Cystocele

Pelvic organ prolapse is bulging of one or more of the pelvic organs into the vagina.

Introduction

Pelvic organ prolapse is bulging of one or more of the pelvic organs into the vagina.

These organs are the uterus, vagina, bowel and bladder.

Symptoms may include:

  • a sensation of a bulge or something coming down or out of the vagina, which sometimes needs to be pushed back
  • discomfort during sex
  • problems passing urine, such as slow stream, a feeling of not emptying the bladder fully, needing to urinate more often and leaking a small amount of urine when you cough, sneeze or exercise (stress incontinence)

Some women do not have any symptoms.

Read more about the symptoms of pelvic organ prolapse.

When to see your doctor

Pelvic organ prolapse is not life threatening, but it can affect your quality of life.

See your doctor if you have any of the symptoms of a prolapse, or if you notice a lump in or around your vagina that you have not felt before.

Your doctor will often need to carry out an internal examination of your pelvis to diagnose a prolapse.

Read more about diagnosing pelvic organ prolapse.

Types of prolapse

Pelvic organ prolapse can affect the front, top or back of the vagina. The main types of prolapse are:

  • anterior prolapse (cystocoele), where the bladder bulges into the front wall of the vagina
  • prolapse of the cervix or top of the vagina, where the cervix or uterus drops, and can be the result of previous treatment to remove the womb (hysterectomy)
  • posterior wall prolapse (rectocoele or enterocoele), when the bowel bulges forward into the back wall of the vagina

It is possible to have more than one of these types of prolapse at the same time.

Why does prolapse happen?

Prolapse is caused by weakening of tissues that support the pelvic organs. This happens for a number of reasons.

In many women, the strain of childbirth weakens these tissues. Up to half of all women who have had children are affected by some degree of prolapse.

It is also more common as women get older, particularly in those who have gone through the menopause.

Things like being overweight, having a persistent cough and having long-term constipation can increase your risk of developing a prolapse.

Prolapse can also be caused by rare genetic conditions that affect your body tissues, such as Marfan syndrome.

Read more about the causes of pelvic organ prolapse.

Can a prolapse be prevented?

There are several things you can do to reduce your risk of prolapse, including:

  • doing regular [pelvic floor exercises]
  • maintaining a healthy weight or losing weight if you are overweight
  • eating a high-fibre diet with plenty of fresh fruit, vegetables and wholegrain bread and cereal to avoid constipation and straining when going to the toilet
  • avoiding heavy lifting

How is prolapse treated?

Many women with prolapse do not need treatment as the problem does not seriously interfere with their normal activities.

Lifestyle changes such as weight loss and pelvic floor exercises are usually recommended in mild cases.

If the symptoms require treatment, a prolapse may be treated effectively using a device that is inserted into the vagina called a vaginal pessary. This helps to hold the prolapsed organ in place.

Surgery may also be an option for some women. This usually involves giving support to the prolapsed organ, but in some cases complete removal of the womb (hysterectomy) is required.

Most women experience a better quality of life after surgery, but there is a risk of problems remaining or even getting worse.

Read more about treating pelvic organ prolapse.

Symptoms

Some women with a pelvic organ prolapse do not have any symptoms and the condition is only discovered during an internal examination for another reason, such as a cervical smear test.

However, many women will experience an uncomfortable sensation of something coming down or out of the vagina.

Other common symptoms include:

  • difficulty going to the toilet, such as not being able to fully empty the bladder
  • difficulty in emptying the bowel, which may mean the bulge has to be pushed back into the vagina to pass a stool
  • difficulty having sex

You may also have stress incontinence, where a small amount of urine is passed if you cough, sneeze or exercise.

A prolapse can also have a significant impact on your quality of life and body image.

When to seek medical advice

See your doctor if you have any of the symptoms of a prolapse, or if you notice a lump in or around your vagina that you have not felt before.

Causes

There is rarely a single cause of pelvic organ prolapse. It is usually the result of a combination of things.

The risk of developing pelvic organ prolapse can be increased by:

  • your age – prolapse is more common as you get older
  • childbirth, particularly if you had a long or difficult labour or gave birth to multiple babies or a large baby
  • changes caused by the menopause, such as weakening of tissue and low levels of the hormone oestrogen
  • being overweight or obese, which creates extra pressure in the pelvic area
  • previous pelvic surgery, such as a hysterectomy or bladder repair
  • repeated heavy lifting and manual work
  • long-term coughing – for example, if you smoke or have a lung condition
  • excessive straining when going to the toilet because of long-term constipation

Other medical conditions

There are some conditions that cause weakening of the tissues in your body and can make a prolapse more likely, including:

Diagnosis

If your prolapse is not visible, your doctor will need to carry out an internal pelvic examination to diagnose pelvic organ prolapse.

Your doctor will ask you to undress from the waist down and lie back on the examination table while they feel for any lumps or bumps in your pelvic area.

In some cases, further tests are carried out in hospital. For example, a small tube (catheter) may be inserted into your bladder to examine your bladder function and identify any leakage problems. This test is known as urodynamics.

If pelvic organ prolapse is confirmed, it will usually be staged to indicate its severity. Most often, prolapses are staged using a number system ranging from 1 to 4, with 1 indicating minimal prolapse and 4 indicating a severe prolapse.

Treatment

There are several treatment options available for a pelvic organ prolapse, depending on your circumstances.

The treatment most suitable for you will depend on:

  • the severity of your symptoms
  • the severity of the prolapse
  • your age and health
  • whether you are planning to have children in the future

You may not need any treatment if your prolapse is mild to moderate and not causing any pain or discomfort.

Self-care advice

If your prolapse is mild, there are some steps you can take that may help improve the condition or reduce the risk of it getting worse.

This may include:

  • doing regular pelvic floor exercises (see below)
  • losing weight if you are overweight, or maintaining a healthy weight for your build (you can check your body mass index (BMI))
  • eating a high-fibre diet with plenty of fresh fruit, vegetables and wholegrain bread and cereal to avoid constipation and straining when going to the toilet
  • avoiding heavy lifting and standing up for long periods of time

Pelvic floor exercises

Your pelvic floor muscles are muscles that you use to control the flow of urine from your bladder. They surround the bladder and the tube that carries urine from the bladder to outside the body (urethra).

Having weak or damaged pelvic floor muscles can make a prolapse more likely. Recent evidence suggests pelvic floor exercises may help improve a mild prolapse or reduce the risk of it getting worse.

Pelvic floor exercises are also used to treat urinary incontinence (when you leak urine), so may be useful if this is one of your symptoms.

Read more about treating urinary incontinence.

To help strengthen your pelvic floor muscles, sit comfortably and squeeze the muscles 10-15 times in a row. Do not hold your breath or tighten your stomach, buttock, or thigh muscles at the same time.

When you get used to doing this, you can try holding each squeeze for a few seconds. Every week, you can add more squeezes, but be careful not to overdo it and always have a rest inbetween sets of squeezes.

Your doctor may refer you to a physiotherapist, who will be able to teach you how to do pelvic floor exercises. It may take a few months before you notice any improvement.

Hormone replacement therapy (HRT)

While there is little evidence that a treatment called hormone replacement therapy (HRT) can directly treat pelvic organ prolapse, it can help relieve some of the symptoms associated with prolapse, such as dryness of the vagina or discomfort during sex.

HRT involves the use of medication to increase the level of a hormone called oestrogen in women who have been through the menopause.

HRT medication is available as:

  • a cream you apply to your vagina
  • a tablet you insert into your vagina
  • a patch you stick on your skin
  • an implant inserted under your skin

HRT is widely used for women who have symptoms of a prolapse after menopause. It may be combined with surgery, pelvic floor muscle exercises or vaginal pessaries (see below).

Vaginal pessaries

A vaginal ring pessary is a device inserted into the vagina to hold the prolapse back. It works by holding the vaginal walls in place. Ring pessaries are usually made of latex (rubber) or silicone and come in different shapes and sizes.

Ring pessaries may be an option if your prolapse is more severe but you would prefer not to have surgery. A gynaecologist (a specialist in treating conditions of the female reproductive system) or a specialist nurse usually fits a pessary.

The pessary may need to be removed and replaced every few months, usually by a health professional.

Side effects

Ring pessaries can occasionally cause vaginal discharge, some irritation and possibly bleeding and sores inside your vagina. Other common side effects include:

  • an imbalance of the usual bacteria found in your vagina (bacterial vaginosis)
  • passing a small amount of urine when you cough, sneeze or exercise (stress incontinence)
  • difficulty with bowel movements
  • interference with having sex, although most women can have intercourse without any problems

These side effects can usually be treated.

Surgery

Surgery may be an option for treating a prolapse if it is felt that the possible benefits outweigh the risks.

In general, surgery for pelvic organ prolapse is relatively common. It is estimated that 1 in 10 women will have had surgery for prolapse by the time they are 80 years old.

Surgery is used to repair the tissue that supports the prolapsed organ or tissue around the vagina.

Surgery to remove the womb (hysterectomy) may also form part of your treatment, but this does not directly treat a prolapse.

These procedures are outlined below.

Surgical repair

One of the main surgical treatments for pelvic organ prolapse involves improving support for the pelvic organs.

This may involve stitching prolapsed organs back into place, as well as stitching existing tissue to make it stronger.

Pelvic organ repair may be done through the vagina or through cuts (incisions). It is usually carried out under general anaesthetic, so you will be asleep during the operation and will not feel any pain.

This type of operation is usually recommended if you want to have children in the future. Your doctors may suggest delaying surgery until you are sure you no longer want to have any more children, however, because pregnancy can cause the prolapse to recur.

Hysterectomy

If the womb (uterus) is prolapsed, then removing it during an operation called a hysterectomy often helps the surgeon to give better support to the rest of the vagina and reduce the chance of a prolapse returning.

A hysterectomy will usually only be considered in women who have been through the menopause, as you cannot get pregnant after having a hysterectomy.

Methods to elevate and support the uterus without removing it do exist, but they are not always widely available.

Complications from surgery

All types of surgery carry some risks. Your surgeon will explain these in more detail, but possible complications could include:

  • bleeding, which may require a blood transfusion
  • damage to the surrounding organs, such as your bladder
  • an infection – you may be given antibiotics to take during and after surgery to reduce the risk of infection
  • pain during sex, usually caused by narrowing of the vagina
  • vaginal discharge and bleeding
  • experiencing more prolapse symptoms, which may require further surgery
  • a blood clot forming in one of your veins (for example, in your leg) – you may be given medication to help reduce this risk after surgery (see deep vein thrombosis (DVT) for more information)

Recovering from surgery

Many prolapse operations are done as day surgeries with no overnight stay, although more major operations may require a stay in hospital for one or two days.

If you need to stay in hospital, you may have a drip in your arm to provide fluids and a thin plastic tube called a catheter to drain urine from your bladder. Some gauze will be placed inside your vagina to act as a bandage for the first 24 hours. This may be slightly uncomfortable. Your stitches will usually dissolve on their own after a few weeks.

For the first few days or weeks after your operation you may have some vaginal bleeding similar to a period. You may also have some vaginal discharge. This may last three or four weeks. During this time you should use sanitary towels rather than tampons.

Enhanced recovery

Enhanced recovery is an NHS initiative to improve patient outcomes after surgery and speed up recovery.

This involves careful planning and preparation before surgery, as well as reducing the stress of surgery by:

  • using pain relief to minimise pain
  • avoiding unnecessary drips, tubes and drains
  • enabling you to eat and drink straight after your operation
  • encouraging early mobilisation

Post-surgery advice

Even with enhanced recovery, there may still be some activities you need to avoid while you recover from surgery. Your care team can advise about activities you may need to avoid, such as heavy lifting and strenuous exercise, and for how long.

Generally, most people are advised to move around as soon as possible, with good rests every few hours.

You can usually shower and bathe as normal after leaving hospital, but you may need to avoid swimming for a few weeks.

You should be able to start having sex again after a short time if your vaginal discharge has stopped.

Your care team will advise about when you can return to work.

Problems with recovery

Vaginal discharge is perfectly normal. However, if the amount of discharge increases over time or becomes smelly, you should contact your doctor because you may have an infection. You should also contact your doctor if you:

  • have a high temperature (fever) of 38°C (104°F) or over
  • experience severe pain low in your tummy
  • have heavy vaginal bleeding
  • experience a stinging or burning sensation when you pass urine
Content supplied by NHS Choices