A prolapse occurs when a structure moves beyond its normal anatomical position. Pelvic organ prolapse (POP) describes the downward movement or bulging of the bladder, uterus (womb) or bowel into or out of the vagina. POP is like having a hernia.

POP may involve the bladder alone, uterus alone, bowel alone or any combination of the three. The reason for more than one structure to be involved is that the uterus sits at the top of the vagina, which itself is sandwiched between your bladder in front and rectum behind.

  • How is prolapse treated? Open or Close

    Treatment is determined by a number of factors including the severity of symptoms, how much the prolapse is affecting your quality of life, the degree of prolapse, your age, your general health, your desire to have more children, whether you have had surgery for prolapse in the past and your wishes. Essentially there are three options:

    1. Do nothing
    This is a perfectly reasonable option if your prolapse does not bother you too much.

    2. Pelvic floor exercises
    Regularly exercising the pelvic floor muscles can improve the feeling of prolapse, but they are unlikely to work for advanced prolapse.

    3. Insert a pessary
    A pessary is a removable device which is placed inside the vagina to support a prolapse. Pessaries are made from plastic or silicone and come in different shapes and sizes to suit each individual woman. Some are soft and flexible whilst others are firm and rigid; they can look rather odd The commonest pessaries used are the ring (if you have a uterus) or a shelf (if you have had a hysterectomy). A pessary is easy to insert (taking just a few seconds) and is usually fitted by a doctor or nurse. This is done in a clinic and does not require an anaesthetic to insert or remove. Once inserted, the pessary stays there, but you should have a check-up every four to six months. If positioned correctly, you should not feel the pessary. If it is uncomfortable, it may be the wrong size and it should be changed. You can use a pessary to control your prolapse for many years. Some types of pessary may make sexual intercourse difficult or impossible.

    Rapid relief of symptoms
    Avoidance of surgery
    Generally safe

    Need regular check-ups.
    Shelf pessaries can sometimes be difficult to remove.
    Pessaries can rub against the vaginal skin and cause ulceration which can result in spotting or a vaginal discharge.
    Sexual intercourse is not possible with a shelf pessary.

    4. Surgery
    Some women opt for or are recommended surgery. There are a number of techniques but one size does not necessarily fit all. The following factors need to be taken into account:
    •    the type of prolapse
    •    your symptoms
    •    whether you have previously have had surgery for prolapse
    •    your age
    •    your desire to have more children
    •    the health of your tissues
    •    your wish to continue to have sexual intercourse
    •    your general health - including the presence of other medical problems

    Most operations are performed through the vagina, but a few are performed from above through the abdomen.

    Significant prolapse of the uterus usually results in its removal, i.e. a hysterectomy, but it may be possible to avoid this in some cases. Broadly speaking, traditional techniques involve using stitches to perform the repair, but recent years have seen the introduction of use of additional support materials such as collagen mesh or synthetic (polypropylene) mesh.

    It is important that you discuss the type of surgery recommended by your specialist, especially the benefits and risks.

  • Does a prolapse require treatment? Open or Close

    Not all cases of prolapse require treatment, which is decided on an individual basis. Treatment is usually only offered if the prolapse is causing problems. Prolapse can get worse as time goes on, but the rate of deterioration is very variable. Some women are quite happy to live with a prolapse. Many women with a prolapse avoid sex, but this is not necessary. You are most unlikely to do yourself any harm by having sex.

    Stage IV prolapse is when the uterus and/or vagina lie outside the body. This degree of prolapse will likely cause rubbing of the tissues on underwear and if neglected can result in ulceration. Treatment is usually recommended for stage III and IV prolapse.

  • How is prolapse diagnosed? Open or Close

    A POP may be detected by chance during a cervical smear test or during a pelvic examination performed for another reason. A POP is easily diagnosed during a vaginal examination which is usually performed with you lying on an examination couch, but sometimes it may be necessary to be examined in the standing position.

    Investigations are not usually required but an MRI scan can be useful in cases of difficulty in bowel evacuation.

    In cases of prolapse of the bladder or bowel, one does not actually see the bladder or bowel as they are covered by the vaginal skin.

    Cystocele - prolapse of the bladder, i.e. there is a bulge of the front (anterior) wall of the vagina. Despite what the name suggests there is no cyst.

    Rectocele - prolapse of the rectum (which is the lowest part of the bowel), i.e. there is a bulge of the back (posterior) wall of the vagina.

    Enterocele - prolapse of the small bowel; there is a bulge of the top of the vagina (if you have had a hysterectomy) or the top of the back wall of the vagina (if you have not).

    The extent of prolapse is often described as mild, moderate or severe or can be graded by stages, I - IV, with stage IV being the most severe.

  • How do I know I have a prolapse? Open or Close

    POP may result in a variety of symptoms. Mild or even a moderate degree of prolapse may not be felt at all. Women who do have symptoms may report a feeling of a bulge or lump in the vagina, a feeling of something coming down or sitting on a ball, their ‘insides falling out’, a heavy, dragging sensation, difficulty passing urine or opening one’s bowel. Occasionally women have to press on the back wall of the vagina or perineum (the part between the vagina and back passage) in order to pass a motion. Some women report that during sex their husbands or partners feel that they are hitting something.

    POP is rarely painful but can be uncomfortable, particularly towards the end of the day or if you have been on your feet for a long time because of the effects of gravity. Similarly, POP may be eased by lying down.

  • What causes pelvic organ prolapse? Open or Close

    POP is a result of weakness of the supports of the vagina and/or uterus. The pelvic organs, i.e. vagina, uterus bladder and bowel, are supported by ligaments, your pelvic floor muscle, which acts like a hammock, and fascia, which is a sheet of tissue consisting of collagen. Damage to these structures through life events or surgery can lead to POP. Pelvic organ support may become weakened as a result of:

    1. Childbirth
    2. A longstanding cough.
    3. Constipation
    4. Obesity
    5. Heavy lifting over a prolonged period
    6. Genetic factors – some women are born with weak supporting tissue.
    7. Growing old – in women, tissues become weaker after the menopause.
    8. Hysterectomy.