Pelvic Organ Prolapse

Pelvic organ prolapse is a condition in which a woman’s pelvic organs (primarily the uterus, vagina, bladder, bowels, and rectum) move from their normal position and push down into the vagina, causing a bulge in the vagina similar to a hernia.

Pelvic organ prolapse occurs when the pelvic floor muscles and connective tissues that support these organs become stretched, weakened or torn and can no longer hold the pelvic organs in their normal position.  

Pelvic organ prolapse is common, affecting as many as one in three women. Many women who have had a baby have some degree of pelvic organ prolapse, but it can also occur in women who have never given birth. Most women with pelvic organ prolapse have minor symptoms, if any, but others may experience bothersome symptoms that negatively affect their quality of life.

Some common factors that cause a loss of support for the pelvic organs and lead to prolapse include:  

• Pregnancy and childbirth – Pregnancy and vaginal delivery can damage the pelvic floor muscles and nerves. Prolapse can occur more commonly in women who have delivered a large baby, needed forceps to deliver the baby, or have had several babies. Symptoms may occur soon after pregnancy, but often take many years to develop. 
• Aging and menopause – Prolapse is more common with age and with loss of estrogen. Age-related changes can weaken the pelvic floor muscles and connective tissues. 
• Health conditions – Health issues that increase intraabdominal pressure, such as obesity, chronic coughing and repeated straining due to constipation, can weaken and injure the pelvic floor muscles and connective tissue over time. 
• Genetics – The strength of your connective tissues is influenced by genetics. Prolapse may be more common for you if it runs in your family.

There are several types of pelvic organ prolapse depending on which organ has dropped down into the vagina. The types of prolapse include:

• Anterior vaginal wall prolapse (cystocele) – the bladder drops down into the front (anterior) wall of the vagina and bulges into the vagina or through the vaginal opening (also known as dropped bladder)
• Posterior vaginal wall prolapse (rectocele) – The rectum push into the back wall of the vagina causing it to bulge forward into the vagina or through the vaginal opening 
• Small bowel prolapse (enterocele) – the small intestine pushes into the top of the vagina, causing it to bulge
• Uterine prolapse – the uterus drops down into the vagina and bulges into the vaginal canal or through the vaginal opening
• Vaginal vault prolapse – the vaginal walls weaken and the top of the vagina (vaginal vault) sags down and bulges into the vaginal canal or through the vaginal opening. This type of prolapse may occur after a hysterectomy. 

Some women may have more than one type of prolapse.

Many women with pelvic organ prolapse have no symptoms at all. The condition may only be detected during their pelvic exam. For those who do have symptoms, they may include:

• Bulging tissue in the vagina
• Pelvic pressure that may worsen with standing, lifting, coughing or as the day passes
• Difficulty urinating, such as a slow stream or the need to push on the bulge to empty your bladder
• Difficulty having a bowel movement and needing to press on the bulge to empty the bowel
• Loss of urine with physical activities such as coughing, sneezing, or jumping.

At your visit your urogynecologist will examine your pelvic floor support and pelvic floor muscle function during a pelvic exam. 

Because some women with pelvic organ prolapse also experience stress urinary incontinence and other women may be at risk of developing it once their prolapse has been repaired, urinary testing is commonly performed prior to prolapse surgery to assess your need for anti-incontinence surgery at the time of prolapse surgery including: 

Your urogynecologist may perform testing of your bladder function, including:

• Postvoid residual volume. This test is performed immediately after you void to measure the urine remaining in your bladder. The test uses either an abdominal ultrasound or a small catheter passed through your urethra to collect any remaining urine.
• Urodynamic testing. Some women with prolapse also have lower urinary tract symptoms such as difficulty passing urine, urinary incontinence, or frequent urination. Urodynamic tests evaluate bladder and urethra function.

Treatment will depend on the type and severity of your prolapse, your age, personal preferences, and other factors. Treatment strategies for pelvic organ prolapse include both non-surgical and surgical options.

Non-Surgical Treatment Options

• Ongoing monitoring. Prolapse is not dangerous or life-threatening. Patients with no symptoms or who are not bothered by their condition may choose to simply monitor their prolapse through regular exams.
• Lifestyle changes. Prolapse symptoms can be reduced by lifestyle changes, including:
  • Addressing constipation to prevent straining with bowel movements
  • Weight loss
  • Treating medical conditions that lead to excessive coughing
  • Quitting smoking, as smoking doubles your risk of having a pelvic floor disorder
• Pelvic floor physical therapy. A specialized pelvic floor therapist can help you strengthen your pelvic floor, abdominal and back muscles to restore normal function and support. Your therapist will help you isolate your pelvic floor muscles, which are typically accessed through the vagina. 
• Pessary use. A pessary is a removable device inserted into the vagina to lift up or support the pelvic organs and prevent the tissue from bulging down out of the vagina. Your urogynecologist will fit and insert the pessary. Patients can either remove pessaries themselves for cleaning or can be seen in the office every few months for pessary removal and cleaning. A pessary offers an effective option for women who want to avoid surgery, who have not completed childbearing, or who have medical issues that prevent surgery from being an option. 

Surgical Treatment Options

Women who are experiencing symptoms that affect their quality of life may choose to have surgery to  correct their prolapse, restoring the normal structure and function of their female pelvic organs. During surgery, the vaginal walls are supported, eliminating the bulge caused by the prolapsed organ. 

Baylor College of Medicine urogynecologic surgeons offer several minimally invasive procedures for pelvic organ prolapse. These procedures are typically same-day (outpatient) surgeries. Patients typically experience faster recovery and return to normal activities compared to traditional surgery. 

Our urogynecologic surgeon will work with you to determine the procedure that best meets your needs and preferences. 

Prolapse surgery can be performed at the same time as a hysterectomy to remove the uterus, fallopian tubes, and/or ovaries. Depending on the type of prolapse you have, your urogynecologist may recommend a hysterectomy as part of your prolapse surgery. 

Minimally invasive procedures for pelvic organ prolapse include:

• Vaginal reconstructive surgery (colporrhaphy). In this procedure, the surgeon makes an incision in the vagina and uses dissolvable sutures and the patient’s own tissue to tighten and strengthen the wall of the vagina and correct the prolapse. 
• Laparoscopic or robotic reconstructive surgery. These procedures are performed through 4 or 5 tiny incisions (5 to 10 mm) in the abdomen. 
  • Sacrocolpopexy: Mesh may be used to lift the vagina up and anchor it to a ligament, restoring its normal position. 
  • Uterosacral ligament suspension: Instead of mesh, the top of the vagina may also be stitched to strong ligaments (uterosacral) located higher up in the pelvis, restoring support.
• Vaginal closure surgery (colpocleisis). In this surgery, performed through the vagina, the walls of the vagina are sutured together, shortening the vagina. It is most appropriate for women who do not plan on having vaginal intercourse. It is the most successful prolapse repair surgery and has the shortest recovery time. 

Call 832-826-7500 to make an appointment with a Baylor College of Medicine urogynecologist.