Pelvic Organ Prolapse
A condition where pelvic organs drop down and press against the vaginal walls
Quick Facts
- Type: Pelvic Floor Disorder
- ICD-10: N81
- Prevalence: 20-40% of women
- Onset: Usually after childbirth or menopause
Overview
Pelvic organ prolapse (POP) is a common condition affecting women where one or more pelvic organs descend from their normal position and press against or protrude through the vaginal walls. This occurs when the muscles and connective tissues that support the pelvic organs become weakened or damaged, typically due to childbirth, aging, or other factors that increase pressure on the pelvic floor.
The pelvic organs that can be affected include the bladder (cystocele), uterus (uterine prolapse), rectum (rectocele), small intestine (enterocele), and the top of the vagina (vaginal vault prolapse). While not life-threatening, pelvic organ prolapse can significantly impact a woman's quality of life, affecting bladder and bowel function, sexual health, and overall comfort.
The condition ranges from mild cases where symptoms are barely noticeable to severe cases where organs protrude outside the vaginal opening. Many women develop multiple types of prolapse simultaneously. Treatment options vary based on the severity of symptoms, the woman's age, sexual activity, and desire for future pregnancies, ranging from conservative management with pelvic floor exercises to surgical repair.
Understanding pelvic organ prolapse is important for women's health, as early recognition and appropriate treatment can prevent progression and significantly improve symptoms. With proper management, most women can maintain an active lifestyle and good quality of life despite having this condition.
Symptoms
Pelvic organ prolapse symptoms can vary significantly depending on which organs are involved and the severity of the prolapse. Many women with mild prolapse have no symptoms, while others experience significant discomfort and functional problems.
Common Symptoms
Urinary Symptoms
- Difficulty emptying bladder completely
- Suprapubic pain or pressure
- Blood in urine (occasionally)
- Bladder symptoms such as urgency
- Need to lift or reposition prolapsed tissue to empty bladder
Bowel and Sexual Symptoms
- Difficulty with bowel movements or incomplete evacuation
- Need to press on the vaginal wall to have a bowel movement
- Constipation or feeling of incomplete bowel emptying
- Pain or discomfort during sexual intercourse
- Reduced sexual satisfaction
Physical Signs
- Visible tissue protruding from the vaginal opening
- Vaginal discharge that may be bloody
- Irregular bleeding between periods
- Tissue that appears red, irritated, or ulcerated
- Lower back pain that worsens with standing
When Symptoms Worsen
- Symptoms typically worsen throughout the day
- Standing for long periods increases discomfort
- Heavy lifting or straining worsens symptoms
- Symptoms often improve when lying down
- Coughing, sneezing, or laughing may worsen urinary symptoms
Causes
Pelvic organ prolapse occurs when the muscles and connective tissues that support the pelvic organs become weakened, stretched, or damaged. This support system, known as the pelvic floor, normally keeps the organs in their proper positions within the pelvis.
Primary Causes
Childbirth and Pregnancy
- Vaginal delivery: The most significant risk factor, especially for larger babies
- Multiple pregnancies: Risk increases with each pregnancy
- Prolonged labor: Extended pushing stage during delivery
- Instrumental delivery: Use of forceps or vacuum extraction
- Pregnancy hormones: Relaxin and progesterone soften supporting tissues
- Third or fourth-degree tears: Severe perineal injuries during delivery
Aging and Hormonal Changes
- Menopause: Decreased estrogen weakens pelvic floor tissues
- Natural aging: Progressive weakening of connective tissues
- Tissue elasticity loss: Reduced collagen production with age
- Muscle weakness: Gradual deterioration of pelvic floor muscles
Contributing Factors
Chronic Pressure Increases
- Chronic constipation: Repeated straining during bowel movements
- Chronic cough: From smoking, asthma, or lung disease
- Obesity: Excess weight increases abdominal pressure
- Heavy lifting: Occupational or recreational activities
- High-impact activities: Intense exercise without proper support
Medical Conditions
- Connective tissue disorders: Ehlers-Danlos syndrome, Marfan syndrome
- Previous pelvic surgery: Hysterectomy or other pelvic procedures
- Neurological conditions: Spinal cord injuries or nerve damage
- Respiratory diseases: Conditions causing chronic cough
Anatomical Factors
- Congenital weakness: Some women born with weaker pelvic floor support
- Genetic predisposition: Family history of prolapse
- Tissue quality: Individual variations in collagen strength
- Pelvic anatomy: Structural variations that affect support
Types of Prolapse by Cause
- Anterior prolapse (cystocele): Bladder drops into front vaginal wall
- Posterior prolapse (rectocele): Rectum pushes into back vaginal wall
- Uterine prolapse: Uterus drops into or through vaginal canal
- Vaginal vault prolapse: Top of vagina falls after hysterectomy
- Enterocele: Small intestine pushes into upper vaginal wall
Risk Factors
Several factors increase the likelihood of developing pelvic organ prolapse:
Reproductive and Obstetric Factors
- Multiple pregnancies: Risk increases with each pregnancy
- Large babies: Delivery of babies weighing over 8.5 pounds
- Difficult deliveries: Prolonged labor or traumatic births
- Advanced maternal age: First pregnancy after age 35
- Multiple births: Twins, triplets, or higher-order multiples
- Short intervals between pregnancies: Less than 18 months apart
Age and Hormonal Factors
- Postmenopausal status: Estrogen deficiency weakens tissues
- Advanced age: Risk increases significantly after age 50
- Early menopause: Natural or surgical menopause before age 45
- Hormone replacement therapy: May affect tissue strength
Lifestyle and Physical Factors
- Obesity: BMI over 30 significantly increases risk
- Smoking: Chronic cough and tissue damage
- Chronic constipation: Regular straining during bowel movements
- Heavy lifting: Occupational or recreational activities
- High-impact exercise: Without proper pelvic floor support
- Poor physical condition: Lack of core muscle strength
Medical and Genetic Factors
- Family history: Genetic predisposition to prolapse
- Previous pelvic surgery: Especially hysterectomy
- Connective tissue disorders: Affecting collagen production
- Chronic respiratory disease: Causing persistent cough
- Neurological conditions: Affecting pelvic floor innervation
Protective Factors
Some factors may reduce the risk of prolapse:
- Cesarean delivery: May reduce but doesn't eliminate risk
- Regular pelvic floor exercises: Strengthens supporting muscles
- Maintaining healthy weight: Reduces pressure on pelvic floor
- Avoiding chronic constipation: Prevents repeated straining
- Proper lifting technique: Using leg muscles instead of back
- Core strengthening exercises: Improves overall pelvic support
Occupational Risk Factors
- Jobs requiring heavy lifting
- Prolonged standing occupations
- High-impact athletic activities
- Occupations with limited bathroom access
Diagnosis
Diagnosing pelvic organ prolapse involves a comprehensive evaluation including medical history, physical examination, and sometimes specialized tests. The diagnosis helps determine the type, severity, and best treatment approach for the prolapse.
Medical History
Your healthcare provider will ask about:
- Symptoms and when they occur
- Pregnancy and delivery history
- Previous pelvic surgeries
- Menstrual and menopausal history
- Urinary and bowel habits
- Sexual function and concerns
- Family history of prolapse
- Medications and medical conditions
- Lifestyle factors (exercise, lifting, smoking)
Physical Examination
Pelvic Examination
- Visual inspection: Looking for visible prolapse
- Valsalva maneuver: Examining while bearing down
- Bimanual examination: Assessing organ position and support
- Speculum examination: Evaluating individual vaginal walls
- Digital examination: Assessing pelvic floor muscle strength
Prolapse Staging
The Pelvic Organ Prolapse Quantification (POP-Q) system grades prolapse severity:
- Stage 0: No prolapse
- Stage I: Prolapse more than 1 cm above hymen
- Stage II: Prolapse within 1 cm of hymen
- Stage III: Prolapse extends beyond hymen
- Stage IV: Complete prolapse or eversion
Specialized Tests
Urodynamic Testing
May be recommended for urinary symptoms:
- Uroflowmetry: Measures urine flow rate
- Cystometry: Assesses bladder function and capacity
- Pressure flow study: Evaluates bladder emptying
- Leak point pressure: Determines stress incontinence severity
Imaging Studies
Sometimes used for complex cases:
- Ultrasound: Pelvic and transvaginal imaging
- MRI: Detailed view of pelvic anatomy
- Defecography: X-ray study of bowel function
- Dynamic MRI: Shows organ movement during straining
Functional Assessment
Questionnaires and Scales
- Pelvic Floor Distress Inventory (PFDI): Symptom assessment
- Pelvic Floor Impact Questionnaire (PFIQ): Quality of life impact
- International Consultation on Incontinence Questionnaire: Bladder symptoms
- Sexual function questionnaires: Impact on intimacy
Differential Diagnosis
Other conditions to consider:
- Urethral diverticulum
- Vaginal cysts or masses
- Pelvic tumors
- Congenital abnormalities
- Inflammatory conditions
When Additional Testing is Needed
- Severe or complex prolapse
- Recurrent prolapse after surgery
- Associated urinary or bowel dysfunction
- Uncertain diagnosis
- Planning for surgical repair
Treatment Options
Treatment for pelvic organ prolapse depends on the severity of symptoms, the degree of prolapse, the woman's age, sexual activity, overall health, and personal preferences. Options range from conservative management to surgical repair.
Conservative (Non-surgical) Treatment
Pelvic Floor Muscle Training
First-line treatment for mild to moderate prolapse:
- Kegel exercises: Strengthen pelvic floor muscles
- Physical therapy: Supervised pelvic floor rehabilitation
- Biofeedback: Helps learn proper muscle contraction
- Electrical stimulation: May help activate weak muscles
- Core strengthening: Improves overall pelvic support
Pessary Devices
Removable devices that support prolapsed organs:
- Ring pessary: Most common type for mild prolapse
- Gellhorn pessary: For more severe prolapse
- Cube pessary: Self-retained by suction
- Donut pessary: For moderate prolapse
- Custom fitting: Professional fitting and follow-up required
Lifestyle Modifications
- Weight management: Reduce pressure on pelvic floor
- Constipation prevention: High-fiber diet, adequate fluids
- Smoking cessation: Reduce chronic cough
- Proper lifting techniques: Avoid straining
- Activity modification: Avoid high-impact activities if symptomatic
Surgical Treatment
Considered when conservative treatment fails or prolapse is severe:
Reconstructive Surgery
Vaginal Approach
- Anterior colporrhaphy: Repair of cystocele
- Posterior colporrhaphy: Repair of rectocele
- Vaginal hysterectomy: For uterine prolapse
- Sacrospinous ligament fixation: Supports vaginal vault
- Uterosacral ligament suspension: Restores normal anatomy
Abdominal Approach
- Sacrocolpopexy: Gold standard for vault prolapse
- Abdominal hysterectomy: With vault suspension
- Paravaginal repair: For lateral defects
Minimally Invasive Surgery
- Laparoscopic sacrocolpopexy: Less invasive approach
- Robotic surgery: Enhanced precision and visualization
- Single-incision procedures: Reduced surgical trauma
Obliterative Surgery
For women who are not sexually active:
- Colpocleisis: Closes the vaginal canal
- Partial colpocleisis: Preserves some vaginal length
- Advantages: Lower recurrence rates, shorter surgery
- Disadvantages: Eliminates possibility of sexual intercourse
Emerging Treatments
- Regenerative medicine: Stem cell therapy research
- Tissue engineering: Biomaterial grafts
- Hormonal therapy: Local estrogen for tissue health
- Radiofrequency treatment: Non-surgical tissue tightening
Treatment Decision Making
Factors to Consider
- Severity of symptoms and their impact on quality of life
- Degree and type of prolapse
- Age and overall health status
- Sexual activity and desires
- Future pregnancy plans
- Previous treatment response
- Patient preferences and goals
Surgery Considerations
- Success rates vary by procedure and surgeon experience
- Risk of recurrence (10-30% depending on technique)
- Potential complications and recovery time
- Impact on bladder, bowel, and sexual function
- Need for additional procedures
Prevention
While not all cases of pelvic organ prolapse can be prevented, especially those related to genetic factors, there are several strategies that may reduce the risk or delay the onset of prolapse.
Pregnancy and Delivery
- Prenatal pelvic floor exercises: Strengthen muscles before delivery
- Controlled pushing: Avoid prolonged or forceful bearing down
- Optimal birthing positions: Upright or side-lying positions
- Perineal support: Proper support during crowning
- Postpartum rehabilitation: Early pelvic floor recovery
- Gradual return to activity: Avoid heavy lifting early postpartum
Pelvic Floor Health
Regular Exercise
- Kegel exercises: Daily pelvic floor muscle training
- Core strengthening: Include deep abdominal muscles
- Proper exercise form: Avoid increasing abdominal pressure
- Progressive training: Gradually increase intensity
- Professional guidance: Learn correct technique from physiotherapist
Breathing and Posture
- Diaphragmatic breathing: Coordinate with pelvic floor
- Good posture: Maintain neutral spine alignment
- Core engagement: Gentle activation during activities
- Movement patterns: Maintain pelvic floor support during activities
Lifestyle Factors
Weight Management
- Maintain healthy BMI: Reduce pressure on pelvic floor
- Gradual weight loss: If overweight, lose weight slowly
- Regular physical activity: Low-impact exercises preferred
- Nutritious diet: Support tissue health and healing
Bowel Health
- Prevent constipation: High-fiber diet and adequate fluids
- Regular bowel habits: Don't delay when urge occurs
- Proper toileting posture: Feet flat, knees slightly elevated
- Avoid straining: Use breathing techniques for elimination
- Probiotics: Support healthy gut microbiome
Activity Modifications
Lifting and Movement
- Proper lifting technique: Bend knees, keep back straight
- Engage core muscles: Before lifting or straining
- Avoid heavy lifting: Especially repetitive heavy loads
- Use assistive devices: Carts, dollies, or ask for help
- Gradual progression: Slowly increase activity levels
Exercise Considerations
- Low-impact activities: Swimming, walking, cycling
- Avoid high-risk exercises: Heavy squats, deadlifts, crunches
- Modify high-impact sports: Use pelvic floor contractions
- Wear supportive garments: During high-intensity activities
- Listen to your body: Stop if symptoms worsen
Health Management
- Treat chronic cough: Address underlying respiratory conditions
- Smoking cessation: Reduce chronic cough and improve tissue health
- Manage chronic conditions: Diabetes, COPD, allergies
- Hormone considerations: Discuss with healthcare provider
- Regular check-ups: Monitor pelvic floor health
Early Detection
- Self-awareness: Know normal anatomy and function
- Regular self-examination: Check for changes
- Report symptoms early: Don't wait for severe symptoms
- Annual gynecologic exams: Include pelvic floor assessment
- Postpartum follow-up: Assess pelvic floor recovery
Special Populations
Menopausal Women
- Consider hormone replacement therapy (discuss risks/benefits)
- Maintain regular exercise and pelvic floor training
- Use vaginal moisturizers and lubricants
- Continue regular gynecologic care
Athletes
- Sport-specific pelvic floor training
- Proper breathing techniques during exertion
- Gradual return to sport after pregnancy
- Use of supportive devices when appropriate
When to See a Doctor
Seek Immediate Medical Attention
- Sudden, severe pelvic pain
- Complete inability to urinate
- Severe bleeding from vaginal tissue
- Signs of infection (fever, foul-smelling discharge)
- Tissue that appears dark, cold, or necrotic
- Severe abdominal pain with prolapsed tissue
Schedule an Appointment Soon
- Visible tissue protruding from the vaginal opening
- Persistent feeling of pelvic pressure or fullness
- Difficulty emptying bladder or bowel completely
- Recurrent urinary tract infections
- Pain during sexual intercourse
- Lower back pain that worsens with standing
- Bleeding or discharge from protruding tissue
- Inability to keep pessary in place
Routine Follow-up
- Annual gynecologic exams for monitoring
- After pregnancy and delivery for assessment
- If using a pessary (every 3-6 months)
- Changes in symptoms or new concerns
- Before starting new exercise programs
- When considering treatment options
Questions to Ask Your Doctor
- What type and stage of prolapse do I have?
- What are my treatment options?
- What are the risks and benefits of each treatment?
- How will treatment affect my daily activities?
- What can I do to prevent worsening?
- How often should I have follow-up appointments?
- When should I consider surgery?
- What activities should I avoid?
- How will this affect my sexual health?
- Are there any complications I should watch for?
Preparing for Your Appointment
- Keep a symptom diary for several weeks
- List all medications and supplements
- Prepare questions about your condition
- Bring information about previous pregnancies and deliveries
- Note which activities worsen or improve symptoms
- Consider bringing a support person
What to Expect During Your Visit
- Detailed medical and obstetric history
- Physical examination including pelvic exam
- Assessment of prolapse severity
- Discussion of symptoms and impact on quality of life
- Review of treatment options
- Possible referral to urogynecologist or pelvic floor specialist
Frequently Asked Questions
While not all cases can be prevented, risk can be reduced through pelvic floor exercises, maintaining healthy weight, avoiding constipation, proper lifting techniques, and not smoking. Prenatal and postpartum pelvic floor training may help reduce risk after childbirth.
Prolapse may worsen gradually over time, especially without treatment. However, the progression varies greatly among women. Some have stable, mild prolapse for years, while others may experience rapid worsening. Early intervention with pelvic floor exercises and lifestyle modifications can help slow progression.
Many women with mild to moderate prolapse can continue to have satisfying sexual relationships. Some may experience discomfort or reduced sensation. Treatment options including pelvic floor therapy, pessaries, or surgery can often improve sexual function. Open communication with your partner and healthcare provider is important.
No, surgery is not always necessary. Many women successfully manage prolapse with conservative treatments like pelvic floor exercises, pessaries, and lifestyle modifications. Surgery is typically considered when conservative treatments fail, symptoms significantly impact quality of life, or the prolapse is severe.
Yes, but modifications may be needed. Low-impact exercises like walking, swimming, and cycling are generally safe. Avoid high-impact activities that increase abdominal pressure. Pelvic floor exercises are particularly beneficial. Work with a pelvic floor physiotherapist to develop a safe exercise program.
Mild prolapse usually doesn't prevent pregnancy, but it may worsen during pregnancy and delivery. Discuss with your healthcare provider about management during pregnancy and delivery options. Some women choose to delay prolapse treatment until after completing their families.
Surgery success rates vary depending on the type of procedure and surgeon experience, typically ranging from 70-95%. Success is measured by symptom improvement and anatomical correction. However, there's always a risk of recurrence (10-30%), and some women may need additional procedures.
A pessary is a removable silicone device inserted into the vagina to support prolapsed organs. It works by providing mechanical support to hold organs in their normal position. Pessaries require proper fitting by a healthcare provider and regular follow-up for cleaning and repositioning.