Pelvic Organ Prolapse

What happens in pelvic organ prolapse

The pelvic floor is a hammock of muscles, ligaments and connective tissue that holds up the bladder, uterus and rectum. Childbirth can stretch or tear these tissues, and lower estrogen after menopause weakens them further. When support fails, organs press into the vaginal walls and descend.

Types of prolapse

Many people have more than one type at the same time.

Stages

Doctors use the POP-Q system to describe how far organs descend relative to the vaginal opening (the hymen):

• Stage 0: no prolapse
• Stage 1: more than 1 cm above the opening
• Stage 2: within 1 cm above or below the opening
• Stage 3: more than 1 cm below the opening but not completely out
• Stage 4: complete eversion, the organ is fully outside

Symptoms usually appear once the prolapse reaches the vaginal opening (stage 2 or more).

Causes and risk factors

• vaginal childbirth, especially multiple births, large babies, long pushing stages or forceps delivery
• aging and menopause
• obesity
• chronic coughing (chronic cough), smoking or lung disease
• chronic constipation and straining
• heavy lifting at work or in sport
• previous pelvic surgery, including hysterectomy
• connective tissue disorders and family history

Symptoms

• a feeling of something coming down, a bulge or a lump in the vagina
• heaviness, pressure or dragging in the pelvis or lower back, worse after standing or at the end of the day
• seeing or feeling tissue at or outside the vaginal opening
• urinary symptoms: leaking with coughing or sneezing (stress incontinence), urgency, a slow stream, incomplete emptying, frequent infections
• bowel symptoms: difficulty emptying, needing to press around the vagina or perineum, constipation
• discomfort, looseness or reduced sensation during sex
• spotting from irritated tissue

Symptoms often improve when lying down.

Diagnosis

• pelvic examination, lying down and sometimes standing, while bearing down
• POP-Q measurements
• urine tests for infection
• bladder scan to check emptying
• urodynamic tests before surgery when urinary symptoms are present
• imaging is rarely needed

Treatment

Treatment depends on symptoms, not on how the prolapse looks. People without bothersome symptoms can be reassured and monitored.

Lifestyle and self-care

• lose weight if overweight
• treat constipation with fiber, fluids and avoiding straining
• stop smoking and treat chronic cough
• avoid heavy lifting, or lift with good technique and pelvic floor engagement

Pelvic floor muscle training

Pelvic floor exercises (Kegels), ideally taught by a pelvic health physical therapist, can improve symptoms and stop mild prolapse from progressing. A typical program is daily exercises for at least 3 to 4 months.

Vaginal pessary

A pessary is a removable silicone device inserted into the vagina to hold organs in place. Many types exist (ring, Gellhorn, cube). It is a good option for people who want to avoid or delay surgery, are pregnant or planning pregnancy, or are not fit for surgery. Pessaries need regular cleaning and checks to prevent sores.

Vaginal estrogen

Low-dose vaginal estrogen after menopause improves tissue health, reduces irritation and helps pessary use.

Surgery

Surgery is considered when symptoms persist despite conservative treatment:

• native tissue repair (anterior or posterior repair) through the vagina
• apical support procedures, such as sacrospinous or uterosacral ligament fixation
• sacrocolpopexy: mesh attaches the top of the vagina to the sacrum, usually laparoscopically, with good long-term durability
• hysterectomy sometimes, depending on the case
• colpocleisis: closing the vagina, a simpler operation for people who are not sexually active and not fit for longer surgery

Transvaginal mesh for prolapse was withdrawn from the US market in 2019 because of complications. Prolapse can recur after surgery.

Prevention

• pelvic floor exercises, including during and after pregnancy
• healthy weight
• avoiding constipation and straining
• not smoking
• safe lifting technique

Frequently asked questions

What are the symptoms of pelvic organ prolapse?

The most common symptom is a feeling of a bulge or heaviness in the vagina, often worse at the end of the day. Other symptoms include urinary leakage or difficulty emptying, bowel emptying problems and discomfort during sex.

Can pelvic organ prolapse be fixed without surgery?

Many people manage well without surgery. Pelvic floor muscle training can reduce symptoms in mild to moderate prolapse, and a vaginal pessary supports organs effectively in most people. Weight loss and treating constipation and cough also help.

What causes pelvic organ prolapse?

The main causes are vaginal childbirth and aging, especially after menopause. Obesity, chronic constipation, chronic coughing, heavy lifting and previous pelvic surgery increase the risk.

Is pelvic organ prolapse dangerous?

Prolapse is not life-threatening, but it can affect quality of life. Rarely, severe prolapse can block urine flow or cause ulcers on exposed tissue. Being unable to urinate or a prolapse that cannot be pushed back needs urgent care.

Can you exercise with a prolapse?

Yes. Walking, swimming, cycling and pelvic floor exercises are generally safe and helpful. High-impact exercise and heavy lifting may worsen symptoms for some people. A pelvic health physical therapist can tailor an exercise plan.