Vaginal Prolapse

What is Vaginal Prolapse and How Do Women Get It?

Pelvic organ prolapse (POP) occurs when there is weakness in supporting structures of the pelvic floor allowing the pelvic organs (the bladder, uterus, or the rectum) to descend down into the walls of the vagina. Prolapse can result in a sense of pressure in the vagina and can be highly uncomfortable.

Pelvic organ prolapse can be caused by giving birth, though women who have not given birth can experience it as well. Constipation lending to repetitive straining may exacerbate potential weakness of the pelvic floor and result in prolapse, as can obesity, vigorous exercise where stress is placed on the pelvis through heavy lifting, and pelvic or abdominal surgery.

When Symptoms Arise

Symptoms may arise at various points in life, from immediately after giving birth to a child, to later in life following menopause. Menopause brings with it a decrease in estrogen which leaves the walls of the vagina thinner, and the pelvic floor muscles weaker, generally making it more susceptible to prolapse.

Mild to moderate cases of pelvic organ prolapse can be treated with very specific pelvic floor strengthening. It is often beneficial to see a pelvic floor physical therapy specialist, who may help to identify and treat other factors leading to prolapse in conjunction with performing specific safe exercises.

Types of Vaginal Prolapse

As mentioned in the introduction, vaginal prolapse can include several different conditions in which organs descend into the vagina. This leads to several distinct types of vaginal prolapse:

Anterior vaginal prolapse (cystocele or urethrocele)

Anterior vaginal prolapse is the most common form of vaginal prolapse, making up about 34.3% of all POP cases. (Hendrix et al, 2002) It is the prolapse of either the bladder (cystocele) or urethra (urethrocele) into the vagina. Either type of anterior vaginal prolapse is more likely to cause symptoms such as urine leaking and incontinence. (Pathak, 2021) 

Apical prolapse

Apical prolapse is the second most common form of vaginal prolapse because it is rare to find a case of anterior vaginal prolapse without apical prolapse. (Rooney et al, 2006) The organ it effects depends on whether the patient still has a uterus. If they do, an apical vaginal prolapse is the descent of the uterus into the vagina (uterine prolapse).

If the patient has had a hysterectomy and therefore does not have a uterus, it describes the descent of the upper vagina (vaginal vault prolapse). (Maher et al, 2016) The risk of apical prolapse seems to be five times higher in those that have had a hysterectomy when compared to those who have not. (Barrington & Edwards, 2000)

Posterior vaginal prolapse (rectocele)

Posterior vaginal prolapse is the next most common form of vaginal prolapse, comprising 18.6% of cases of POP. (Hendrix et al, 2002) It is the prolapse of the rectum into the vagina, which can cause foul odors, backaches, discomfort during intercourse, and constipation. (Pathak, 2021)

Small bowel prolapse (enterocele)

The final type of prolapse we’ll cover here is the prolapse of the small bowel or small intestine, otherwise known as enterocele. This can cause a backache and uncomfortable intercourse, as well as foul odor. (Pathak, 2021)

Symptoms of Vaginal Prolapse

Some people do not experience any symptoms from their vaginal prolapse; however, when they are found, the symptoms of pelvic organ prolapse are uncomfortable, painful, and sometimes embarrassing.

They can include (Hendrix et al, 2002):  

  • Feeling a bulge or protrusion from within your vagina
  • Urinary and fecal incontinence (these share a link with pelvic organ prolapse as all three can be caused by weak pelvic floor muscles) 
  • Trouble urinating, including an increased frequency, inability to empty completely, or urinary urgency
  • Difficulty emptying the bowels
  • Sexual dysfunction
  • Back pains
  • Unpleasant vaginal odor

Treating Vaginal Prolapse

Pessary

A pessary is a silicon device—most commonly a ring—that is placed inside the vagina to help support the pelvic organs and keep them in place. It is the most common first-line treatment for vaginal prolapse, with about two thirds of prolapse patients choosing it as their first treatment. (Iglesia & Smithling, 2017)

Pessaries can sometimes improve a vaginal prolapse, decrease the feeling of pressure, and can almost always prevent the prolapse from getting any worse, thus avoiding the need for surgery. (Handa & Jones, 2002) That said, pessaries are not without risks including vaginal discharge, bleeding, bacterial vaginosis, and irritation. (Iglesia & Smithling, 2017)

Pelvic Floor Muscle Training

Pelvic floor muscle training (PFMT) involves contracting and releasing the muscles in your pelvic floor. The most common form of PFMT is the Kegel exercise, but other tools such as Kegel weights can also be helpful for training the pelvic floor. (Wiegersma et al, 2014)

Some studies have shown a greater improvement or reversal in vaginal prolapse when a pessary is used in combination with pelvic floor muscle training—but the effect is probably not significant enough on its own. (Bugge et al, 2020) Many exercise that engage or build your core muscles can also be helpful in improving your pelvic floor strength.

Surgery

Each year, about 200,000 United States citizens with vaginas undergo surgery for one of the types of vaginal prolapse listed above. (Boyles, Weber, & Meyn, 2003)

There are several different surgical procedures offered to treat pelvic organ prolapse—vaginal surgeries (including vaginal hysterectomy, anterior or posterior vaginal wall repair, perineal reconstruction, and others) or abdominal surgeries (including hysterectomy, posterior vaginal wall repair, vault suspending, paravaginal repair, and others). 

If you need surgery for your pelvic organ prolapse, your doctor will be able to advise you on which surgery best meets your needs. It’s not uncommon for more than one type of prolapse to occur at once, especially anterior and apical prolapse, so more than one treatment may be needed. (Maher et al, 2013)

That said, there is a relatively high rate of recurrence (58%!) for vaginal prolapse treated with surgery; this rate is higher in younger patients or those with more advanced vaginal prolapse. (Whiteside et al, 2004)

Conclusion

Pelvic Organ Prolapse (POP), also known as vaginal prolapse, can be a very uncomfortable condition that plays out in several different ways. The most common cause of vaginal prolapse is pregnancy or childbirth, but a hysterectomy, pelvic organ cancer, chronic constipation or respiratory problems, or obesity can all increase your likelihood, as can age.

You may also be more prone to vaginal prolapse if you have a family history of it, which may point to a genetic component to POP by way of genetically weak connective tissue in your vagina. (Pathak, 2021)

Vaginal prolapse is treatable with various kinds of physical therapy and/or surgeries. You may need to use more than one treatment method simultaneously, such as a pessary in combination with pelvic floor muscle training, or pelvic floor muscle training following corrective surgery.

However, it bears repeating: if you have had a pelvic organ prolapse, do not try to do crunch or sit-up exercises! Ask your doctor or physical therapist what other exercises you want to avoid following treatment for POP.

References

  1. Hendrix, S. L., Clark, A., Nygaard, I., Aragaki, A., Barnabei, V., & McTiernan, A. (2002). Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity. American journal of obstetrics and gynecology, 186(6), 1160-1166. https://doi.org/10.1067/mob.2002.123819 
  2. Pathak, Neha (ed.) (2021). Pelvic Organ Prolapse. WebMD. https://www.webmd.com/women/guide/pelvic-organ-prolapse 
  3. Rooney, K., Kenton, K., Mueller, E. R., FitzGerald, M. P., & Brubaker, L. (2006). Advanced anterior vaginal wall prolapse is highly correlated with apical prolapse. American journal of obstetrics and gynecology, 195(6), 1837–1840. https://doi.org/10.1016/j.ajog.2006.06.065 
  4. Maher C, Feiner B, Baessler K, Christmann‐Schmid C, Haya N, Brown J. (2016). Surgery for women with apical vaginal prolapse. Cochrane Database of Systematic Reviews 2016, Issue 10. Art. No.: CD012376. https://doi.org/10.1002/14651858.CD012376
  5. Barrington, J. W., & Edwards, G. (2000). Posthysterectomy vault prolapse. International Urogynecology Journal, 11(4), 241-245. https://doi.org/10.1007/s001920070033 
  6. Iglesia, C. B., & Smithling, K. R. (2017). Pelvic Organ Prolapse. American family physician, 96(3), 179–185. https://www.aafp.org/afp/2017/0801/p179.html 
  7. Handa, V. L., & Jones, M. (2002). Do pessaries prevent the progression of pelvic organ prolapse?. International Urogynecology Journal, 13(6), 349-352. https://doi.org/10.1007/s001920200078 
  8. Wiegersma, M., Panman, C. M., Kollen, B. J., Berger, M. Y., Lisman-Van Leeuwen, Y., & Dekker, J. H. (2014). Effect of pelvic floor muscle training compared with watchful waiting in older women with symptomatic mild pelvic organ prolapse: randomised controlled trial in primary care. Bmj, 349. https://doi.org/10.1136/bmj.g7378 
  9. Bugge, C., Adams, E. J., Gopinath, D., Stewart, F., Dembinsky, M., Sobiesuo, P., & Kearney, R. (2020). Pessaries (mechanical devices) for managing pelvic organ prolapse in women. Cochrane Database of Systematic Reviews, (11). https://doi.org/10.1002/14651858.CD004010.pub4 
  10. Boyles, S. H., Weber, A. M., & Meyn, L. (2003). Procedures for pelvic organ prolapse in the United States, 1979-1997. American journal of obstetrics and gynecology, 188(1), 108–115. https://doi.org/10.1067/mob.2003.101 
  11. Maher, C., Feiner, B., Baessler, K., & Schmid, C. (2013). Surgical management of pelvic organ prolapse in women. Cochrane database of systematic reviews, (4). https://doi.org/10.1002/14651858.CD004014.pub5 
  12. Whiteside, J. L., Weber, A. M., Meyn, L. A., & Walters, M. D. (2004). Risk factors for prolapse recurrence after vaginal repair. American journal of obstetrics and gynecology, 191(5), 1533-1538. https://doi.org/10.1016/j.ajog.2004.06.109