In women with pelvic organ prolapse (POP), the vaginal walls protrude toward or through the vaginal opening. POP can range from a small, asymptomatic bulge to a bulge down to the thigh. POP is a common condition affecting women of all ages, but many women with POP are reluctant to discuss the subject with their family and friends, let alone their physician, and do not seek medical care. Studies show that up to 40 percent of women have some form of prolapse, and about 11 percent undergo surgery for prolapse or incontinence (loss of urine) at some point in their lifetime. Risk factors for developing pelvic organ prolapse include pregnancy, vaginal childbirth, aging, chronic straining, menopause, trauma, genetics, smoking, and previous surgery.
The vagina is divided into three compartments of support: anterior (front), apical (top) and posterior (back). A complex network of muscles, ligaments, and tissues supports the pelvic organs and holds them in place. If this support is weakened or breaks, various structures may fall into the vaginal opening. The bladder sits on the front vaginal wall and prolapse of the bladder is commonly referred to as a cystocele. The uterus (womb) sits on the top vaginal wall and prolapse of this area leads to uterine prolapse. In women who have undergone a hysterectomy, the area where the uterus used to be can prolapse and this is called vaginal vault prolapse; this is commonly associated with an enterocele (small bowel hernia). If the posterior vaginal wall relaxes (often referred to as a rectocele), the rectum bulges into the vagina.
Symptoms of Vaginal or Pelvic Organ Prolapse
Not all women with POP have symptoms, but some describe a "bulge," vaginal pressure, bladder and bowel problems, pain with intercourse, back pain, and/or pelvic pain. Women should discuss any of these problems with their doctors, especially bladder, bowel, and sexual problems, as treatments for POP are designed to improve these symptoms. Bladder symptoms may include frequency, urgency, hesitancy, incomplete emptying, urinary tract infections, and incontinence. Bowel symptoms may include constipation and incontinence. Sexual symptoms include pain with intercourse, inability to have intercourse, lack of satisfaction or orgasm, and incontinence with intercourse.
Treatment for Vaginal or Pelvic Organ Prolapse
Doctors treat POP with three basic approaches:
- Observation: Vaginal prolapse is rarely a life-threatening condition, so observation in women without symptoms is an excellent option. Because the condition gradually worsens in most women, doctors recommend periodic follow-up exams.
- Nonsurgical management: Pelvic floor muscle training (Kegel exercises) can tighten the muscles of the pelvic floor, and can be helpful in women with mild prolapse, but they are less helpful in those with moderate to severe prolapse. Postmenopausal or post-hysterectomy patients may benefit from vaginal estrogen application, which can improve the health of the vaginal walls.
- A pessary, a supportive device that a doctor places in the vagina, can restore the normal position of the prolapsed organs and relieve symptoms. Doctors sometimes use pessaries to show patients how their symptoms can improve following surgery. Women who are medically unfit for surgery or who want to avoid surgery are excellent candidates for a pessary.
- Surgery: Doctors treat POP with vaginal, abdominal, and laparoscopic surgeries, all aimed at restoring the prolapsing organs to their normal position. Because there is a high rate of recurrence of POP after prolapse surgery, many doctors advocate using materials such as mesh and cadaveric materials to provide additional support and help prevent recurrences.