had children, but can also occur in younger women and women who have not had children. It is estimated that at least half the women who have had more than one child have some degree of genital prolapse (although only 10-20% complain of symptoms

Types of prolapse

Causes

Prolapse occurs due to a weakness or damage that has occurred to the structures which hold the pelvic organs in place. There are a number of contributing factors including:

Pregnancy and childbirth -The most significant causal factor for prolapse is having children. During pregnancy, hormonal changes and the extra weight and pressure of the baby can contribute to the weakening of the pelvic floor. In addition, a vaginal delivery can result in the supporting pelvic structures being stretched or torn. Damage to the pelvic floor occurs particularly in long second stages of labour, instrumental deliveries (the use of forceps or vacuum extraction) and in the delivery of large infants (2). Often damage that occurs during pregnancy and childbirth goes unnoticed at the time, with symptoms only developing later in life, following menopause.
Menopause/ageing – The female hormone oestrogen plays an important role in maintaining the strength of the pelvic floor. At menopause, a woman’s oestrogen levels decrease and, as a result, the pelvic floor becomes weaker. The lack of oestrogen at this time often exacerbates existing damage that may have occurred as a result of childbirth or other factors. The pelvic support structures also relax due to the natural ageing process.
Pressure in the abdomen – Factors such as obesity, chronic coughing (eg. coughing associated with smoking or conditions like bronchitis or asthma), the lifting of heavy objects, straining during a bowel movement and the presence of pelvic masses (ie., fibroid) all place pressure on the pelvic floor. If these pressures are sustained over a long period of time they can weaken the pelvic floor.
Genetic – Some women are born with a weakness in their pelvic floor muscles and so are at a higher risk of prolapse. Congenital weakness explains why some young women and women who have never had children develop a prolapse.
Pelvic surgery – Women who have previously had pelvic organ prolapse surgery may be at increased risk of developing other prolapses.

Prevention

While women have little control over some contributing factors to prolapse (eg., having a long labour or giving birth to a large infant), there are a number of other steps they can take to reduce their risk.

Perform pelvic floor exercises regularly, particularly during pregnancy after childbirth and into menopause.
Avoid constipation and straining during a bladder and bowel movement. A physiotherapist or continence nurse can provide information on toileting positions to minimise risk to the pelvic floor and assist in the complete emptying of the bladder and bowel.
Treat the cause of any chronic cough (if it is smoking-related seek assistance in quitting).
Maintain a healthy weight.
Avoid lifting heavy objects frequently. If lifting heavy objects, make sure to bend at the knees and keep the back straight.

Treatment

There are a range of treatment options available for prolapse. The most appropriate treatment will depend upon the type of prolapse or prolapses, their severity, the age of the woman, her state of health and her plans regarding children. Treatments can be divided into three types, conservative, mechanical and surgical. Conservative and mechanical treatments are generally considered for those with a mild prolapse, women whose childbearing is not complete and for those who do not wish to have surgery or who are unsuitable candidates for surgery (eg., elderly women).

Conservative
Lifestyle changes
Pelvic floor exercises
Mechanical (pessaries)
Surgical treatment