Prolapse

Up to half of all women who have had children are affected by some degree of prolapse.  

Prolapse occurs when one or more of the pelvic organs slip down from its normal position and into the vagina, because the supportive tissues have become weak. Prolapse can have a significant impact on a woman’s quality of life and on her body image.


Prolapse is a condition that is often not talked about. Find out more about this condition, access the expert interview, read another woman’s story, find out the truth behind common myths and see the research we are funding.

Overview

 

Prolapse is more common as women get older, particularly in those who have gone through the menopause. It is rare in women who have not had children. The pelvic organs, such as the womb, rectum and bladder, are normally held in place by muscles, tissue and ligaments. Prolapse occurs when the supportive tissues become weak. Prolapse is also associated with being overweight and with having a persistent cough. It is the most common reason for hysterectomy in women aged over 50.

There are different types of prolapse:

Uterine - the womb pushing through into the vagina

enterocele - part of the small bowel pushing through into the vagina

rectocele - part of the rectum pushing through into the vagina

cystocele - part of the bladder pushing through into the vagina

vaginal vault - the top of the vagina sagging after the removal of the womb (after a hysterectomy)

Stages of prolapse

The severity of the prolapse can be determined using the following grading system.

stage 1: the prolapse is more than 1cm above the opening of the vagina

stage 2: the prolapse is 1cm or less from the opening of the vagina

stage 3: the prolapse sticks out of the vagina opening more than 1cm, but not fully

stage 4: the full length of the prolapse bulges out of the vagina

 

SYMPTOMS

Some women do not have any symptoms - the condition is only discovered during an internal examination for another reason.

Most women with a prolapse will experience an uncomfortable feeling of fullness, dragging or heaviness in the vagina, which is sometimes associated with pain.

There may be a sensation of something coming down or out of the vagina. If the prolapse is more advanced, it may be possible to see it.

Other common symptoms include:

·         lower back pain

·         difficulty passing bowel movements

·         cystitis - bladder infection causing a frequent and urgent need to urinate

·         difficulty walking

·         difficulty having sex

·         stress incontinence - where a small amount of urine is involuntarily passed when coughing, sneezing or exercising

 

CAUSES

Risk Factors

·         more common with age

·         childbirth – particularly if labour has been long or difficult, multiple babies or a previous large baby

·         menopause changes - such as weakening of the tissues and low levels of the hormone oestrogen

·         being overweight or obese - creates extra pressure in the pelvic area

·         previous pelvic surgery - hysterectomy or bladder repair

·         heavy lifting- manual work

·         long-term coughing (e.g. if a smoker)

·         long-term constipation -causes excessive straining when going to the toilet

Conditions

Some conditions cause weakening of the body tissues making prolapse more likely.

·         joint hypermobility syndrome - where the joints are very loose

·         Marfan syndrome - 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

 

DIAGNOSIS

See your GP if you have any of the symptoms of a pelvic organ prolapse, especially if you can see or feel something near or at the vaginal opening

Some women may put off going to their GP if they are embarrassed or worried about what the doctor may find. An internal examination may be required but only takes a few minutes. Prolapse is very common, so there is no need to be embarrassed. The doctor will feel for lumps or bumps in the pelvic area and may ask you lie on your side to make a full assessment.  

Stage 3 or 4 prolapse may be diagnosed without internal examination, as it will be visible outside the vaginal opening.

 

TREATMENT

There are several treatment options available. No treatment may be required if the prolapse is mild to moderate and not causing any pain or discomfort.

Which treatment is used depends on:

  • the stage of the prolapse
  • how severe your symptoms are
  • age and health
  • whether future children are planned

Self care advice

There are ways to improve the condition, prevent it from worsening and limiting discomfort.

·         avoid standing for long periods of time.

·         Eat a high-fibre diet to prevent constipation and reduce straining when going to the toilet.

·         losing weight (if overweight) may resolve or reduce symptoms.

·         Pelvic floor exercises

The pelvic floor muscles are the muscles that are used to control the flow of urine from the bladder.

Having weak or damaged pelvic floor muscles can make a prolapse more likely.  Pelvic floor exercises may help to support the prolapse in mild cases.

Pelvic floor exercises are also used to treat urinary incontinence (involuntary leakage of urine), so they can be useful if this is one of the symptoms.

Hormone replacement therapy (HRT)

The menopause is where a woman’s monthly periods stop, which usually occurs at around 52 years of age.

After the menopause, the levels of oestrogen and progesterone hormones will start to fall.  The lack of oestrogen weakens the tissues in the pelvis, leading to prolapse.

Taking HRT will increase oestrogen levels and therefore may help to strengthen the vaginal walls and pelvic floor muscles and tissues.

Oestrogen is available as:

·         a cream applied to the vagina

·         a tablet inserted into your vagina

·         a patch stuck on your skin

·         an implant inserted under the skin

One trial found that taking oestrogen reduced the need for prolapse surgery in women over 60 years of age, but further research is needed to confirm this.

Despite the lack of evidence, oestrogen is widely used for women who have symptoms of a prolapse after the menopause. It may also be combined with pelvic floor muscle exercises or vaginal pessaries

Vaginal pessaries

A vaginal ring pessary is a device inserted into the vagina to hold 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 the prolapse is more severe but would prefer not to have surgery. A gynaecologist or a specialist nurse usually fits a pessary. The pessary is removed every three to six months and replaced with a new one.

Possible side effects:

·         vaginal discharge

·         irritation inside the vagina

·         urinary tract infection

·         imbalance of the usual bacteria in the vagina (bacterial vaginosis)

·         involuntary passage of a small amount of urine when coughing, sneezing or exercising (stress incontinence)

·         difficulty passing bowel movements

·         interfering with having sex

Surgery

There are procedures to treat more severe cases of prolapse. Surgery can be used to repair the supporting tissues, or to remove the womb.

Suspension treatment

A synthetic mesh (suspension sling) is inserted into the vagina to support the sagging organ or to prevent future prolapse of the vagina. 

Suspension treatment is recommended if a woman wants to have children in the future.

Surgery to close the opening of the vagina

The prolapsed organ is moved back into place and the vaginal canal is closed off. This is a very effective treatment for a severe prolapse, but sexual intercourse will no longer be possible.

Hysterectomy

A hysterectomy is a major operation that involves removing the womb (uterus). It may be considered as a treatment for some types of pelvic organ prolapse, although it can put women at increased risk of vaginal vault prolapse (where the top of the vagina falls in).

Complications from surgery

·         the mesh wearing away - further surgery may be required to remove and replace the mesh

·         damage to the surrounding organs, such as the bladder

·         infection pain during sex

·         vaginal discharge or bleeding

·         experiencing more prolapse symptoms - which may require further surgery

·         a blood clot forming in one of the veins (for example, in your leg)

Recovering from surgery

Most repair operations take about an hour and hospital stay is often for three to five days, depending on the type of procedure. Some newer techniques allow for the woman to go home on the same day as the procedure or on the following day.

Recovering at home

The recovery time after surgery for prolapse can vary. It can take up to three months to recover fully.

For the first 8-12 weeks after surgery a woman should avoid heavy lifting, strenuous exercise or standing for long periods of time. One should also try to prevent constipation – drink plenty of water and eat a high fibre diet.

If the vaginal discharge has stopped, normal sexual activity can resume about 6 weeks after the procedure

 

PREVENTION

To reduce the risk of a genital prolapse or prevent a mild prolapse from getting worse.

·         perform regular pelvic floor exercises

·         maintain a healthy weight for build (normal body mass index BMI 19-25)

·         eating a high-fibre diet to avoid constipation and straining when going to the toilet

·         avoiding heavy lifting

·         stopping smoking prevent a chronic cough

 

 

Read Women's Stories

Philippa's story-

"I have always been fit and healthy. I love to cycle and consider myself to be in good shape. I am 37 and never imagined that I would have a uterine (womb) prolapse. I have 2 fantastic children George and Anna.

Both George and Anna were normal births, but with George the labour and the pushing stage was a lot longer. I didn’t have any problems after George and as instructed tried to do pelvic floor exercises. I then went on to have Anna  2 years later. The labour was extremely quick and 1 hr 45 mins later Anna was born! I went home very quickly as we had George waiting at home and everything was fine with me and Anna. A mention of pelvic floor exercises in hospital did not come onto the radar because we were in and out so quickly.  I knew pelvic floor exercises were needed and tried to do them in between everything else that you have to do.

A year later I noticed that tampons would not stay in place and I mentioned this when having a coil fitted and no concerns were raised. 9 months further down the line, just before Anna turned 2, we were getting ready to go out for a party and something awful happened. It was during my period and something did not feel right. I could feel my cervix protruding out of my vagina. I was really shocked and frightened. I had to wait to see the doctor so I arranged to see a specialist myself. The specialist said that it was significant, but surgery could be avoided by specialist muscle training. I was so relieved when she said I may be able to solve it without surgery and a referral to a gynae (specialist) physiotherapist was made so I could start specific exercises.

I had mixed success with these exercises. I found a biofeedback pressure meter most helpful; this lets you measure the success of the exercises you are doing. It was helpful to me as it gave me feedback. There was some improvement, but I really noticed a difference when I combined these with an exercise class that focused on core strength and pelvic floor. The classes were sociable and fun and it was a great way to exercise. I went back to the specialist, all the hard work had paid off and the prolapse had significantly improved. I do have to keep up with the exercises to maintain the progress, but it was fantastic to know that my body was able to heal itself.

My advice to other women would be: don’t ignore you pelvic floor even if you consider yourself to be very active. Find a way to exercise that works for you and keeps you motivated. If this has happened to you, know that you are not alone, this happens to more women than people think and there might be a non-surgical solution to the problem".


If you would like to tell us your story so we can help and inform other women; there is more information available HERE

Expert Interview - Podcast

This podcast was recorded in January 2012.

Consultant Urogynaecologist Mark Slack explains more about pelvic organ prolapse.

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Prolapse: Text Version

 

Hello and thank you for joining us. Today we are joined by Mark Slack who is head of Urogynaecology and Pelvic Floor Reconstructive Surgery and Consultant Gynaecologist at Addenbrooke’s Hospital, Cambridge. He is going to talk to us and give his expert opinion on pelvic organ prolapse.

Hi Mark and thanks for joining us.


Hi Karina. Thanks for having me.

First of all, can you describe a little bit about what pelvic organ prolapse is and how common is it?

Right, well pelvic organ prolapse is a condition that occurs usually following childbirth but it can occur in isolation of it, it is descent or loss of support of the pelvic organs. So that is the uterus, the pelvic floor, the bladder and in some cases the rectum which is the back passage. It is extremely common. It affects a very high percentage of the population who have had children and it affects a smaller percentage of the population who haven’t had children, but are tending towards old age.

And since it is more common than many people think why do you think so many women suffer in silence?

There are a couple of aspects to that. I mean for some of the people it is just ignorance. They do not realise that something can be done about it and they just say well that’s an inevitable consequence of age and I just have to put up with it. In others they are embarrassed to go forward because it is such a personal thing- especially some of our older patients who are a bit embarrassed to come forward and complain about a lump or a bulge in a rather private area of their body.

What would your advice to them be?

Well if they discussed it with their friends and their family they would find that there are quite a lot of sufferers around them. Almost certainly once people get to their late 40s, 50s and 60s they will find a lot of their friends will suffer from a similar problem and yes don’t be embarrassed go to your general practitioner and ask advice and get opinion.

Great. That is what we need to know. You said a little bit about the risk factors... Why does it happen? Are the main two risk factors to do with getting older and child birth?

Well, I think the single major risk factor is age. So the incidence of prolapse doubles with every decade of age. Childbirth is enormously important. So you see it much more commonly in people who have had children than people who haven’t had children. The mode of delivery seems to have some effect as well, in terms of whether or not people had instrumental deliveries. And then there are certain key occupations that increase the incidence of it like manual workers and healthcare assistants, who due to the nature of their work lifting heavy weights, get a higher incidence than the normal population.

So putting stress on the pelvic floor?

And of course there is another small group who are congenital. Probably all the women who have prolapse probably have a degree of congenital difference from the normal population. But then there is a sub group of ladies who have abnormality of their collagen and are therefore pre-disposed to prolapse from a very early age.

Would that be something like Marfan’s Syndrome?

Yes. That is the extreme of the syndromes so right on the extremes you have got Marfan’s and Ehlers-Danlos Syndrome and so on. But collagen diseases are very pertain and there is a whole lot where you have minor collagen abnormalities but it’s not really measurable and they contribute to the prolapse patients.

You mentioned how prolapse can affect different pelvic organs. I know there are several different types. Can you tell us what are the most common? What do you see most often because I know there is uterine prolapse?

Well for practical purposes we divide prolapse into three areas. So it is the front, the middle and the back. So the front tends to be the bladder and that will come down and we call it a cystocele or bladder prolapse. The central part is the uterus which comes down and that’s uterine or utero-vaginal prolapse and then the back part is the rectum and the bottom part of the bowel which bulges into the vagina. You can have each one in isolation, or all three all together or you can have a combination of two out of the three. So they all can present in a variety of forms and of course then you also get the ladies who have had a hysterectomy in the past, who despite having the uterus removed, can present with just a prolapse of the vagina. Something a lot of my women patients struggle to understand.

Because you think by having a hysterectomy that problem has been removed...

Correct. So the uterus can be out, but the pelvic floor can still collapse and just the vagina itself can almost turn inside out like you turn a sock inside out. It comes down and out.

Also you mentioned before- if you are worried go and see your GP. What is often the first line treatment that women can expect? I know it depends on the severity. Are there non surgical options?

Well I think it is a very important area because it all depends on symptoms and it depends on the symptoms that the patients present with. Now I always say that there are good symptoms of prolapse and there are bad symptoms. The good symptoms are when the person says: doctor I am aware of a bulge, I can see a bulge, it feels like it is dragging, it’s there all the time, it parts the labia so I get this protrusion of tissue, it’s fine in the morning when I get up but gets worse with activity and it is relieved by lying down. Those are all very good symptoms that would tell me that when I examine the patient there is a good chance they are going to have a prolapse. Bad symptoms are when they tell me they have got pain. Prolapse seldom causes pain it causes discomfort or backache because backache alone is seldom caused by prolapse but they occur very commonly together. Patients who have prolapse can also have bad tissue and therefore also get bad backs. If they tell me they have urinary symptoms, while that is important, the urinary symptoms are probably not caused by the prolapse. But of course the urinary symptoms and the prolapse symptoms occur very commonly so people tend to join them up together.

How important are pelvic floor exercises? Would that be something that could be used as a first line treatment?

I think always. I mean that is another point. If I went down the high street and took 100 asymptomatic women off the street and examined them about 40 would have evidence of prolapse but would not be aware of it. And for that group of patients we do not want to do anything because they are comfortable, well, fit, happy and getting on with their lives. In terms of what we would treat them with- we always go for conservative first because there is no coming back from surgery. Once you are there you have crossed the rubicon you have done it. So what we always recommend is conservative therapy which takes a range of options. So one is general exercise- just getting slightly fitter, losing weight (weight is definitely a risk factor for prolapse) and then pelvic floor exercises. Now exercises will help some types of prolapse and not others, but nothing is lost by doing exercises. If at the end of three months of exercises it hadn’t worked, well then all you have done is got a bit fitter, understood the condition a bit more and then you can still have the definitive treatment should it be necessary.

But you still might have improved it?

But you may well have improved it and it may be enough to stop you needing any more invasive treatment and then of course with conservative (with exercise) we will very often ask them if they would like to try a pessary. There are a range of pessaries, about 150 different designs. The most commonly used one is called a ring pessary and a lot of patients just raise their eyes in horror because they equate that with their grandmothers but I have lots of much younger patients who don’t want surgery who wear them.

Yeah. So it is a way to avoid surgery.

It’s a way to avoid surgery, the patients are seen regularly to make sure there are no complications from it. The complications are themselves very uncommon and that may well be a way of either deferring surgery because you are too busy or work is too demanding, or you just are scared of surgery and then at a point where you feel you have got the time or the pessary is not working then you can do the definitive operation.

So if it does have to go down the route of surgery- there are several different options aren’t there and that does depend on the type of prolapse and the severity?

I think that once the patient has been seen and appropriately conservatively managed, but continues to be troubled by the symptoms, that is the time for the patient to be referred through to the specialist. By specialist I mean somebody who works in urogynaecology who sees people regularly with these symptoms, to do a proper assessment of the symptoms of prolapse, of the bladder symptoms (should they exist) and make sure that appropriate conservative therapy has been offered. And then also a person who knows what to do and they also know which operations are available, because depending on what you have actually presented with, depending on the severity, there are  a wide range of different procedures which we employ to actually achieve the end.

That are appropriate for that woman?

Correct. So it’s everything from as simple as doing what a lot of patients understand as a vaginal hysterectomy and repair (which is a fairly straight forward operation with pretty good outcomes), to really complex operations employing the use of artificial materials and telescopes and abdominal operations so it’s a big spectrum. But what you want to do is to see a person that can do all the operations so that you can make sure you are getting the operation that you need.

And they can advice on the best course.

Correct.

Are there any top tips that you would give somebody when they go and see a specialist? What should they be asking? Should they be asking how many of these have you done, what are the success rates?

Always, always. I think it is good to find out. Your general practitioner can often point you in the right direction to what we call urogynaecologists. These are gynaecologists that have chosen to do extra training in this field and it is good to find out whether the patient practice is along those lines. You can look it up on the web and see what people do and if you are unhappy with the first opinion always ask for a second opinion- which I think a patient deserves. This is a benign condition, it can be very uncomfortable, it can be quite limiting on your day to day activity but it is not life threatening, so there is no rush and if you are not happy with the advice you get- get a second opinion.

I think that is great advice. That’s really helpful for everybody listening because sometimes you don’t have the confidence to do that.

Well I think it is really important. There are a lot of grey areas in prolapse and the surgery is pretty major. So it’s very important that the patient fully understands what is going to be done, what the surgery is likely to achieve, and then much more importantly, you also need to have a discussion with the surgeon about what the possible complications are and the downs sides. Finally the decision is made by the patient who ways up how bad their symptoms are, what limitations it puts on their day to day existence and whether that justifies the risks of surgery with the attendant complications. Of course the other thing that the surgeon should be able to give you is an information leaflet and a list of complications and how commonly they occur.

So you can make that informed decision...

Much better - and one of the reasons why we give patients pessaries. A lot of my patients get pessaries because they can then go home and see how much of an improvement the pessary gives them and decide whether that’s enough to justify going ahead with surgery. Very often they will say- well actually that’s fine, I am comfortable like that and that’s worked.

Is there any advice you can give to women that want to prevent prolapse? I mean we have talked about pelvic floor exercises...

You know, it’s very difficult to limit normal activities and often what are enjoyable events like going to the gym or doing exercise for fitness. I certainly wouldn’t want people to give up a preferred sport like rowing or something. I am not convinced that we really can prevent it to be quite honest. I certainly would not be advocating that people go for caesarean sections, because that will lessen your degree of prolapse but it won’t prevent it. Once you have had your pregnancy I am afraid that you have the risk of pelvic floor dysfunction. So we would never advocate any behaviour like that to avoid pelvic organ prolapse. Weight is a very important thing, keep your weight under control, keep fit generally and hope that you have the right genes.

One last quick question... I know you do a lot of research and international research. Is there any area in this field that you feel needs more research and needs more funding to get that input?

All the areas. Sadly for us it is a benign condition and therefore it does not generate the sort of research money that cancer or heart disease does. The big fund achiever is cancer. In the United States they get about 3 billion a year for research, cardiac in the United States gets about 700-800 million and then things like pelvic floor dysfunction get 1 or 2-3 million at the bottom. So all the areas we need to understand why it happens, we need to understand who are the patients that are most at risk, so we need to do basic science work and genetics, we need to do work on collagen in the muscle and then we need to do an enormous amount more work on the operations we do and the outcomes we achieve and the symptom control. So there is just so much research that needs to be done in this field in order to improve women’s health.

So it needs the level of funding that other conditions attract..

If I had the sort of money that the HIV or the cancer charities had, we would probably have a lot more answers already. People must not under estimate the burden that this disease has on  lives, walking around on a daily basis with the dragging feeling; and the patients will say to you by 3 o’clock in the afternoon I just want to sit down and rest. They can’t go about their normal day to day activities, it has an impact on their psychosexual life, so yes it is something that so deserves more research funding.

Thank you. Thanks for coming today. Is there anything else that you would like to add?

I think not Karina, you have mentioned the most important one at the end I think which is to plug the research line. We are always very keen to talk to patients about it. We understand why cancer and cardiac get the money, what we are just trying to encourage the population to say is that there are other health conditions that have a major impact on people’s day to day activity, which really could go to improving society if we had more knowledge.

Thank you and thanks for your advice today.

Common Myths

Discover the truth behind some of the myths surrounding pelvic organ prolapse.

Prolapse can be prevented by having a caesarean section.

Pregnancy it’s self is a risk factor and having a caesarean does not mean that you are not at risk of prolapse. It is a major abdominal operation that should be avoided unless medically necessary.

Lots of exercise can cause prolapse.

Straining and heavy lifting can increase the risk of prolapse, but lots of exercise on its own does not cause it. Often the first line treatment is gentle exercise to try and improve symptoms. If prolapse is diagnosed, then heavy exercise should be stopped and gentle exercise continued.

It is just one of those things you have to live with.

No. Do not suffer in silence. More people are affected then you are aware of- don’t be afraid to go and see your GP. There are lots of treatment options and many don’t involve surgery.

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Page last updated February 2013

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