Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is a medical condition that occurs when the pelvic organs, such as the uterus, bladder, rectum or vaginal walls, drop from their normal position and bulge into or out of the vagina. This condition typically happens when the pelvic floor muscles and connective tissues become weakened or damaged, leading to a loss of support for these organs.

Pelvic organ prolapse can affect women of all ages but is more common in older women, particularly those who have given birth vaginally or undergone multiple childbirths.

Treatment for pelvic prolapse by specialists at The University of Kansas Health System is tailored to each person’s situation and desires. Our physicians are highly experienced and well-trained to help you manage your prolapse symptoms and develop a care plan just for you.

Pelvic organ prolapse occurs when the muscles and supporting connective tissues of the pelvic floor become too weak to support the pelvic organs. This causes the organs to fall from their normal position, affecting their ability to function properly.

The supportive muscles and tissues of the pelvic floor can become stretched or torn due to childbirth and labor, or they may weaken with age. The presence of other pelvic floor disorders can also contribute.

There are several types of pelvic organ prolapse, each depending on which pelvic organ is affected:

• Cystocele: This occurs when the bladder drops into the front wall of the vagina. It’s one of the most common types of POP and can cause symptoms like urinary incontinence and a frequent need to urinate.
• Rectocele: A rectocele happens when the rectum protrudes into the back wall of the vagina. This can lead to difficulty with bowel movements, constipation and a sensation of incomplete emptying.
• Uterine prolapse: In uterine prolapse, the uterus descends into the vaginal canal. Women with uterine prolapse may experience pelvic pressure, a feeling of fullness in the lower abdomen and sometimes pain during sexual intercourse.
• Vaginal vault prolapse: This type occurs when the upper part of the vagina drops down into the vaginal canal or even protrudes outside the body. It often happens after a woman has had her uterus removed through a hysterectomy.
• Enterocele: An enterocele occurs when the small intestine pushes into the space behind the uterus and into the vaginal wall, causing discomfort and pressure.

The symptoms of pelvic organ prolapse vary in severity and type of discomfort from person to person, depending on the extent of prolapse. Symptoms of pelvic organ prolapse may include:

• A protrusion or bulge through the vaginal opening
• A sensation of pressure in the pelvis
• Constipation
• Incomplete emptying of the bladder
• Pain or discomfort with intercourse
• Pressure and pain with bowel movements
• The need to press on the vagina or nearby to evacuate the stools adequately
• The need to strain to urinate
• Urinary incontinence

The causes of and risk factors for pelvic organ prolapse are multifactorial and can include:

• Childbirth: Vaginal childbirth, especially with prolonged or difficult deliveries, can weaken the pelvic floor muscles and stretch connective tissues.
• Aging: Natural aging processes can lead to a gradual weakening of pelvic tissues and muscles.
• Hormonal changes: Reduced estrogen levels after menopause can contribute to tissue laxity.
• Chronic straining: Conditions like chronic constipation, chronic coughing or heavy lifting can strain the pelvic floor.
• Obesity: Excess body weight can put increased pressure on the pelvic organs and supporting structures.
• Genetics: Some individuals may have a genetic predisposition to pelvic organ prolapse.

Pelvic organ prolapse can be diagnosed by your doctor during a standard pelvic exam. During the exam, your doctor can assess the strength of your pelvic muscles. Your doctor can also check whether your uterus has fallen into the vagina and how far.

A complete medical history that includes a full overview of your symptoms helps your doctor determine the specifics of your prolapse and the effects your symptoms have on your quality of life. This helps your doctor recommend the most effective approach to treatment.

In some cases, imaging tests like ultrasound or MRI may be used to get a more detailed view of the pelvic anatomy.

The symptoms and protrusion associated with prolapse can be successfully corrected in many cases with nonsurgical treatment options, although surgical procedures may be necessary in some cases. This depends on your personal preferences as well as lifestyle and medical/surgical history. For some women, prolapse can be watchfully monitored over time. However, this rarely helps to resolve the prolapse.

Nonsurgical treatment options for pelvic organ prolapse include:

• Lifestyle modifications: These can include weight management, dietary changes to prevent constipation and avoiding heavy lifting.
• Medications: In some cases, estrogen therapy may be prescribed to help improve tissue health and alleviate symptoms, particularly for postmenopausal women.
• Pelvic floor exercises (Kegel exercises): These exercises can help strengthen the pelvic floor muscles and may be recommended for mild cases.
• Pelvic floor physical therapy is useful and nonsurgical, but the improvement may depend on how bad the prolapse is. Pelvic floor physical therapy involves exercises for the vagina guided by a trained therapist over the course of a few weeks.
• A pessary may be used for cases where therapy may not help. A pessary is a plastic device that looks like a diaphragm and can support the prolapse.

Nonsurgical treatment for pelvic organ prolapse may not work in all instances, in which case surgery may be recommended.

Surgical prolapse repair procedures can include:

• Cuff suspension (tuck of the top side of the vagina)
• Cystocele repair (commonly called bladder tuck)
• Hysterectomy, if the uterus is prolapsing and causing discomfort
• Rectocele repair (tuck on the posterior vaginal wall)

The recommended surgical technique will depend on which area is weak and how large the prolapse is. To repair the prolapse, it is important that your physician perform a support procedure to hold the vagina in place. Otherwise, recurrence of the prolapse might be rapid.

Our specialists are specially trained on this type of repair and procedure. These techniques do not involve the use of mesh, but instead involve the use of your own tissues and stitches that dissolve over time, allowing your body to develop its own support system to help prevent recurrence of the prolapse.

Commonly performed procedures for prolapse of the top of the vagina include:

• High uterosacral ligament suspension
• Mayo-Mccall colpo-suspension
• Sacrospinous ligament fixation

Some women may be candidates for a type of robotic surgery called sacrocolpopexy. This procedure involves attaching mesh around the vaginal walls and then to a strong ligament near the tailbone. This procedure is often considered a gold standard treatment for prolapse.