Pelvic organ prolapse is the dropping or sagging of one of more pelvic organs into the vagina. It is a type of herniation that occurs because the muscles, ligaments and soft tissue (called as the fascia) of the pelvis are weakened and cannot hold the pelvic organs in their normal positions.
What are types of prolapse?
Prolapse can involve any of the walls and/or the top of the vagina. The types include:
- Prolapse of the anterior compartment: This is the most common type and involves the herniation of the bladder and/or the urethra into the vagina. This is called as a cystocele or a cysto-urethrocele. You can read more about cystocele here.
- Prolapse of the posterior compartment: This involves the herniation of the rectum into the back wall of the vagina (called as a rectocele). You can read more about rectocele here. Rectocele may/may not be associated with the herniation of part of the small bowel into the upper part of the back wall of the vagina (called as an enterocele). You can read more about enterocele here.
- Prolapse of the apical compartment or the top of the vagina:This is of two types:
- Uterine prolapse: This occurs when the uterus herniates into the vagina. This is the second most common type of prolapse.
- Vaginal vault prolapse:This occurs following hysterectomy. The top of the vagina may lose its support and invert into the vagina like a stocking everted inside out.
- You can read more about uterine and vault prolapse here.
The severity of prolapse can vary from a slight herniation to a bulge that comes out of the vagina.
How common is prolapse?
Prolapse is likely to affect about one in three women who have had children. However prolapse varies in severity and only one in 9 women (11%) will need to undergo surgery for the problem.
What are the causes of prolapse?
The pelvic organs are supported in their normal position by the muscles and ligaments of the pelvis that work in a coordinated manner under the control of nerves from the spinal cord to withstand any rise in the intra-abdominal pressure. Damage to this support system results in prolapse. Damage can result from
- Pregnancy and childbirth: These are the most common causes of prolapse, especially vaginal delivery. The severity of the damage is more in patients who have undergone forceps delivery or an episiotomy. The prolapse can manifest shortly after the pregnancy or many years later.
- Aging and the hormonal changes resulting from menopause cause further weakening of the pelvic floor structures.
- Conditions that increase the intra-abdominal pressure and cause excessive pressure on the pelvic floor, such as obesity, chronic cough, chronic constipation, heavy lifting and straining.
- Genetic factors can also play a role: some women have increased risk for prolapse due to their genetic inheritance. Some connective tissue disorders like Marfan’s syndrome and Ehlers-Danlos syndrome can also be associated with weak soft tissue leading to prolapse, but these conditions are rare.
What are the symptoms of prolapse?
Many patients are asymptomatic. The symptoms include
- a feeling of a vaginal bulge or a lump in the vagina sometimes extending outside the vagina
- discomfort during sexual intercourse
- a dragging sensation in the vagina and lower back
- in case of cystocele, urinary symptoms can co-exist such as slow urinary stream, a feeling of incomplete bladder emptying, urinary frequency or urgency and stress urinary incontinence
- in case of a rectocele, bowel symptoms can co-exist such as difficulty emptying the bowel or the need to press on the back wall of the vagina to pass stools.
How can prolapse be treated?
The treatment of prolapse of individual compartments of the pelvic floor has been covered in the article on each type of prolapse. But broadly, the treatment options can be categorized as non-surgical and surgical:
Non-surgical treatment options: