Pelvic Organ Prolapse

What is pelvic organ prolapse?

Pelvic organ prolapse (POP) is when your pelvic organs (vagina, uterus, bladder, rectum) drop from their typical positions. It happens when your pelvic floor (the muscles, ligaments and tissues that support your pelvic organs) become too weak to hold your organs in place. Your pelvic floor supports the organs in your pelvis from underneath — almost like a hammock. If these supports become too loose, the organs they support shift out of place or sag into the vagina. Your pelvic floor can weaken due to things like childbirth or aging.

With mild cases of POP, your organs may drop slightly. In severe cases, they may extend outside your vagina and cause a bulge. People with a prolapse typically describe it as fullness or pressure in their vagina, as if something were falling out. Your exact symptoms will depend on what type of prolapse you have and how severe it is.

There are nonsurgical and surgical options to treat pelvic organ prolapse. Your healthcare provider can discuss what your options are based on your situation.

What are the different types of pelvic organ prolapse?

The type of prolapse you have depends on where the weaknesses are in your pelvic floor and what organs the weakness affects.

• Anterior vaginal wall prolapse (dropped bladder). Weakened pelvic floor muscles above your vagina can cause your bladder to slip out of place and bulge into your vagina. This type of prolapse is also called cystocele. Anterior vaginal wall prolapse is the most common type of POP.
• Urethrocele. Weakened pelvic floor muscles can cause your urethra to drop. A dropped urethra often accompanies a dropped bladder.
• Posterior vaginal wall prolapse (rectocele). Weakened pelvic floor muscles between your vagina and rectum can cause your rectum to bulge onto the back wall of your vagina.
• Enterocele. Weakened muscles in your pelvis can cause your small intestine to bulge onto the back wall or the top of your vagina.
• Uterine prolapse (dropped uterus). A weakened pelvic floor can cause your uterus to drop down into your vaginal canal.
• Vaginal vault prolapse. Weakened pelvic floor muscles can cause the top part of your vagina (vaginal vault) to drop into your vaginal canal.

How common is pelvic organ prolapse?

Around 3% to 11% of people with a vagina experience POP. About 37% of people with pelvic floor disorders, including POP, are between ages 60 and 79. Over half are 80 or older.

These figures may not be exact because many people don’t seek treatment. Often, conditions that affect the genitals go untreated because people may feel embarrassed about their symptoms. It’s important to know that you’re not alone and many people have a form of pelvic organ prolapse.

What are the symptoms of pelvic organ prolapse?

The most common symptom is feeling a bulge in your vagina, as if something were falling out of it. Other symptoms include:

• Fullness or pressure in your vagina
• Fullness, pressure or aching in your pelvis
• Pressure or pain during intercourse (dyspareunia)
• Changes to how you pee or poop

Your symptoms depend on where the prolapse is. Telling your healthcare provider about your symptoms helps them locate the spots where your pelvic floor is weakest.

Many people don’t tell their provider about their symptoms until they experience trouble peeing and pooping, or until sex becomes painful. These side effects often occur with POP. Symptoms include:

• Leaking pee when you cough, laugh or exercise (stress incontinence).
• A constant urge to pee or feeling like your bladder is full.
• Constipation or being unable to control when you poop.

What causes pelvic organ prolapse?

Your pelvic floor can weaken for many reasons. It happens most often when your pelvic floor muscles, ligaments and tissues overstretch. It can also happen due to underuse when the muscles don’t work enough.

Any of the following factors make you more at risk for pelvic organ prolapse:

• Vaginal childbirth. This is the most common cause of prolapse. Multiple vaginal deliveries, having twins or triplets, having a large baby (fetal macrosomia), and having a delivery with forceps or a vacuum all increase the odds that your pelvic floor muscles will weaken.
• The aging process. Your muscles lose strength with age. One factor is declining estrogen. During menopause, your body produces less estrogen. The decline can cause the connective tissues that support your pelvic floor to weaken.
• Having a heavier body weight. Studies have shown that people who have overweight or obesity are more likely to develop POP than people who are within a weight range that’s healthy for them.
• Long-term pressure in your abdominal cavity. Pressure on your pelvic floor muscles can weaken them. Chronic constipation, chronic coughing and frequent heavy lifting all increase your chance of developing POP.
• Family history. Research into the genetic components of POP is ongoing, but it’s possible that you inherited a weaker pelvic floor.
• Connective tissue diseases. People with conditions like Ehlers-Danlos syndrome, Marfan syndrome or joint hypermobility syndrome are at risk of POP.

What are the complications of pelvic organ prolapse?

Pelvic organ prolapse can be uncomfortable and affect your quality of life. Other than urinary and fecal incontinence, some of the other possible complications of a prolapse are:

• Infection. If the prolapse prevents you from peeing, your pee could back up into your urinary tract or kidneys, causing urinary tract infections (UTIs) or kidney infection.
• Kidney damage. In severe cases, chronic infection and urine obstruction could cause kidney damage.
• Emotional distress. A prolapse can disrupt your everyday life and affect your emotional well-being.

How is pelvic organ prolapse diagnosed?

During your appointment, your healthcare provider will review your symptoms and perform a pelvic exam. During the exam, your provider may ask you to cough so that they can see the full extent of your prolapse when you’re straining and when you’re relaxed. They may examine you while you’re lying down and while you’re standing. Often, a pelvic exam is all it takes to diagnose a prolapse.

Additional tests may include:

• Pelvic floor function tests that allow your provider to see how strong the muscles and ligaments in your pelvis are. This could include performing certain movements and motions or tightening and relaxing your muscles.
• Bladder function tests that allow your provider to look for signs of urinary issues that are common with POP. Tests may include a cystoscopy, a procedure that allows your provider to see inside your bladder and urethra. Your provider may also perform a urodynamics test to see how well your bladder and urethra are storing and releasing pee.
• Imaging procedures that allow your provider to view inside your pelvic cavity. Your provider may order a pelvic floor ultrasound or MRI to determine the extent of your prolapse. Providers typically only use imaging in complex cases.

What are the stages of pelvic organ prolapse?

The Pelvic Organ Prolapse Quantification (POP-Q) system classifies POP based on how far your pelvic organs drop relative to your hymen. Your hymen is a piece of tissue at the exit of your vagina.

The scale ranges from zero to four:

1. Stage zero means your organs haven’t shifted out of place at all.
2. Stage one means the prolapse is mild. The organ measures at least 1 cm above your hymen.
3. Stage two means the prolapse is moderate. The organ is less than 1 cm from your hymen.
4. Stage three means the prolapse is severe. The organ is more than 1 cm below your hymen but the prolapse isn’t completely outside your vagina.
5. Stage four means you have a complete prolapse. A complete prolapse is the most severe kind. It involves a prolapse bulging completely outside of your vagina.

Pelvic organ prolapse may affect different organs in different ways. For example, you could have a stage three bladder prolapse and a stage one uterine prolapse.

How is pelvic organ prolapse treated?

Your treatment plan will depend on how severe the prolapse is, where it is and how much your symptoms affect you. There are surgical and nonsurgical treatment options. For example, you may not need treatment if the prolapse is mild and not bothering you. Your provider can discuss all possible treatment methods with you and help you decide what may work best for your situation.

Nonsurgical treatments

Nonsurgical treatment focuses on managing your symptoms and improving your quality of life. Your results may not be permanent depending on how severe the prolapse is. But many people prefer nonsurgical options or determine that this method is best for them.

Treatments for pelvic organ prolapse that don’t involve surgery include:

• Vaginal pessary. This is a removable, silicone device that your provider can insert into your vagina to hold a sagging organ in place.
• Pelvic floor exercises (Kegel exercises). These are strengthening exercises for your pelvic floor. Your provider may refer you to a pelvic floor specialist or urogynecologist to test the strength of individual muscles and teach you targeted exercises to train these muscles.

Surgical treatments

Surgery may be an option if your symptoms don’t improve with conservative treatments or if your provider believes surgery gives you the best quality of life moving forward. Be sure to discuss the risks and benefits of surgery with your provider.

There are several different methods your surgeon may choose to fix pelvic organ prolapse. Two main types of surgeries are available: obliterative surgery and reconstructive surgery.

Obliterative surgery narrows the opening of your vagina, preventing the organs from slipping out. This may eliminate your ability to have penetrative sex.

• Colpocleisis is an obliterative procedure that results in a shortened vagina. It prevents any organs from bulging outside your body. It’s a good option if you’re too frail for reconstructive surgery and don’t wish to have penetrative sex anymore.

Reconstructive surgery repairs the weak parts of your pelvic floor and moves the organs back to their typical position.

• Sacrocolpopexy treats uterine prolapse and vaginal vault prolapse using a mesh material to attach your vagina to a ligament by your tailbone. It’s usually performed through small incisions in your abdomen through laparoscopy.
• Sacrohysteropexy also treats uterine prolapse. Your provider attaches surgical mesh to your cervix and vagina and attaches it to your tailbone, lifting your uterus into place.
• Colporrhaphy treats anterior and/or posterior vaginal wall prolapse. With colporrhaphy, your healthcare provider performs surgery through your vagina. They reinforce your vaginal walls with dissolvable sutures to support your bladder and rectum.
• Uterosacral or sacrospinous ligament fixation uses your tissues to treat uterine prolapse or vaginal vault prolapse. A surgeon performs it through your vagina (like colporrhaphy). During the procedure, your provider attaches the top of your vagina to a ligament or muscle in your pelvis, using dissolvable sutures. This type of surgery is sometimes called native tissue repair.

At what stage in prolapse do you need surgery?

There isn’t one specific stage that requires surgery to treat a pelvic organ prolapse. It depends on factors like how your symptoms impact your life and if you plan on having children. It’s typically more common to need surgery if you have a third or fourth stage prolapse.

It’s important to discuss all treatment options with your healthcare provider, including whether they recommend surgery or prefer nonsurgical options first.

Will pelvic organ prolapse go away?

Yes, with treatment, it can go away. With mild POP, you can strengthen your muscles so that they hold the organs in their correct locations. Reconstructive surgeries strengthen the weaknesses in your pelvic walls so that your organs return to their original locations.

Can I push my prolapse back up?

Yes. With more severe prolapse, you may have to push the bulging organ back into place, especially when pooping or peeing. But, this fix is temporary. See your healthcare provider for treatment if a pelvic organ prolapse is this severe.

How can I prevent pelvic organ prolapse?

Many causes of POP are out of your control. But you can put healthy habits into place to reduce your risk.

• Do pelvic floor exercises daily. Having muscle control in your pelvic floor provides stronger support for your organs.
• Maintain a healthy weight. Talk to your provider about what a healthy weight means for you.
• Prevent constipation. Chronic constipation can strain your pelvic floor muscles. Choosing high-fiber foods and drinking plenty of fluids can help prevent constipation.
• Don’t smoke. Smoking can lead to chronic coughing, which can put undue pressure on your abdominal cavity and strain your pelvic floor muscles.
• Protect your pelvic floor when you lift. Get help lifting heavy objects. When lifting alone, bend your hips and knees to squat while keeping your back as straight as possible. Don’t twist your torso while you’re lifting. Correctly positioning your body prevents injury to your lower back and protects your pelvic floor, too.

What can I expect if I have pelvic organ prolapse?

Your outlook depends on several things like where the prolapse is, how severe it is, your symptoms and the treatment options you pursue. Be sure to think carefully about what you hope to accomplish with treatment. Weigh the pros and cons of each treatment option with your healthcare provider. Discuss how treatment will help you live a more comfortable life.

The one thing to remember is that pelvic organ prolapse is treatable and you don’t have to live with the discomfort. Seek help from a healthcare provider and let them tell you your options. Most people who have pelvic organ prolapse find relief from their symptoms with treatment.

When should I see my healthcare provider?

Contact a healthcare provider if you have signs of pelvic floor prolapse. Possible symptoms include:

• Feelings of pressure or fullness in your pelvis
• Discomfort during sex
• Feeling like something is falling out of your vagina
• Losing control of your bowels or being constipated
• Leaking pee or feeling like you always have to pee