Pelvic Organ Prolapse

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Pelvic Organ Prolapse

Topic Overview

What is pelvic organ prolapse?

Pelvic organ prolapse occurs when a pelvic organ—such as your bladder—drops (prolapses) from its normal spot in your lower belly and pushes against the walls of your vagina. This can happen when the muscles that hold your pelvic organs in place get weak or stretched from childbirth or surgery.

Many women will have some kind of pelvic organ prolapse. It can be uncomfortable or painful. But it isn't usually a big health problem. It doesn't always get worse. And in some women, it can get better with time.

More than one pelvic organ can prolapse at the same time. Organs that can be involved when you have pelvic prolapse include the:

What causes pelvic organ prolapse?

Pelvic organ prolapse is most often linked to strain during childbirth. Normally your pelvic organs are kept in place by the muscles and tissues in your lower belly. During childbirth these muscles can get weak or stretched. If they don't recover, they can't support your pelvic organs.

You may also get pelvic organ prolapse if you have surgery to remove your uterus (hysterectomy). Removing the uterus can sometimes leave other organs in the pelvis with less support.

Pelvic organ prolapse can be made worse by anything that puts pressure on your belly, such as:

  • Being very overweight (obesity).
  • A long-lasting cough.
  • Frequent constipation.
  • Pelvic organ tumors.

Older women are more likely to have pelvic organ prolapse. It also tends to run in families.

What are the symptoms?

Symptoms of pelvic organ prolapse include:

  • Feeling pressure from pelvic organs pressing against the vaginal wall. This is the most common symptom.
  • Feeling very full in your lower belly.
  • Feeling as if something is falling out of your vagina.
  • Feeling a pull or stretch in your groin area or pain in your lower back.
  • Releasing urine without meaning to (incontinence), or needing to urinate a lot.
  • Having pain in your vagina during sex.
  • Having problems with your bowels, such as constipation.

How is pelvic organ prolapse diagnosed?

Your doctor will ask questions about your symptoms and about any pregnancies or health problems. Your doctor will also do a physical exam, which will include a pelvic exam.

How is it treated?

Decisions about your treatment will be based on which pelvic organs have prolapsed and how bad your symptoms are.

If your symptoms are mild, you may be able to do things at home to help yourself feel better. You can relieve many of your symptoms by adopting new, healthy habits. Try special exercises (called Kegels) that make your pelvic muscles stronger. Reach and stay at a healthy weight. Cut back on caffeine, which acts as a diuretic and can cause you to urinate more often. Avoid lifting heavy things that put stress on your pelvic muscles.

If you still have symptoms, your doctor may have you fitted with a device called a pessary to help with the pain and pressure of pelvic organ prolapse. It is a removable device that you put in your vagina. It helps hold the pelvic organs in place. But if you have a severe prolapse, you may have trouble keeping a pessary in place.

Surgery is another treatment option for serious symptoms of pelvic organ prolapse. But you may want to delay having surgery if you plan to have children. The strain of childbirth could cause your prolapse to come back.

You may want to consider surgery if:

  • You have a lot of pain because of the prolapsed organ.
  • You have a problem with your bladder and bowels.
  • The prolapse makes it hard for you to enjoy sex.

Types of surgery for pelvic organ prolapse include:

  • Surgery to repair the tissue that supports a prolapsed organ.
  • Surgery to repair the tissue around your vagina.
  • Surgery to close the opening of your vagina.
  • Surgery to remove the uterus (hysterectomy).

Pelvic organ prolapse can come back after surgery. Doing Kegel exercises to make your pelvic muscles stronger will help you recover faster from surgery. The two together can help you more than surgery alone.

Frequently Asked Questions

Learning about pelvic organ prolapse:

Being diagnosed:

Getting treatment:

Ongoing concerns:

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  Pelvic Organ Prolapse: Should I Have Surgery?

Cause

Pelvic organ prolapse is usually caused by damage to the tissues (muscles, ligaments, and connective tissue) that support the pelvic organs. Damage or stretching of these tissues allows the organs to move out of their normal positions, causing them to press against (and sometimes move) the inside walls of the vagina.

Having a baby makes it more likely that you will have pelvic organ prolapse later. Vaginal childbirth has been strongly linked to weakened and stretched support structures in the pelvic area. This loss of support is the biggest cause of pelvic organ prolapse. Having a cesarean section, on the other hand, seems to be less strongly linked to pelvic organ prolapse.1 (But having a cesarean section may lead to other problems. For more information, see the topic Cesarean Section.)

Another cause of reduced support in the pelvis is lower levels of the hormone estrogen. Estrogen levels are lower during and after menopause. The lower levels of estrogen in the body mean less collagen, a protein that helps the pelvic connective tissues stretch and return to their normal positions.

Pelvic organ prolapse can also occur after surgical removal of the uterus (hysterectomy) for another health problem, such as endometriosis. Removal of the uterus can sometimes leave the other organs in the pelvic area with less support.

Other conditions that may cause pelvic organ prolapse include:

  • Obesity, which can lead to long-term pressure within the abdomen.
  • Smoking and/or lung disorders, which are often causes of chronic coughing.
  • Conditions affecting the spinal cord, such as muscular dystrophy, multiple sclerosis, and spinal cord injury, that cause paralysis of the muscles of the pelvic floor.

Symptoms

Although many women who have pelvic organ prolapse do not have symptoms, the most common and bothersome symptom is pressing of the uterus or other organs against the vaginal wall. The pressure on your vagina may cause minor discomfort or problems in how your pelvic organs work. Symptoms of pelvic organ prolapse include:

  • A feeling of pelvic pressure.
  • A feeling as if something is actually falling out of the vagina.
  • A pulling or stretching in the groin area or a low backache.
  • Painful intercourse.
  • Spotting or bleeding from the vagina.
  • Urinary problems, such as involuntary release of urine (incontinence) or a frequent or urgent need to urinate, especially at night.
  • Problems with bowel movements, such as constipation or needing to support the back (posterior) of the vaginal wall to have a bowel movement.

Symptoms of pelvic organ prolapse are made worse by standing, jumping, and lifting and usually are relieved by lying down.

What Happens

The pelvic organs are kept in place by the muscles and connective tissues of the pelvis (pelvic diaphragm). The vagina of an adult woman is normally a round-topped, muscular tube that also supports the other pelvic organs. The pelvic muscles and tissues can be stretched or damaged, most commonly by childbirth. When they don't recover, they lose their ability to support the organs.

The location and severity of pelvic organ prolapse is related to where in the pelvis the injury or muscular damage has occurred. You may have several areas of injury that contribute to prolapse. Prolapse may occur after surgery to remove the uterus (hysterectomy) if the procedure removes or damages support of the bladder, urethra, or bowel wall. If other conditions, such as childbirth, damage muscles or nerves in the pelvis, the pelvic diaphragm may lose its dome shape, become more like a funnel, and then bulge down into or out of the vagina.

Pelvic organ prolapse may increase pressure on the vagina and interfere with sexual activity, sometimes leading to sexual dysfunction. For more information, see the topic Sexual Problems in Women.

Lower estrogen levels during and after menopause make pelvic organ prolapse more likely. Estrogen helps your body to make collagen, a protein that enables the supportive tissues of the pelvis to stretch and return to their normal positions. Less collagen makes it more likely that those supportive tissues will tear. When estrogen levels go down, so do collagen levels.

Pelvic organ prolapse may be a progressive condition, gradually getting worse and causing more severe symptoms. But in many cases it does not progress and may improve over time.2

What Increases Your Risk

Pelvic organ prolapse is often related to stretching and pressure during labor and childbirth. This can occur when a woman delivers a large baby [over 9 lb (4 kg)] or when she has a long, difficult labor and delivery. Pelvic organ prolapse most often appears during menopause, as pelvic tissues damaged during childbearing age and lose strength.

Other factors that may increase the risk of developing pelvic organ prolapse include:3

  • Obesity. Women who are overweight have increased pressure in the abdomen and have a higher rate of pelvic organ prolapse.
  • Smoking and lung conditions that cause chronic coughing, which increases pressure in the abdomen and pelvis. Smoking also decreases your body's store of the protein collagen, which increases the likelihood that connective tissue in the pelvis may tear.
  • Constipation. Chronic constipation causes increased pressure from the bowel on the vaginal wall.
  • Certain occupations that require heavy lifting or jumping.
  • Pelvic surgery, such as removal of the uterus (hysterectomy), which may damage support for a pelvic organ, resulting in movement of organs within the pelvis.
  • Diseases of the nervous system. Pelvic organ prolapse is more common in women who have multiple sclerosis, muscular dystrophy, or a spinal cord injury than in women who do not have such conditions.
  • Genetic factors. A weakness in the supportive tissue of the pelvis can be passed through families. If your mother or sister has had pelvic organ prolapse, you may be more likely to get it too.

When To Call a Doctor

Call your doctor to schedule an appointment if:

  • You notice a bulge of tissue inside your vagina or bulging out of your vagina.
  • You have a sensation of pulling or increased pelvic pressure that is made worse when you strain or lift but is relieved when you lie down.
  • Pain in your low back or pelvic area is interfering with your daily activities.
  • Sexual intercourse has become difficult or painful.
  • You have irregular spotting or bleeding from the vagina.
  • Urinary symptoms, such as involuntary release of urine (incontinence), urinating frequently, having an urgent need to urinate, or urinating frequently at night, have developed and are interfering with your daily activities.
  • You have difficulty having a bowel movement.

Watchful Waiting

Watchful waiting is a period of time during which you and your doctor observe your symptoms or condition without using medical treatment. This period may vary from a few days to weeks, months, or years. If you have been diagnosed with pelvic organ prolapse and you do not have symptoms, or if you have mild symptoms that are not interfering with your daily activities, you may wish to try watchful waiting. Many women who have pelvic organ prolapse do not have symptoms and therefore do not require treatment.

If you have symptoms, such as a feeling of pressure in your vagina, schedule an appointment with your doctor.

Who To See

Your doctor can evaluate symptoms caused by pelvic organ prolapse. Pelvic organ prolapse can be diagnosed and treated by the following health professionals:

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

A prolapse of a pelvic organ is sometimes difficult to diagnose. Pelvic organ prolapse that does not cause symptoms is often discovered during a routine exam. You may be aware that there is a problem but be unsure of the exact location or cause. If prolapse is suspected, your doctor will take your medical history, including your symptoms and your history of pregnancies and other health problems, and perform a physical exam, including a pelvic exam.

Tests that may be done to find out the nature of a prolapse include:

Doctors use a classification system to determine the level of an organ's prolapse. Identifying the exact level of prolapse helps guide decisions about which treatments are most likely to offer long-term success. One standard classification uses "stages" of prolapse and is based on how close the lowest part of the organ is to the opening of your vagina (the hymen).

Treatment Overview

Many women who have pelvic organ prolapse do not have symptoms and do not require treatment. If your symptoms are bothersome, you may want to consider treatment. Treatment decisions should take into account which organs are affected, how bad symptoms are, and whether other medical conditions are present. Other important factors are your age and sexual activity.

Many women are able to reduce pain and pressure from a pelvic organ prolapse with nonsurgical treatment, which may include making lifestyle changes, doing exercises, and/or using a removable device called a pessary that is placed into the vagina to support areas of prolapse.

If your pelvic organ prolapse is causing pain or problems with bowel and bladder functions or is interfering with your sexual activity, you may want to consider surgery. Surgical procedures used to correct different types of pelvic organ prolapse include repair of the supporting tissue of the prolapsed organ or vagina wall. Another option is the removal of the uterus (hysterectomy) when it is the prolapsed organ or if it is causing the prolapse of other organs (such as the vagina).

Sometimes surgery cannot repair all the prolapsed organs. And sometimes pelvic organ prolapse comes back after surgery.

Initial treatment

Pelvic organ prolapse can be a long-lasting condition. But it does not have to be a cause of symptoms that disrupt your life. Many women with pelvic organ prolapse are able to relieve their symptoms without treatment by adjusting their activities and lifestyle habits. These changes might include:

  • Doing pelvic floor (Kegel) exercises every day to tighten and strengthen pelvic muscles.
  • Eating high-fiber foods to prevent constipation. Get at least 20 g of fiber a day.
  • Cutting down on caffeine (found in coffee, tea, and soft drinks), which acts as a diuretic, causing you to urinate more often.
  • Reaching and staying at a healthy weight.
  • Avoiding activities that stress your pelvic muscles, such as heavy lifting.

If your symptoms are not relieved by these lifestyle changes, you may want to consider treatment for pelvic organ prolapse. Treatment will be different depending on which organs are involved, how bad your symptoms are, and what other medical conditions are present. Treatment may include using a vaginal pessary, a removable device that is placed into the vagina to support areas of prolapse.

Ongoing treatment

Pelvic organ prolapse can be a long-lasting condition, but it often responds to adjustments in activities and lifestyle habits. If you have tried self-care, such as eating high-fiber foods, staying at a healthy weight, and doing pelvic floor (Kegel) exercises, but your symptoms are increasingly bothersome, you may want to consider nonsurgical treatment. Treatment will be different depending on which organs are involved, how bad your symptoms are, and what other medical conditions are present. Treatment may include using a vaginal pessary, a removable device that is placed into the vagina to support areas of pelvic organ prolapse.

Treatment if the condition gets worse

If you have pain and discomfort from pelvic organ prolapse that does not respond to nonsurgical treatment and lifestyle changes, you may want to consider surgery. The choice of surgery depends upon which organs are involved, how bad your symptoms are, and what other medical conditions are present. Also, your surgeon may have experience with and preference for a certain procedure. Types of surgery for pelvic organ prolapse include:

Often the doctor does more than one of these surgeries at the same time. These surgeries are designed to treat specific symptoms, so other symptoms may remain after surgery.

For more information about surgery, see:

Click here to view a Decision Point. Pelvic Organ Prolapse: Should I Have Surgery?

What To Think About

If you are considering having children, you may want to delay pelvic organ surgery. If you have surgery and then deliver a child vaginally, the strain on your pelvic organs may cause them to prolapse again.

Sometimes surgery cannot repair all the prolapsed organs. And sometimes surgery to repair pelvic organ prolapse will lead to prolapse in another area.

Pelvic organ prolapse may be a progressive condition, gradually getting worse and causing more severe symptoms. But in many cases it does not progress and may improve over time.2

Prevention

Pelvic organ prolapse is most often a result of tissue damage caused by labor and childbirth. Although you may not be able to prevent the damage to your pelvic organs caused by childbearing, you may be able to control the progression of the prolapse. Lifestyle changes that may slow the prolapse process include:

  • Reaching and staying at a weight that is healthy for your height.
  • Not smoking. The chronic cough associated with smoking may cause or speed pelvic organ prolapse. For more information, see the topic Quitting Smoking.
  • Correcting constipation. The straining caused by constipation weakens and damages the connective tissue and muscles in the pelvis.
  • Avoiding heavy lifting and jumping.
  • Doing pelvic strengthening exercises (Kegel exercises) every day. These exercises help strengthen the muscles of the pelvis.

The hormone estrogen is sometimes prescribed for women during menopause to preserve or strengthen the tissues of the pelvis. Estrogen may be used in pill form, as estrogen replacement therapy (ERT) or as hormone replacement therapy (HRT), which is estrogen combined with progesterone. Studies have shown that taking ERT or HRT can increase risks of serious diseases. Estrogen is also available as a low-dose vaginal cream, ring, or vaginal tablets. These low-dose forms are not thought to have the same risks. Talk to your doctor about taking or applying estrogen.

Home Treatment

Home treatment can relieve the discomfort of pelvic organ prolapse. It can also help to keep prolapse from getting worse.

  • Do Kegel exercises every day to strengthen the muscles and ligaments of the pelvis:
  • Prevent or correct constipation. The straining caused by constipation increases pressure from the bowel on the vaginal wall and weakens and damages the connective tissue and muscles in the pelvis.
    • Try gentle exercise. Take a short walk each day. Gradually increase your walking time until you are walking for at least 20 minutes each day.
    • Make sure you drink enough fluids.
    • Eat plenty of high-fiber foods such as whole grains, fruits, and vegetables every day. Have a bran muffin or bran cereal for breakfast, and try eating a piece of fruit for an afternoon snack. Try to eat about 20 g of fiber every day.
    • Schedule time each day for a bowel movement—after breakfast, for example. Having a daily routine may help. Take your time.
    • If you continue to be constipated, try taking processed or synthetic fiber (such as Citrucel, Metamucil, or Perdiem) each day.
    • If your stools are very hard, try taking a stool softener, such as Colace, to prevent straining.
  • Reach and stay at a healthy weight. For more information, see the topic Weight Management.
  • Avoid activities that stress your pelvic muscles, such as heavy lifting.

Medications

Although taking or applying the hormone estrogen will not cure an existing pelvic organ prolapse, it is sometimes prescribed for women during menopause to preserve or strengthen the tissues of the pelvis, which may help prevent prolapse. Estrogen prevents drying and thinning of the vaginal tissues (vaginal atrophy) and improves your ability to effectively use a support device for your vagina (pessary).

Studies have shown that taking estrogen replacement therapy (ERT) or hormone replacement therapy (HRT) can increase risks of serious diseases.4 Estrogen as a low-dose vaginal cream is not thought to pose the same risks to women's health. Talk to your doctor about taking or applying estrogen.

Surgery

If you have pain and discomfort from pelvic organ prolapse that does not respond to nonsurgical treatment and lifestyle changes, you may want to consider surgery. The choice of surgery depends upon which organs are involved, how bad your symptoms are, and what other medical conditions are present. Also, your surgeon may have experience with and preference for a certain procedure. The goals of surgery are to relieve your symptoms and restore the normal functioning of your pelvic organs.

There are several types of surgery to correct stress urinary incontinence. These can be done at the same time as surgery to repair prolapse. These surgeries lift the urethra and/or bladder into their normal position. To learn more about these surgical procedures, see the topic Urinary Incontinence in Women.

Click here to view a Decision Point. Pelvic Organ Prolapse: Should I Have Surgery?

Surgery Choices

Surgical procedures used to correct different types of pelvic organ prolapse include:

What To Think About

Surgeries are designed to treat specific symptoms, so you may still have other symptoms after surgery. An examination while you have a pessary in your vagina may help the doctor see if urinary incontinence would be a problem after surgery. If the pessary test shows that urinary incontinence will be a problem, another surgery can be done at the same time to fix the problem.

Surgery in one part of your pelvis often makes a prolapse in another part worse, possibly requiring separate treatment in the future.5

Pelvic organ prolapse can come back after surgery. Doing Kegel exercises after surgery has been shown to improve symptoms of pelvic organ prolapse more than surgery alone. Other exercises recommended by a physical therapist, when done after surgery, can have the same result.6

Pelvic organ prolapse is strongly linked to labor and vaginal delivery, so you may want to delay surgery if you plan to have children.

Other Treatment

You may be able to relieve symptoms of pelvic organ prolapse by using a pessary. A pessary is a removable device that fits into your vagina and supports the pelvic organs, helping to keep them in place.

What To Think About

Many women can successfully control symptoms of pelvic organ prolapse for years using a vaginal pessary. But if you have a severe prolapse, you may have difficulty keeping a pessary in place.

Other Places To Get Help

Organizations

American Congress of Obstetricians and Gynecologists (ACOG)
409 12th Street SW
P.O. Box 96920
Washington, DC  20090-6920
Phone: (202) 638-5577
Email: resources@acog.org
Web Address: www.acog.org
 

American Congress of Obstetricians and Gynecologists (ACOG) is a nonprofit organization of professionals who provide health care for women, including teens. The ACOG Resource Center publishes manuals and patient education materials. The Web publications section of the site has patient education pamphlets on many women's health topics, including reproductive health, breast-feeding, violence, and quitting smoking.


American Urological Society Foundation
2025 M Street NW
Suite 800
Washington, DC 20036
Phone: (202) 367-1167
Fax: (202) 367-2167
Email: info@augs.org
Web Address: www.mypelvichealth.org
 

The American Urogynecologic Society (AUGS) is a nonprofit organization dedicated to research and education in urogynecology, and the detection, prevention, and treatment of female lower urinary tract disorders and pelvic floor disorders. AUGS provides information to patients about pelvic floor disorders.


National Women's Health Information Center
8270 Willow Oaks Corporate Drive
Fairfax, VA  22031
Phone: 1-800-994-9662
(202) 690-7650
Fax: (202) 205-2631
TDD: 1-888-220-5446
Web Address: www.womenshealth.gov
 

The National Women's Health Information Center (NWHIC) is a service of the U.S. Department of Health and Human Services Office on Women's Health. NWHIC provides women's health information to a variety of audiences, including consumers, health professionals, and researchers.


National Women's Health Information Center
8270 Willow Oaks Corporate Drive
Fairfax, VA  22031
Phone: 1-800-994-9662
(202) 690-7650
Fax: (202) 205-2631
TDD: 1-888-220-5446
Web Address: www.womenshealth.gov
 

The National Women's Health Information Center (NWHIC) is a service of the U.S. Department of Health and Human Services Office on Women's Health. NWHIC provides women's health information to a variety of audiences, including consumers, health professionals, and researchers.


References

Citations

  1. Larsson MD, et al. (2009). Cesarean section and risk of pelvic organ prolapse: A nested case-control study. American Journal of Obstetrics and Gynecology, 200(3): 243.e1–243.e4.
  2. Handa VL, et al. (2004). Progression and remission of pelvic organ prolapse: A longitudinal study of menopausal women. American Journal of Obstetrics and Gynecology, 190: 27–32.
  3. Tarnay CM (2007). Pelvic organ prolapse. In AH DeCherney et al., eds., Current Diagnosis and Treatment Obstetrics and Gynecology, 10th ed., pp. 720–734. New York: McGraw-Hill Medical.
  4. Rossouw JE, et al. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the Women's Health Initiative randomized controlled trial. JAMA, 288(3): 321–333.
  5. Clark AL, et al. (2003). Epidemiologic evaluation of reoperation for surgically treated pelvic organ prolapse and urinary incontinence. American Journal of Obstetrics and Gynecology, 189(5): 1261–1267.
  6. Jarvis SK, et al. (2005). Peri-operative physiotherapy improves outcomes for women undergoing incontinence and or prolapse surgery: Results of a randomised controlled trial. Australian and New Zealand Journal, 45(4): 300–303.

Other Works Consulted

  • American College of Obstetricians and Gynecologists (2007, reaffirmed 2009). Pelvic organ prolapse. ACOG Practice Bulletin No. 85. Obstetrics and Gynecology, 110(3): 717-729.
  • Cain JM, et al. (2010). Pelvic floor dysfunction. In FC Brunicardi et al., eds., Schwartz's Principles of Surgery, 9th ed., pp. 1488-1490. New York: McGraw-Hill.
  • Deng DY (2008). Female urology and sexual dysfunction. In EA Tanagho, JW McAninch, eds., Smith's General Urology, 17th ed., pp. 611-624. New York: McGraw-Hill.
  • Feiner MC, et al. (2010). Surgical management of pelvic organ prolapse in women. Cochrane Database of Systematic Reviews (5).
  • Herschorn S (2007). Vaginal reconstructive surgery for sphincteric incontinence and prolapse. In AJ Wein et al., eds., Campbell-Walsh Urology, 9th ed., vol. 3, pp. 2187–2233. Philadelphia: Saunders Elsevier.
  • Liang CC, et al. (2004). Pessary test to predict postoperative urinary incontinence in women undergoing hysterectomy for prolapse. Obstetrics and Gynecology, 104(4): 795–800.
  • Onwude JL (2009). Genital prolapse in women, search date June 2009. Online version of BMJ Clinical Evidence: http://www.clinicalevidence.com.
  • Reynolds RK, Loar PV (2010) Gynecology. In GM Doherty, ed., Current Diagnosis and Treatment: Surgery, 13th ed., pp. 966-984. New York: McGraw-Hill.

Credits

By Healthwise Staff
Primary Medical Reviewer Sarah Marshall, MD - Family Medicine
Specialist Medical Reviewer Femi Olatunbosun, MB, FRCSC - Obstetrics and Gynecology
Last Revised April 28, 2011

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