Pelvic organ prolapse

Pelvic organ prolapse is bulging of one or more of the pelvic organs into the vagina.

These organs are the uterus, vagina, bowel and bladder.

Symptoms may include:

• a sensation of a bulge or something coming down or out of the vagina, which sometimes needs to be pushed back
• discomfort during sex
• problems passing urine – such as slow stream, a feeling of not emptying the bladder fully, needing to urinate more often and leaking a small amount of urine when you cough, sneeze or exercise (stress incontinence)

Some women with a pelvic organ prolapse don't have any symptoms and the condition is only discovered during an internal examination for another reason, such as a cervical screening.

When to see your GP

Pelvic organ prolapse isn't life-threatening, but it can affect your quality of life.

See your GP if you have any of the symptoms of a prolapse, or if you notice a lump in or around your vagina.

Internal pelvic examination

Your doctor will need to carry out an internal pelvic examination. They'll ask you to undress from the waist down and lie back on the examination bed, while they feel for any lumps in your pelvic area.

Some women may put off going to their GP if they're embarrassed or worried about what the doctor may find. However, the examination is important, only takes a few minutes and is similar to having a smear test.

Further tests

If you have bladder symptoms, such as needing to rush to the toilet or leaking when you cough and sneeze, further tests may need to be carried out in hospital.

For example, a small tube (catheter) may be inserted into your bladder to examine your bladder function and identify any leakage problems. This test is known as urodynamics.

Your doctor will decide if further tests are needed before treating the prolapse.

Types of prolapse

If pelvic organ prolapse is confirmed, it will usually be staged to indicate how severe it is. Most often, a number system is used, ranging from one to four, with four indicating a severe prolapse.

Pelvic organ prolapse can affect the front, top or back of the vagina. The main types of prolapse are:

• anterior prolapse (cystocele) – where the bladder bulges into the front wall of the vagina
• prolapse of the uterus and cervix or top of the vagina – which can be the result of previous treatment to remove the womb (hysterectomy)
• posterior wall prolapse (rectocoele or enterocoele) – when the bowel bulges forward into the back wall of the vagina

It's possible to have more than one of these types of prolapse at the same time.

Why does prolapse happen?

Prolapse is caused by weakening of tissues that support the pelvic organs. Although there's rarely a single cause, the risk of developing pelvic organ prolapse can be increased by:

• your age – prolapse is more common as you get older
• childbirth, particularly if you had a long or difficult labour, or gave birth to multiple babies or a large baby – up to half of all women who have had children are affected by some degree of prolapse
• changes caused by the menopause – such as weakening of tissue and low levels of the hormone oestrogen
• being overweight, obese or having large fibroids (non-cancerous tumours in or around the womb) or pelvic cysts – which creates extra pressure in the pelvic area
• previous pelvic surgery – such as a hysterectomy or bladder repair
• repeated heavy lifting and manual work
• long-term coughing or sneezing – for example, if you smoke, have a lung condition or allergy
• excessive straining when going to the toilet because of long-term constipation

Certain conditions can also cause the tissues in your body to become weak, making a prolapse more likely, including:

• joint hypermobility syndrome – where your joints are very loose
• Marfan syndrome – an inherited condition that affects the blood vessels, eyes and skeleton
• Ehlers-Danlos syndrome – a group of inherited conditions that affect collagen proteins in the body

Can a prolapse be prevented?

There are several things you can do to reduce your risk of prolapse, including:

• doing regular pelvic floor exercises
• maintaining a healthy weight or losing weight if you're overweight
• eating a high-fibre diet with plenty of fresh fruit, vegetables, and wholegrain bread and cereal to avoid constipation and straining when going to the toilet
• avoiding heavy lifting

If you smoke, stopping smoking may also help to reduce your risk of a prolapse.

How is prolapse treated?

Many women with prolapse don't need treatment, as the problem doesn't seriously interfere with their normal activities.

Lifestyle changes such as weight loss and pelvic floor exercises are usually recommended in mild cases.

If the symptoms require treatment, a prolapse may be treated effectively using a device inserted into the vagina, called a vaginal pessary. This helps to hold the prolapsed organ in place.

Surgery may also be an option for some women. This usually involves giving support to the prolapsed organ. In some cases, complete removal of the womb (hysterectomy) is required, especially if the womb has prolapsed out.

Most women experience a better quality of life after surgery, but there's a risk of problems remaining or even getting worse.

There are several treatment options available for a pelvic organ prolapse, depending on your circumstances.

The treatment most suitable for you depends on:

• the severity of your symptoms
• the severity of the prolapse
• your age and health
• whether you're planning to have children in the future

You may not need any treatment if your prolapse is mild to moderate and not causing any pain or discomfort.

The various treatments for pelvic organ prolapse are outlined below.

Self care advice

If your prolapse is mild, there are some steps you can take that may help improve it or reduce the risk of it getting worse.

This may include:

• doing regular pelvic floor exercises (see below)
• losing weight if you're overweight, or maintaining a healthy weight for your build (you can check your body mass index (BMI) using the BMI chart)
• eating a high-fibre diet with plenty of fresh fruit, vegetables and wholegrain bread and cereal to avoid constipation and straining when going to the toilet
• avoiding heavy lifting and standing up for long periods of time

If you smoke, giving up will help, because coughing can make a prolapse worse. Read guidance on stopping smoking for more information.

Pelvic floor exercises

The pelvic floor muscles are a group of muscles that wrap around the underside of the bladder and rectum.

Having weak or damaged pelvic floor muscles can make a prolapse more likely. Recent evidence suggests that pelvic floor exercises may help to improve a mild prolapse or reduce the risk of it getting worse.

Pelvic floor exercises are also used to treat urinary incontinence (when you leak urine), so may be useful if this is one of your symptoms.

Read more about treating urinary incontinence

To help strengthen your pelvic floor muscles, sit comfortably on a chair with your knees slightly apart. Squeeze the muscles eight times in a row and perform these contractions three times a day. Don't hold your breath or tighten your stomach, buttock, or thigh muscles at the same time.

When you get used to doing this, you can try holding each squeeze for a few seconds (up to 10 seconds). Every week, you can add more squeezes, but be careful not to overdo it and always have a rest inbetween sets of squeezes.

Your doctor may refer you to a specialist physiotherapist, who can assess your pelvic floor and teach you how to do pelvic floor exercises. It usually takes at least three months before you notice any improvement.

Hormone replacement therapy (HRT)

While there's little evidence that hormone replacement therapy (HRT) can directly treat pelvic organ prolapse, it can relieve some of the symptoms associated with prolapse, such as vaginal dryness or discomfort during sex.

HRT increases the level of oestrogen in women who have been through the menopause.

HRT medication is available as:

• a cream you apply to your vagina
• a tablet you insert into your vagina
• a patch you stick on your skin
• an implant inserted under your skin

HRT is used for women with prolapse after menopause who have the symptoms described above. Creams, tablets or pessaries may be used for a short time to improve these symptoms.

Vaginal pessaries

A vaginal ring pessary is a device inserted into the vagina to hold the prolapse back. It works by holding the vaginal walls in place. Ring pessaries are usually made of latex (rubber) or silicone and come in different shapes and sizes.

Ring pessaries may be an option if your prolapse is more severe, but you would prefer not to have surgery. A gynaecologist (a specialist in treating conditions of the female reproductive system) or a specialist nurse usually fits a pessary.

The pessary may need to be removed and replaced every four to six months.

Side effects

Ring pessaries can occasionally cause vaginal discharge, some irritation and possibly bleeding and sores inside your vagina. Other side effects include:

• passing a small amount of urine when you cough, sneeze or exercise (stress incontinence)
• difficulty with bowel movements
• interference with having sex, although most women can have intercourse without any problems
• an imbalance of the usual bacteria found in your vagina (bacterial vaginosis)

These side effects can usually be treated.

Surgery

Surgery may be an option for treating a prolapse if it's felt the possible benefits outweigh the risks.

Surgery for pelvic organ prolapse is relatively common. It's estimated that 1 in 10 women will have surgery for prolapse by the time they're 80 years old.

These procedures are outlined below.

Surgical repair

One of the main surgical treatments for pelvic organ prolapse involves improving support for the pelvic organs.

This may involve stitching prolapsed organs back into place and supporting the existing tissues to make them stronger.

Pelvic organ repair may be done through cuts (incisions) in the vagina. It's usually carried out under general anaesthetic, so you'll be asleep during the operation and won't feel any pain.

If you're planning to have children and have a prolapse, your doctors may suggest delaying surgery until you're sure you no longer want to have any more children. This is because pregnancy can cause the prolapse to recur.

Hysterectomy

If the womb (uterus) is prolapsed, then removing it during an operation called a hysterectomy often helps the surgeon to give better support to the rest of the vagina and reduce the chance of a prolapse returning.

A hysterectomy will usually only be considered in women who don't wish to have any more children, as you can't get pregnant after having a hysterectomy.

Methods to elevate and support the uterus without removing it do exist, but these need to be discussed with your doctor.

Complications from surgery

All types of surgery carry some risks. Your surgeon will explain these in more detail, but possible complications could include:

• risks associated with anaesthesia
• bleeding, which may require a blood transfusion
• damage to the surrounding organs, such as your bladder or bowel
• an infection – you may be given antibiotics to take during and after surgery to reduce the risk of infection
• pain during sex, usually caused by narrowing of the vagina
• vaginal discharge and bleeding
• experiencing more prolapse symptoms, which may require further surgery
• a blood clot forming in one of your veins (for example, in your leg) – you may be given medication to help reduce this risk after surgery (see deep vein thrombosis (DVT) for more information)

Recovering from surgery

Most prolapse operations require an overnight stay in hospital. More major operations, such as a hysterectomy, may require a few nights in hospital.

If you need to stay in hospital, you may have a drip in your arm to provide fluids and a thin plastic tube called a catheter to drain urine from your bladder. Some gauze may be placed inside your vagina to act as a bandage for the first 24 hours. This may be slightly uncomfortable. Your stitches will usually dissolve on their own after a few weeks.

For the first few days or weeks after your operation, you may have some vaginal bleeding similar to a period. You may also have some vaginal discharge. This may last three or four weeks. During this time, you should use sanitary towels rather than tampons.

Enhanced recovery

Enhanced recovery is an NHS initiative to improve patient outcomes after surgery and speed up recovery.

This involves careful planning and preparation before surgery, as well as reducing the stress of surgery, by:

• using pain relief to minimise pain
• avoiding unnecessary drips, tubes and drains
• enabling you to eat and drink straight after your operation
• encouraging early mobilisation

Post-surgery advice

Even with enhanced recovery, there may still be some activities you need to avoid while you recover from surgery. Your care team can advise about activities you may need to avoid, such as heavy lifting and strenuous exercise, and for how long.

Generally, most people are advised to move around as soon as possible, with good rests every few hours.

You can usually shower and bathe as normal after leaving hospital, but you may need to avoid swimming for a few weeks.

It's best to avoid having sex for around four to six weeks, until you've healed completely.

Your care team will advise about when you can return to work.

Problems with recovery

Contact your GP if you experience:

• a high temperature (fever) of 38C (100.4F) or over
• severe pain low in your tummy
• heavy vaginal bleeding
• a stinging or burning sensation when you pass urine
• abnormal vaginal discharge, as this may be an infection