Pelvic Organ Prolapse
Pelvic organ prolapse is a condition involving one or some of the pelvic organs dropping into or bulging into the walls of the vagina due to weak or underactive pelvic floor muscles, fascia, or ligaments.
Although many women find it embarrassing to talk about and often live with the discomfort, pelvic organ prolapse can be successfully treated. Keep reading, to learn more about the causes, symptoms, and treatments for pelvic organ prolapse.
What are the Pelvic Floor Muscles?
Made up of muscles, ligaments, and connective tissues, the pelvic floor is akin to a supportive hammock for the pelvic organs and connects with the core muscles to stabilize the spine and pelvis.
These supportive and stabilizing muscles wrap from the pubic bone at the front of the body to the tailbone at the back and outward to the left and right of the pelvis. In addition to holding organs like the bladder, rectum, uterus, and vagina in place, the pelvic floor also enables bodily functions like bowel movements, urination, and sex.
What is Pelvic Organ Prolapse?
The word prolapse means ‘to fall out of place’, which is essentially what happens to the pelvic organs when pelvic organ prolapse occurs. When the pelvic floor muscles become damaged, loose, or too weak to support the pelvic organs, they can drop or fall out of position. Pelvic organ prolapse (POP) occurs when one or more of the pelvic organs descends into the vagina or can be seen protruding out of the vaginal opening.
According to statistics, 11% of women aged 60-70 are affected by POP, although medical professionals believe this number to be higher because many women are too embarrassed to seek treatment. Even though POP is most common in women over 60, it can happen to women at any age.
Different Types of Pelvic Organ Prolapse
The type of prolapse depends on which part of the pelvic floor muscles are injured, weak, or loose and which pelvic organ is affected.
Anterior vaginal wall prolapse, which is also called cystocele or a dropped bladder, is caused by weak pelvic floor muscles in the front of the vagina. It is one of the most common types of pelvic organ prolapse and results in the bladder falling into the vagina. A dropped bladder may occur in conjunction with another form of organ prolapse called urethrocele, which refers to a prolapse of the urethra, or the tube that transports urine from the bladder.
Posterior vaginal wall prolapse, which is also called rectocele or a dropped rectum, is caused by weak pelvic floor muscles between the rectum and the vagina. This type of prolapse results in the rectum pressing into the back wall of the vagina.
Uterine prolapse, also known as a dropped uterus, occurs when the pelvic floor muscles are too weak to support the weight of the uterus (womb). With uterine prolapse, the uterus can fall into the vaginal canal and sometimes bulge out of the vaginal opening. Prolapse of the small intestine, also called enterocele, is often linked to uterine prolapse.
Vaginal prolapse, which is also known as vaginal vault prolapse, occurs when the top of the vagina falls into the vaginal canal, and generally associated with hysterectomy.
What are the Symptoms of Pelvic Organ Prolapse?
A patient’s recognition of pelvic organ prolapse often begins with a feeling of pressure or fullness in the pelvic area, particularly during exercise, intercourse, or when inserting a tampon. This feeling is known to worsen as the day unfolds or after standing for a long time.
Leaking urine while laughing, sneezing, or coughing (stress incontinence) is common with pelvic organ prolapse. Many women with POP also experience a frequent urge to pee (urge incontinence) and bowel movements can also become more difficult, sometimes resulting in constipation.
Pain during sex (dyspareunia) and lower back pain are also common symptoms of POP.
Depending on the type and stage of prolapse, an uncomfortable bulge might become apparent in the vagina, and when POP is severe, the prolapsed organ can slip out through the vaginal opening. When this occurs, women may need to move the protruding organ aside to urinate or move their bowels.
Causes of Pelvic Organ Prolapse
Pelvic organ prolapse is caused when the pelvic floor is injured, or too weak to support the organs within the pelvis. The most common causes of damaged, weak, or loose pelvic floor muscles are as follows:
Childbirth is known to weaken the pelvic floor muscles and contribute to the possibility of pelvic organ prolapse later in life. Vaginal births of babies weighing over 3.5 kilos can increase the risk of POP and even women who have given birth via C-section can suffer from pelvic organ prolapse due to the weight of the still-enlarged uterus upon weakened pelvic floor muscles.
Abdominal pressure from chronic constipation, heavy lifting, or chronic coughing can also weaken the pelvic floor muscles to the point that pelvic organ prolapse can occur.
Aging is known to increase the risk of POP, particularly during perimenopause and menopause when estrogen production slows down. Low estrogen levels during this phase of life can cause the vaginal tissues and connective tissues of the pelvic floor to thin and weaken, resulting in pelvic organ prolapse for many.
Medical History and Genetics
Medical history within families is currently under research as a possible cause of POP. Due to several cases of pelvic organ prolapse occurring across generations of the same families, researchers believe that a weak pelvic floor could be genetic.
How to Know If You Have Pelvic Organ Prolapse?
If you experience any of the above-mentioned symptoms, don’t be too embarrassed to make an appointment with your doctor or female health expert to discuss it. To diagnose or rule out POP, doctors will typically ask a few questions regarding symptoms and carry out a gentle pelvic exam to check for any sign of prolapse.
During the pelvic exam for POP, doctors will typically ask patients to cough or strain their pelvic floor to check the extent of prolapse and/or incontinence. Findings from these pelvic exams, and in some cases an ultrasound, are used to categorize patients into one of the four stages of pelvic organ prolapse and prescribe the appropriate treatment.
Stages of Pelvic Organ Prolapse
When diagnosing POP, doctors typically perform a pelvic exam and use the Pelvic Organ Prolapse Quantification System (POP-Q) to determine the stage of the condition. The system includes four stages with one being the mildest and four the most severe.
Stage 1 is described as mild organ prolapse. In this phase, patients typically experience no obvious symptoms, and the mild organ prolapse is typically recognized during a routine smear test or pelvic exam.
Stage 2 is described as moderate organ prolapse. This is when the organ has slipped out of its usual position but remains inside the body. During this stage, patients might begin to notice a feeling of heaviness in the pelvic area and/or pain during sex.
Stage 3 is described as severe organ prolapse. In this phase, patients can typically feel the prolapsing organ as a lump or bulge within the vagina and a deeper sensation of heaviness or aching in the pelvic region. Other symptoms could include lower back pain and incontinence or constipation. When coughing, laughing, exercising, or sneezing during this phase of POP, the prolapsed organ might temporarily jut out of the vagina before retreating.
Stage 4 is described as complete prolapse and symptoms are typically more intensely felt during this phase. These can include heaviness in the pelvis, incontinence, constipation, and lower back pain, as well as the prolapsed organ protruding permanently from the vaginal opening.
Treating Pelvic Organ Prolapse
Treatment options for pelvic organ prolapse typically depend on which stage of POP patients are experiencing. Other factors that determine the type of treatment include the patient’s age, if they wish to continue having sex, and any underlying conditions they may have.
Non-surgical treatments are normally effective for the earlier stages and can usually prevent the more severe stages from occurring. If POP has been left untreated, however, and progressed to stage three or four, surgery might be required.
Non-surgical treatments include the following:
Depending on the stage of pelvic organ prolapse and the patient’s health, certain lifestyle changes, along with the help of other therapies, can help to relieve and treat the associated symptoms.
For example, regular exercise and eating healthier might be recommended if prolapse is caused by abdominal pressure due to excess weight. When chronic constipation causes POP, patients are advised to try eating a diet rich in fiber. And if the prolapse is caused by chronic coughing as a smoker, patients could see substantial improvement by giving up smoking.
When the early stages of POP occur during or after menopause, the first line of treatment is rebalancing the low estrogen levels with hormone therapy (HT). That said, given the risky side effects of HT when treating estrogen deficiencies, a natural remedy called Chasteberry is considered much safer and becoming more popular.
As a phytoestrogen that mimics the effects of estrogen in the body, rather than supplementing it, Chasteberry helps to alleviate the symptoms of menopause without any of the side effects.
Patients with POP are often referred to a physical therapist specializing in pelvic health. By assessing the strength of the muscles, ligaments, and connective tissues within the pelvic floor, physical therapists can teach patients specific exercises that target and strengthen the right pelvic muscles to alleviate prolapse.
Kegel Exercises & Kegel Weights
Kegel exercises are muscle training movements to re-strengthen the pelvic floor and performing them regularly can help to alleviate the symptoms of pelvic organ prolapse. Kegels are performed by lifting, squeezing, and holding the pelvic floor muscles before releasing and repeating several times per day.
Although practicing daily Kegel exercises will strengthen the pelvic floor over time, pelvic health physical therapists recommend adding Kegel Weights (aka vaginal weights) for more effective training and faster results. Similar to how one might use dumbbells to improve muscle strength in the arms, Kegel weights do the same for the pelvic floor. That said, Kegel weights might not be effective for severe stages of POP, so it’s best to check with a healthcare provider first.
A pessary is a removable medical device that is used to support sagging pelvic organs by inserting it into the vagina.
Surgical Procedures to Treat Pelvic Organ Prolapse include the following:
If symptoms don’t improve with non-surgical treatments, or POP has progressed to stage 3 or 4 without treatment, surgery could be the next step. Surgical options depend on the patient’s age and whether they are still sexually active.
There are two types of surgery for treating POP - reconstructive surgery or obliterative surgery.
Reconstructive surgery involves repairing the weak or injured parts of the pelvic floor either with the patient’s body tissue or with synthetic mesh.
Undergoing obliterative surgery means the vaginal walls are sewn together to prevent pelvic organs from bulging out through the vaginal opening. This surgery is only recommended if women are no longer interested in having sex.
Pelvic organ prolapse (POP) occurs when injured or weak pelvic floor muscles are no longer capable of supporting pelvic organs like the bladder, rectum, uterus, and vagina. This lack of support can cause one or more of the pelvic organs to sag into the vagina or protrude from the vaginal opening.
POP is a common female ailment, particularly for those in menopause, but it can happen to women of any age. It is nothing to be embarrassed about, and when caught early, non-surgical treatments like Kegel weights, hormone balancing, and certain lifestyle changes can be effective.
Office on Women’s Health – Pelvic Organ Prolapse - https://www.womenshealth.gov/a-z-topics/pelvic-organ-prolapse
Cleveland Clinic – Pelvic Floor Muscles - https://my.clevelandclinic.org/health/body/22729-pelvic-floor-muscles
Johns Hopkins Medicine - Vaginal Prolapse - https://www.hopkinsmedicine.org/health/conditions-and-diseases/vaginal-prolapse
Science Direct – Phytoestrogens & Conditions of the Reproductive Organs - https://www.sciencedirect.com/topics/neuroscience/phytoestrogen
National Library of Medicine - Comparison of Pelvic Organ Prolapse Quantification and Simplified Pelvic Organ Prolapse Quantification Systems in Clinical Staging of Iranian Women with Pelvic Organ Prolapse - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8047234/
Minia Scientific Nursing Journal - Effect of Kegel Exercise on Improving Manifestations of Uterine Prolapse among Premenopausal Women - chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://msnj.journals.ekb.eg/article_188046_1b5cffd96b6d97093ca7bc0c7f26af31.pdf
National Library of Medicine - Vaginal weights for assessment and training of the pelvic floor - https://pubmed.ncbi.nlm.nih.gov/9791381/