Prolapse (Falling Out)

The vagina is normally like a long tube, pulled up on the inside, and anchored to the sides and top of the pelvis by ligaments. The front part (anterior wall) of this flattened tube holds up the bladder, the back part (posterior wall) keeps the rectum in place, and the top part (apex) helps to hold the small bowels in place. In women with a uterus, the ligaments that support the uterus also help to hold the vagina in place.

When the pelvic ligaments that hold up the vagina stretch or break, or when the vagina itself stretches and becomes loose, the vagina turns “inside out” on itself, and bulges downward towards the opening. The term “pelvic organ prolapse” refers to the bulging of the vaginal and pelvic tissues.

The types of female pelvic organ prolapse include:

• Cystocele – when the front part of the vagina and bladder prolapse
• Rectocele – when the back part of the vagina and the rectum prolapse
• Uterine prolapse – when the top part of the vagina and uterus prolapse
• Enterocele – in a woman who has had a hysterectomy, the top part of the vagina and the small intestine prolapse

Other names used to describe pelvic organ prolapse include vaginal prolapse, prolapsed vagina, bladder prolapse, prolapsed bladder, dropped bladder, and dropped uterus.

Symptoms of POP include:

• Pelvic pressure
• Low back pain
• Seeing or feeling tissue bulging from the vaginal opening, usually worse at the end of the day
• Urinary frequency
• A feeling of incomplete bladder emptying
• Urinary urge incontinence

Some women with prolapse also complain of difficulty emptying their bowels. Women with prolapse also report needing to put their fingers on the perineum or in the vagina to help with bowel movements and/or bladder emptying.

POP is diagnosed by examining the vagina and looking for the bulging tissues. Sometimes, a woman may have to strain or bear down in order to demonstrate the prolapse. Advanced prolapse can usually be seen at rest, with the pelvic tissues bulging out of the vaginal opening.

The biggest risk factor for POP is vaginal childbirth. Other risk factors include hysterectomy, chronic coughing, straining, and a lifetime of repeatedly lifting heavy objects. Repeated straining due to constipation is also a risk factor for developing prolapse.

Nonsurgical treatments for prolapse include pessaries (internal prosthetic devices) and pelvic floor exercises.

There are no known medications that can successfully restore the vaginal support necessary to treat prolapse.

Pelvic organ prolapse surgery resuspends the vagina and pulls it back up into the pelvis. Some therapies also involve strengthening the stretched vaginal walls. Surgery to repair prolapse can be performed using minimally invasive abdominal approaches using laparoscopic and/or robotic surgery but prolapse can also be corrected using minimally invasive vaginal approaches.

For women who cannot tolerate major surgery, there is a low intensity surgical intervention that can correct prolapse by closing off the vagina using stitches. In his book “Prolapse Repair,” Dr. Hoyte discusses the various options for treating pelvic organ prolapse.

Generally, prolapse is not life threatening, but prolapse can adversely affect a woman’s quality of life. Sometimes POP can cause severe urinary retention, leading to recurrent life-threatening kidney infections. In other cases, the exposed vaginal tissues can become infected and put a woman at risk for major infection. In these very rare cases, prolapse can be life threatening, and prompt treatment is required.

In most cases if a woman chooses, prolapse can be safely ignored without problems. However, it is important to have the prolapse evaluated by a pelvic floor specialist to determine if it is safe to ignore.