Pelvic Organ Prolapse

The pelvic floor, the upper and lower vaginal support and the internal and external anal sphincter.) is a network of muscles, ligaments and other tissues that form a sling or hammock across the opening of the pelvis holding up the pelvic organs. These muscles, together with their surrounding tissues, are responsible for keeping all of the pelvic organs (bladder, uterus and rectum) in place and functioning correctly.

To understand how prolapse occurs, it is helpful to understand the normal positions of organs in the pelvic region. The bladder is located in front of the vagina and the rectum is located behind the vagina. Generally these internal organs are maintained in their position by a body of connective tissue and muscles that form a strong shelf on which all of the pelvic organs sit. If these muscles are damaged or weakened through normal aging, child birth, pelvic surgery or trauma the organs loose their normal positioning and the uterus and pelvic contents move into the vaginal vault.

INCIDENCE

More than 50% of woman age 55 and older suffer one or more problems caused by pelvic floor dysfunction. One out of every 9 woman will undergo surgery for pelvic floor disorder. Eight times more woman than men suffer from a pelvic floor disorder. Woman who suffer from pelvic floor disorders under report there condition due to embarrassment. One out of every three woman will suffer from sphincter muscle damage due to vaginal birth. Thirty percent of woman with overactive bladder or urinary incontinence also suffer from loss of bladder control.

Although men can suffer from pelvic floor disorders, the obvious difference in anatomy and function of the pelvic floor organs and their support that exist between men and woman makes this set of disorders more common in woman.

CONTRIBUTING FACTORS

A number of different factors contribute to the weakening of pelvic muscles over time, but the two most significant factors are thought to be pregnancy and aging (menopause). Pregnancy is believed to be the main cause of pelvic organ prolapse, whether the prolapse occurs immediately after pregnancy or 20 years later. A vaginal delivery may weaken or stretch some of the supporting structural muscles in the pelvis. The delivery may damage nerves, leading to muscle weakness. Certain situations in pregnancy and birth further increase the likelihood of an extent of damage, such as a large baby, a long labor and the use of forceps or extractive devices. The aging process with already damaged pelvic floor muscles further weakens the pelvic muscles. The natural reduction in estrogen at menopause also causes muscles to become less elastic.

Woman who are severely overweight or have large fibroids or pelvic tumors, are at an increased risk of prolapse due to the extra pressure this creates in their abdominal area. Chronic coughing from smoking, asthma or bronchitis, straining during bowel movements and heavy lifting cause also contribute to pelvic floor disorders. Other causes include hysterectomy, nerve disorders, connective tissue disorders, degenerative neurologic conditions and prior pelvic surgery.

TYPES OF PROLAPSE

Prolapse comes from the Latin word to fall. In medicine this term indicates that an organ has slipped out of its proper place. Woman with pelvic floor disorders may suffer from the rectum protruding through the back of the wall of the vagina (rectocele). The bladder protruding out of the anterior wall (cystocele) or the entire vagina (vaginal vault prolapse [or uterus] uterus prolapsing through the vaginal opening). The small intestine may even prolapse (enterocele), especially in woman who have had a hysterectomy.

In the prolapse of the uterus (PROCIDENTIA) the uterus drops down into the vagina. It usually results from weakening of the connective tissue and ligaments supporting the uterus. The uterus may bulge only in the upper part of the vagina, into the middle part or all the way through the opening of the vagina causing total uterine prolapse. Prolapse of the uterus may cause pain in the lower back or over the tail bone. Although many woman have no symptoms. Woman with uterine prolapse may feel a dragging or heaviness in their pelvic area, often described as feeling like my insides are falling out. Symptoms that may occur with all types of prolapse include feeling a lump or heavy sensation in the vagina, lower back pain that eases when you lie down, pelvic pain or pressure, and pain or lack of sensation during sex. Total uterine prolapse, which is obvious, can cause pain during walking. Sores may develop on the protruding cervix and cause bleeding, a discharge, and an infection. Prolapse of the uterus may cause a kink of the urethra. A kink may hide urinary incontinence if present or make urinating difficult. Woman with total uterine prolapse may also have difficulty having a bowel movement.

In the prolapse of the vagina, the upper part of the vagina drops into the lower part, so that the vagina turns inside out. The upper part may drop part of the way through the vagina or all the way through, protruding outside the body and causing total vaginal prolapse. Prolapse of the vagina occurs only in woman who have had a hysterectomy. Total vaginal prolapse may cause pain while sitting or walking.

A cystocele develops when the bladder drops down and protrudes into the wall of the vagina. It results from the weakening of the connective tissue and supporting structures around the bladder. A cystourethrocele is similar but develops when the upper part of the urethra [bladder neck] also drops down. Either of these disorders may cause stress incontinence or overflow incontinence. After urination the bladder may not feel completely empty. Sometimes urinary tract infections develop. Because the nerve to the bladder or urethra can be damaged, woman who have these disorders may develop urge incontinence. An enterocele develops when the small intestine and the lining of the abdominal cavity [peritoneum] bulge downward between the uterus and/or the rectum, if the uterus has been removed, between the bladder and the rectum. It results from weakening of the connective tissue and ligaments supporting the uterus. An enterocele often causes no symptoms. But some woman have a sense of fullness or pressure or pain in the pelvis. Pain may also be in the lower back.

A rectocele develops when the rectum drops and protrudes into the back of the vagina. It results from weakening of the muscular wall of the rectum and the connective tissue around the rectum. A rectocele can make a bowel movement difficult and may cause a sensation of constipation. Some woman need to place a finger in the vagina to have a bowel movement.

LIVING WITH PELVIC ORGAN PROLAPSE

Living with prolapse can be a challenge, both physically and emotionally, as the symptoms can disrupt day to day life. A doctor can usually diagnosis pelvic floor disorders by performing a pelvic exam. Procedures to determine how well the bladder and rectum are functioning, such as urine test, may be performed. These procedures may help doctors whether drugs or surgery is the best treatment. If a woman has a problem with passage of urine or urinary incontinence, doctors may use a flexible scope to view the inside of the bladder [procedure called cystoscopy] or the urethra [procedure called urethroscopy]. Also the amount of urine the bladder can hold without leakage and the rate of urine flow may be measured. Doctors may determine whether prolapse of the uterus maybe preventing urinary incontinence.

NON-SURGICAL TREATMENT

Living with prolapse can be a challenge, both physically and emotionally, as the symptoms can disrupt day to day life. Below are a few suggestions that may make living with the prolapse a little easier.

  • Avoid standing for long periods of time.
    Many woman find their symptoms get worse when they stand and improve when they lie down. 
  • Do pelvic floor exercises.
    These help prevent prolapse but can also strengthen weakened muscles, aid recovery after surgical treatment and may reduce symptoms such as leaking urine and back pain. Kegel exercises target the muscles around the vagina, urethra and the muscles used to stop a stream of urine. These muscles are tightly squeezed for about 10 seconds, then relax for about 10 seconds. The exercises can be done 10 to 20 times in a row. Performing the exercises several times a day is recommended. Woman can do Kegel exercises when sitting, standing or lying down. Learn more about Kegel exercises
  • Prevent or correct constipation by eating a high fiber diet to help prevent constipation or reduce straining. 
  • Can wear panty liners or incontinence pads.
    If you occasionally leak very small amounts of urine you could wear an odor controlled panty liner, but if you leak more or frequently, you should use incontinence pads. They come in a range of sizes and are better suited to leaking urine then sanitary towels. 
  • Carry wet wipes.
    If you have bladder or bowel symptoms use wet wipes to keep yourself clean as well as reduce odor. If a prolapse is severe, a pessary may be used to support the pelvic organs. A pessary is a small device common similar to a diaphragm or cervical cap, which is inserted into the vagina to hold the prolapse organ in place. Pessary's are made of latex or silicone and come in many different shapes and sizes. Ring Pessary's are most common but may not be right for every woman. Pessaries are generally recommended as treatment for women who are waiting for surgery, women who are pregnant or want to have more children in the future, and women who are unable or choose not to have surgery. Pessarys need to be individually fitted and you need to try a few different shapes and sizes before you find the one that feels comfortable and stays in place. 
  • Estrogen vaginal suppositories or creams may be used.
    These preparations are used to keep the vaginal tissues healthy and can prevent sores from forming. Hormone replacement therapy may help strengthen the vaginal walls and the pelvic floor muscles by increasing the estrogen and collagen levels in the body, but there is little evidence to whether it is effective in treating prolapse. Before you make a decision about whether or not to use HRT or hormone replacement therapy, discuss the risks and benefits with your doctor.

SURGICAL TREATMENTS

Most of the surgical treatments for prolapse aim to lift the prolapse organ back into place. Hysterectomy for uterine prolapsed is the only treatment that removes the prolapsed organ all together. The choice of surgery depends on the type of prolapse you have, your age, and whether or not you want to keep your uterus or have children in the future, whether you are sexually active, the skill of your surgeon and your personal preferences. Before your operation, you and your doctor should have confidence that your diagnosis is accurate. It is very common to have more than one type of prolapse at the same time and each one should be taken into consideration when planning. Your doctor may give you a series of bladder tests before your operation even if you do not have bladder symptoms. This is because your prolapse may be masking stress incontinence by pushing up against your urethra and preventing urine from leaking. Repairing your prolapse may fix one condition but leave you with another: incontinence. Your urologist may recommend another procedure to prevent incontinence.

As with all surgery, the degree of success depends on many factors. While surgical treatment may be successful for one woman, it may be very disappointing results for another. The surgical treatments that you choose may repair your prolapse, but they may not relieve all of your symptoms, and in some cases they may make your symptoms worse or cause other problems. Statistics show that one in three women have a surgical repair go on to have additional surgery.