Genital or pelvic floor prolapse (or ‘prolapse’ for short) occurs when the pelvic organs bulge or protrude into a woman’s vagina or outside the opening of her vagina. The organs in the pelvis that can prolapse include the vagina, the uterus, the bladder, the rectum and the urethra. These organs are supported by ligaments, connective tissue, fascia, muscles and the bony structures of the pelvic floor. A prolapse results when the pelvic supports can no longer contain the pelvic organs within the pelvis and they descend from their usual anatomic position.
Who experiences prolapse?
Prolapse in women can occur after menopause, but is not limited to more mature women. It is also more common in women who have had more than one child – around 50% of these women can have an element of pelvic floor prolapse. However, it can also occur in young women and in women who have had no children, but only 10% to 20% of women experience symptoms.
Why do prolapses occur?
Vaginal deliveries are the most common predisposing factor to pelvic organ prolapse. This occurs because the birthing process stretches and weakens the muscles and the supports of the pelvic floor. Other factors that predispose women to prolapse include age, being postmenopausal and lifting heavy weights.
If you are overweight, obese or suffer from chronic constipation and straining during bowel moments, this can make a prolapse more likely and may worsen your prolapse over time. Patients who have a chronic cough and a number of medical conditions (including asthma or chronic bronchitis), or patients who smoke are also more likely to have a prolapse.
How do I know if I have a prolapse?
Many women have no symptoms of a prolapse, particularly if it is only a minor prolapse. Your obstetrician or gynaecologist can diagnose this during a physical examination, but the symptoms you may notice yourself include a bulging sensation inside the vagina, a sensation of fullness or pressure in the pelvis, difficulty in emptying the bladder or bowel, lower back pain or a dragging sensation in the pelvis.
You may have problems with intercourse, inserting tampons or applying vaginal creams or pessaries, or it may be as simple as noticing a lump outside your vagina. Prolapse can also be associated with a loss of self-esteem or a negative self-mage.
What are the different types of prolapse?
The terminology for pelvic floor prolapse is derived from the type of organ that has ‘dropped’. These include:
• Cystocoele: bladder prolapse
• Enterocoele: small intestine prolapse
• Rectocoele: lower large bowel prolapse
• Uterine prolapse: prolapse of the womb
• Vaginal vault prolapse: a prolapse of the upper part of the vagina
How are prolapses treated?
In terms of how to treat a prolapse, it can be done via both surgical and non-surgical methods. Non-surgical methods include:
Reducing predisposing factors
These include losing weight if you are overweight or obese, not straining when emptying your bowel or bladder, and treating a chronic cough, which can prevent prolapse from worsening.
If surgery is required, you can also learn how to reduce the strain on the pelvic floor by positioning yourself correctly when toileting. Engaging with a physiotherapist is important in this instance, as they can assist with making a permanent result from surgery much more likely.
Pelvic floor exercises
These can improve mild prolapse symptoms and reduce the progression of larger prolapses, particularly if surgery has been discussed. They involve the tightening up of the muscles that pull the vagina, bladder and rectum back and upwards.
To do these, you simply hold the muscles for three seconds and then relax your pelvis for three seconds. Do ten contractions three times a day, increasing the length of contraction time from three seconds to up to ten seconds. Do this by an increment of about one second per week, and in a couple of months you will have perfected the technique!
These are devices that are inserted into the vagina to help contain a prolapse. They are usually inserted by a doctor and kept in place for around six months. Vaginal creams are normally necessary to maintain the thickness of the vaginal skin to reduce the risk of the pessary causing irritation and ulceration. If you develop irritation, bleeding, pain or discomfort, it is vital you let your doctor know – they may decide to remove the pessary.
Surgery for prolapse is generally referred to as a ‘repair operation’. In order to repair a weakness in the bladder or urethra, an anterior repair or colporrhaphy is performed. To repair weaknesses in the side supports of the vagina, a paravaginal repair may be performed. A posterior colporrhaphy or posterior repair involves re-supporting the tissues in the back wall of vagina, ie. to correct a rectocoele or an enterocoele.
Most of these procedures are performed through the vagina, although sometimes they can be performed with the aid of a telescope through the abdomen (laparoscopy). If the uterus itself prolapses, a hysterectomy may also be performed.
Other procedures include sacrospinous vault fixation, which involves suturing the top of the vagina to a strong ligament, or sacrospinous colpopexy, where the top of the vagina can be sutured to the boney structure of the sacral bone. In some cases, the uterus can be preserved even though it is prolapsing. One of these operations is called a Manchester repair, in which the neck of the womb is removed and the rest of the uterus is preserved and elevated.
Surgery is generally regarded as being about 90% successful in treating prolapse. However, over a number of years, particularly with the persistence of predisposing factors, prolapses may recur. In this case, further surgery may be required, and this occurs in around 30% of cases.
How do I prevent a prolapse?
Regular pelvic floor exercise (ideally under the supervision of a physiotherapist) is one of the best ways of preventing a pelvic floor prolapse. Having a good bowel and bladder habit, avoiding straining during toileting and maintaining a healthy lifestyle and a healthy weight can also be helpful.
Women susceptible to prolapse should avoid lifting very heavy objects, which can reduce the strain on the pelvic floor and both prevent prolapse and maintain the integrity of any surgical procedure after a prolapse repair. Quitting smoking and the appropriate treatment of asthma symptoms or a chronic cough can also minimise the risk of a prolapse occurring.