Pelvic Organ Prolapse

Overview

What Is It?

Pelvic organ prolapse (POP) occurs when one or more organs in your pelvis—your uterus, vagina, urethra, bladder or rectum—shifts downward and bulges into or even out of your vaginal canal.

Pelvic organ prolapse (POP) occurs when one or more organs in your pelvis—your cervix, uterus, vagina, urethra, bladder or rectum—shifts downward and bulges into or even out of your vaginal canal..

Just one symptom that can be associated with the condition—urinary incontinence—costs the country more than $20 billion annually in direct and indirect medical costs, while surgeries to correct POP cost more than $1 billion annually. Approximately 200,000 surgeries are done each year in the United States to correct POP.

The condition is poised to become much more common in the United States and other Western countries with the aging of the Baby Boomers (women born between 1946 and 1964). In fact, an estimated 11 percent to 19 percent of women will undergo surgery for POP or urinary incontinence by age 80 to 85, and 30 percent of them will require an additional surgery to correct the problem.

Many women don't have any symptoms of POP. These fortunate women need not do anything but preventive nonsurgical treatment, such as lifestyle options.

Those who do have symptoms may experience a feeling of vaginal or pelvic fullness or pressure or feel as if a tampon is falling out. They may also experience incontinence, inability to completely empty the bladder, pain in the pelvic area unrelated to menstruation, lower back pain and difficulty getting stools out. Some women also complain of not being able to fully void stools and of fecal soiling of their underwear.

Treatments include lifestyle options, such as exercises to strengthen the pelvic floor, devices designed to support the pelvic organs, physical therapy and surgery to repair or support damaged ligaments and reposition the prolapsed organs. For women not planning to have sex, obliterative surgeries, which close the vaginal opening, are also an option.

Risk factors for POP include pregnancy (particularly pregnancies that have ended with a vaginal birth, especially a forceps-assisted birth), genetic predisposition, aging, obesity, estrogen deficiency, connective tissue disorders, prior pelvic surgery and chronically increased intra-abdominal pressure from strenuous physical activity, coughing or constipation. In many cases, women with POP have at least two or more risk factors.

Having been pregnant with and given birth to a child—particularly two or more children—is a significant risk factor. According to the National Association for Continence, as many as 50 percent of women who have ever given birth have some degree of POP.

While cesarean section delivery reduces the risk of POP and urinary incontinence, there is still no good evidence to support elective cesarean sections for preventing POP. Having a hysterectomy may also increase your risk of POP, depending on how the surgery was performed and how well the surgeon reattached the ligaments that typically hold up the uterus to the top of the vagina, where the cervix used to be.

Genetic factors also contribute to your risk of POP. If possible, talk to your mother, grandmother, aunts and sisters about any pelvic organ problems they've had. Also ask about urinary and fecal incontinence; although it's embarrassing to talk about, both are often associated with POP.

Diagnosis

The most common symptoms associated with pelvic organ prolapse (POP) are related to urination. You may have feelings of urgency, in which you suddenly have to urinate, find yourself urinating more often than normal, experience urinary incontinence or have difficulty urinating and completely emptying your bladder.

Some women experience sexual dysfunction, such as problems reaching orgasm and reduced sexual desire or libido. Although prolapse does not directly interfere with sexuality, it may affect self-image. Data shows that women with urge incontinence have the most problems with sexuality and that urge incontinence interferes with sexuality more than any other form of incontinence.

Some women avoid sex because they are embarrassed about the changes in their pelvic anatomy, and some worry that having sex will "hurt" something or cause more damage. Nothing could be further from the truth. Intercourse exercises the pelvic floor muscles and replaces the prolapsed organs to their appropriate position. It does not cause any damage and, for most women, when their partner is on top, the prolapse is not visible.

You may also experience problems in the rectal area. Some women with POP have pain and/or straining during bowel movements, and some experience anal incontinence, in which they inadvertently release stool.

Other symptoms include feeling as if a tampon is falling out. In fact, if the cervix has descended into the vagina, you may find you can't use a tampon at all.

However, doctors may have trouble diagnosing the condition because many symptoms can be related to situations and medical conditions unrelated to POP. The following questions can help alert your doctor to the possibility that you may have POP:

• Do you ever have to push tissue back in the vagina to urinate?
• Do you have to use your fingers in the vagina, on the perineum (the area between the anus and vagina) or in the rectum to have a bowel movement?
• Do you ever feel a bulge or that something is "falling out" of your vagina? Or do you feel like you're sitting on an egg or a ball?

Let your doctor know if you answered yes to any of these questions.

Diagnosing POP begins with a complete medical history and physical examination. The doctor will carefully examine your vulva and vagina for any lesions, masses or ulcers and will perform an internal examination to identify any prolapsed organs. The doctor will also conduct a rectal examination to test for the resting tone and contraction of the anal muscle and to look for any abnormalities in that region. The doctor may also examine you while you're standing (to see if gravity brings the organs down) and may ask you to strain as if you were urinating or having a bowel movement. A check of the nerves and reflexes in this area may be included.

POP refers to a displacement of one of the pelvic organs (uterus, vagina, bladder or rectum). These displacements are typically graded on a scale of 0 to 4, with 0 being no prolapse and 4 being total prolapse (called procidentia). Your doctor will determine which type of prolapse you have. The different types include the following:

• Bladder prolapse (cystocele). In this form, the bladder falls toward the vagina, creating a bulge in the vaginal wall. Usually the urethra also prolapses with the bladder, called urethrocele. The two together are called cystourethrocele. Symptoms include stress incontinence (when you urinate a little when you sneeze, cough, jump, etc.) or problems urinating.
• Rectal prolapse (rectocele). This occurs when the back wall of the vagina—the rectum—prolapses, pushing against the vaginal wall and creating a bulge. You notice this form most often during bowel movements.
• Uterine prolapse (uterine descensus). This is a very common form of POP. It occurs when the ligaments that hold the uterus in place weaken, like a rubber band that's been stretched too often or broken. This causes the uterus to fall, weakening the back walls of the vagina.
• Cervical prolapse. After a supracervical hysterectomy, in which the body of the uterus is removed but the cervix is left intact, the remaining cervix may prolapse with the vagina, causing a bulge.
• Vaginal vault prolapse. This form occurs when the vaginal supports weaken and the vagina drops into the vaginal canal after a hysterectomy. It may also occur when the front and back walls of the vagina separate, allowing the intestines to push against the vaginal wall in a form of prolapse called enterocele. Enterocele may occur with a uterus in place, but vaginal vault prolapse occurs only after hysterectomy when the uterus no longer supports the top of the vagina.

Tests

Your doctor may order several tests to confirm a diagnosis of POP. These include:

• Urinary tract infection screening. You pee in a cup and your urine is evaluated for the presence of bacteria.
• Postvoid residual urine volume test. This determines if any urine remains in your bladder after voiding. After urinating, the doctor or nurse inserts a catheter, or thin tube, into the urethra to measure any remaining urine or uses an ultrasound to identify any urine remaining in the bladder.
• Urodynamic testing. This test uses special pressure sensors placed in the bladder and rectum or vagina to measure nerve and muscle response.
• Imaging. Magnetic resonance imaging or ultrasound may sometimes be used to show POP details.
• Anal ultrasound or anorectal manometry. These may be used to evaluate fecal incontinence. Anorectal manometry is a rectal balloon expulsion test.

If you have problems with bowel movements, your doctor will likely refer you to a gastroenterologist for a thorough evaluation, including a colonoscopy to rule out colon cancer, which can cause constipation and straining.

Treatment

Pelvic organ prolapse (POP) is not a dangerous medical condition. Treatment options range from doing nothing and observing your condition over time to surgery to correct the prolapse. The choice of treatment typically depends on how your POP affects your quality of life, on your overall health and on your physician's expertise.

Nonsurgical options

• Observation. If you're not having symptoms, or your symptoms are not interfering with your quality of life, you should choose a wait-and-see approach. Every year, you undergo a complete examination to evaluate your POP. Just make sure you contact your health care professional if your condition changes during the year. If you have no symptoms, treatment cannot improve your quality of life and should be avoided.
• Addressing symptoms. Another option is to address any symptoms you have without actually "fixing" the underlying prolapse. For instance, if you're experiencing urinary or fecal incontinence, your doctor may recommend Kegel exercises (described below) or medication. If you are constipated and straining with bowel movements, then changing your diet, adding fiber supplements or taking medications such as laxatives may help.
  • Kegel exercises. These exercises strengthen your pelvic floor, which can help strengthen your organs in the pelvic region and may relieve pressure from prolapse. To make sure you know how to contract your pelvic floor muscles correctly, try to stop the flow of urine while you're going to the bathroom. If you can do this, you've found the right muscles. But do not do the actual exercises while stopping the stream of urine or you may develop a voiding dysfunction.
    
    To do Kegel exercises, empty your bladder and sit or lie down. Contract your pelvic floor muscles for three seconds, then relax for three seconds. Repeat 10 times. Once you've perfected the three-second contractions, try doing the exercise for four seconds at a time and then resting for four seconds, repeating 10 times. Gradually work up to keeping your pelvic floor muscles contracted for 10 seconds at a time, relaxing for 10 seconds in between. Aim to complete a set of 10 exercises, three times a day.
• Pessaries. Pessaries are diaphragm-like devices placed in the vagina to support the pelvic organs. They are commonly used in women with POP to reduce the frequency and severity of symptoms, delay or avoid surgery and prevent the condition from worsening.
  
  Most pessaries are made from silicone, plastic or medical-grade rubber. Silicone is probably best, since it is nonallergenic, doesn't absorb odors or secretions, can be repeatedly cleaned and is pliable and soft. You typically remove the pessary at bedtime and replace it in the morning, although you can arrange to remove it less often or have it removed and cleaned at your doctor's office. Most doctors prescribe vaginal estrogen with a pessary in postmenopausal women to prevent any irritation of the vaginal walls.
  
  Pessaries do not have good long-term track records. In women who get fitted for and start to use a pessary, about 40 percent stop using it within one to two years.
• Bladder support devices. These are new over-the-counter supports (brand name Poise Impressa) that are inserted into the vagina like a tampon but have a soft supportive frame inside. They reduce the movement of the urethra with exercise, coughing and sneezing, thereby reducing or eliminating leakage in women for whom these activities are problematic and cause stress incontinence. The device is not absorbent and can be inserted for eight hours. There is minimal risk or discomfort.

Surgery

An estimated 11 percent to 19 percent of women will undergo surgery for POP or urinary incontinence by age 85, and 30 percent of these women will require an additional surgical procedure. The goal of surgery for POP is to improve your symptoms by addressing the underlying cause. Surgery can be reconstructive, which corrects the prolapsed vagina while maintaining or improving sexual function and relieving symptoms, or obliterative, which moves the organs back into the pelvis and partially or totally closes the vaginal canal.

Surgery may involve repairs to any pelvic organs, including the various parts of the vagina, the perineum (the region between your vagina and anus), bladder neck and anal sphincter (anus). The goal of surgery is to reposition the prolapsed organs and secure them to the surrounding tissues and ligaments.

Although hysterectomy is still commonly performed in women with symptomatic POP, several other surgical procedures are available. Which your doctor recommends depends on your condition and the specific type of prolapse. Surgeries can be performed through an abdominal incision, vaginally or laparoscopically, with or without robotic assistance, through small incisions in your belly.

Studies find that the vaginal or laparoscopic approach results in fewer wound complications, less postoperative pain and shorter hospital stays than with open abdominal surgery. Today, a large number of POP surgeries are performed vaginally, laparoscopically or robotically. However, all forms carry a risk of relapse.

In terms of the surgery itself, procedures vary depending on the type of prolapse. In most cases, surgery for POP is performed under general or regional anesthesia (epidural or spinal), and patients may stay in the hospital overnight.

Here's an overview of the surgical procedures used to treat the various forms of POP:

• Rectal prolapse (rectocele). Surgery to repair a rectocele, or prolapse of the rectum, is performed through the vagina. The surgeon makes an incision in the wall of the vagina and secures the rectovaginal septum, the tissue between the rectum and the vagina, in its proper position using the patient's connective tissue. The opening of the vagina is tailored to the appropriate dimension, and extra support is reinforced between the anal opening and the vaginal opening.
• Bladder prolapse (cystocele). Surgery to correct bladder prolapse, or cystocele, is usually performed through the vagina. The surgeon makes an incision in the vaginal wall and pushes the bladder up. He or she then uses the connective tissue between the bladder and the vagina to secure the bladder in its proper place. If urinary incontinence is also a factor, the surgeon may support the urethra with a sling made out of a special nylon like material.
• Prolapse of the uterus (uterine descensus). In postmenopausal women or women who do not want more children, prolapse of the uterus is often corrected with a hysterectomy. In women who want more children, a procedure called uterine suspension may be an option. Some doctors now use laparoscopic surgery or vaginal surgery to repair the ligaments supporting the uterus so that hysterectomy is not necessary. This operation requires only a short hospital stay, has a quicker recovery time and involves less risk than a hysterectomy. The long-term results, however, are still being studied, so talk to your health care professional about what's right for you. If you have heavy bleeding or other uterine problems, you may want to consider hysterectomy, but if there are no other problems than prolapse, the ligament repair may be preferable. Generally, surgery for prolapse is not recommended until after you have completed childbearing because pregnancy can make it worse.
• Vaginal vault prolapse and herniated small bowel (Enterocele). Vaginal vault prolapse and herniated small bowel often occur high in the vagina, so surgery to correct the problems may be done through the vagina or the abdomen. There are a number of surgical procedures used to treat these forms of POP. The most common involves vaginal vault suspension, in which the surgeon attaches the vagina to the sacrum or to the sacrospinous ligament. This can be done through an incision in the abdomen, by laparoscopy (belly button surgery) or via robotic surgery. Robotic surgery takes many hours but accomplishes the surgery without a big incision. Sacrospinous ligament suspension is done through the vagina and is very effective as well. It can result in temporary buttock pain.
  
  It is important to be aware that fixing POP is a significant cause of incontinence with activity (stress incontinence). The abdominal/laparoscopic route results in leakage of urine in 26 percent of women who did not leak before, and the vaginal route results in a 40 percent risk of leakage. This is not always severe and does not always require treatment, but it should be explained and discussed before any surgery. Most women who undergo surgery to fix POP do not leak, but a significant number do. Some women opt for a preventive sling procedure to avoid this risk.

Prevention

Preventing pelvic organ prolapse (POP) begins in your teens. Get in the habit of practicing Kegels or pelvic tilts as done in yoga several times a day, until doing them becomes as routine as brushing your teeth.

When you get pregnant, make sure you're aware of the risks and benefits of a forceps delivery in case one is necessary. A forceps delivery creates a very high risk for incontinence and prolapse. Talk to your health care professional about the options of a vacuum delivery or a cesarean section.

Maintaining a healthy weight and quitting smoking may also help prevent pelvic floor problems, including POP.

You should also avoid straining during bowel movements and when lifting heavy items, and if you have a chronic cough, get it checked out. Chronic coughing creates the kind of straining that can lead to POP.

Facts to Know

1. Pelvic organ prolapse (POP) occurs when one or more organs in your pelvis—your uterus, urethra, bladder urethra bladder or rectum—shifts downward and bulges into your vagina.
2. Pelvic organ prolapse is poised to become much more common in the United States and other Western countries with the aging of the Baby Boomers.
3. Symptoms of POP include a feeling of pelvic fullness or pressure; feeling as if a tampon were falling out; incontinence; uncomfortable intercourse; pelvic pain (not menstrually related); lower back pain; and difficulty getting stools out. However, many women don't have any symptoms.
4. Causes of POP include pregnancy, childbirth, aging, obesity and menopause. Straining with bowel movements, lifting heavy items and chronic cough can also contribute to POP. In some cases, hysterectomy can increase the risk, while a cesarean section may reduce it. The condition also has a genetic component.
5. Urinary symptoms are the most common symptoms associated with POP. These include feelings of urgency, frequent urination, urinary incontinence or difficulty urinating.
6. Diagnosing POP begins with a complete medical history and physical examination, including an internal exam and an anal examination. Tests to evaluate the health of your urinary system and bladder may be performed.
7. There are four stages of POP, ranging from 0 (no prolapse) to 4 (total prolapse).
8. There are several types of POP, including bladder prolapse, or cystocele; rectal prolapse, or rectocele; uterine prolapse, or uterine descensus; and vaginal vault prolapse.
9. Treatment for POP depends on the type of prolapse. Treatment options range from doing nothing and observing your condition over time to surgery to correct the prolapse.
10. Kegel exercises help strengthen your pelvic floor and may relieve pressure from prolapse. They are an excellent way to treat and prevent POP.

Questions to Ask

Review the following Questions to Ask about pelvic organ prolapse (POP) so you're prepared to discuss this important health issue with your health care professional.

1. What type of POP do I have? Do I have more than one type?
2. What treatment do you recommend to treat my prolapse?
3. What is the success rate of the treatment you recommend? What are the benefits and potential risks?
4. Can you treat my prolapse, or do I need a referral to a physician who regularly treats patients with my condition, such as a urogynecologist?
5. How many patients with prolapse do you see a month?
6. How many procedures do you perform monthly to treat prolapse?
7. What are my treatment options if I still want to have children?
8. Will treatment affect my sexual function?
9. Where is this procedure usually performed and how?
10. How soon after treatment can I return to my daily activities?

Key Q&A

Organizations and Support

For information and support on coping with Pelvic Organ Prolapse, please see the recommended organizations, books and Spanish-language resources listed below.

American Association of Gynecologic Laparoscopists (AAGL)
Website: https://www.aagl.org
Address: 6757 Katella Avenue
Cypress, CA 90630
Hotline: 1-800-554-AAGL (1-800-554-2245)
Phone: 714-503-6200

American College of Obstetricians and Gynecologists (ACOG)
Website: https://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American Society for Reproductive Medicine (ASRM)
Website: https://www.asrm.org
Address: 1209 Montgomery Highway
Birmingham, AL 35216
Phone: 205-978-5000
Email: asrm@asrm.org

American Urogynecologic Society
Website: https://www.augs.org
Address: 2025 M Street NW, Suite 800
Washington, DC 20036
Phone: 202-367-1167
Email: info@augs.org

American Urological Association
Website: https://www.auanet.org
Address: 1000 Corporate Blvd.
Linthicum, MD 21090
Hotline: 1-800-RING-AUA (1-866-746-4282)
Phone: 410-689-3700
Email: aua@auanet.org

National Association for Continence (NAFC)
Website: https://www.nafc.org
Address: P.O. Box 1019
Charleston, SC 29402
Hotline: 1-800-BLADDER (1-800-252-3337)
Phone: 843-377-0900
Email: memberservices@nafc.org

Society of Interventional Radiology
Website: https://www.sirweb.org
Address: 3975 Fair Ridge Drive, Suite 400 North
Fairfax, VA 22033
Hotline: 1-800-488-7284
Phone: 703-691-1805
Email: info@sirweb.org

Books

The Incontinence Solution: Answers for Women of All Ages
by William Parker, Amy Rosenman, and Rachel Parker

Pelvic Organ Prolapse: The Silent Epidemic
by Sherrie Palm

Spanish-language resources

Medline Plus: Pelvic Support Problems
Website: https://www.nlm.nih.gov/medlineplus/spanish/pelvicsupportproblems.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov