Pelvic Organ Prolapse:
When the muscles and ligaments supporting a woman’s pelvic organs weakens, the bladder, rectum, uterus, or bowel may begin to bulge into or beyond the vagina. The different types of pelvic prolapse are named for the organ that is herniating into the vagina. These disorders are referred to as cystoceles, rectoceles, enteroceles, and uterine prolapse. These can be uncomfortable or painful, and in some woman can cause other symptoms such as urinary retention, urinary incontinence, lower abdominal pain or chronic back pain. Pelvic floor weakness is usually initiated with stretching with pregnancy and delivery. Pelvic surgery, such as a hysterectomy can cut suspension ligaments and cause prolapse. Aging tissue and lack of estrogen also worsens pelvis muscle sagging along with anything that puts extra pressure on the abdomen like chronic constipation or coughing.
Pelvic organ prolapse, affects about one-third of all women over their lifetime.
What Is Pelvic Organ Prolapse?
To understand how prolapse occurs, it is helpful to understand the normal positions of the organs in the pelvic region. The bladder is located in front of the vagina and the rectum is located behind the vagina. Generally these internal organs are maintained in their position by a body of connective tissue and muscles that form a strong shelf on which all of the pelvic organs sit. If these muscles are damaged or weakened through normal aging, child birth, pelvic surgery or trauma the organs loose their normal positioning and the uterus and pelvic contents move into the vaginal vault.
Pelvic organ prolapse refers to the prolapse or drooping of any of the pelvic floor organs that descend into or down through the vaginal canal. You may hear them referred to in these ways:
Types of Pelvic Organ Prolapse:
Prolapse comes from the Latin word to fall. In medicine this term indicates that an organ has slipped out of its proper place. Woman with pelvic floor disorders may suffer from the rectum protruding through the back of the wall of the vagina (rectocele), the bladder protruding out of the anterior wall (cystocele) or the entire vagina (vaginal vault prolapse [or uterus] uterus prolapsing through the vaginal opening). The small intestine may even prolapse (enterocele), especially in woman who have had a hysterectomy.
In the prolapse of the uterus the uterus drops down into the vagina. It usually results from weakening of the connective tissue and ligaments supporting the uterus. The uterus may bulge only in the upper part of the vagina, into the middle part or all the way through the opening of the vagina causing total uterine prolapse. Prolapse of the uterus may cause pain in the lower back, although many woman have no symptoms. Woman with uterine prolapse may feel a dragging or heaviness in their pelvic area, often described as feeling like their insides are falling out. Symptoms that may occur with all types of prolapse include feeling a lump or heavy sensation in the vagina, lower back pain that eases when you lie down, pelvic pain or pressure, and pain during sex. Total uterine prolapse, which is obvious, can cause pain during walking. Sores may develop on the protruding tissues and cause bleeding, discharge, and infection. Prolapse of the uterus may cause a kink of the urethra. A kink may hide urinary incontinence if present or make urinating difficult. Woman with total uterine prolapse may also have difficulty having a bowel movement.
In the prolapse of the vagina, the upper part of the vagina drops into the lower part, so that the vagina turns inside out. The upper part may drop part of the way through the vagina or all the way through, protruding outside the body, causing total vaginal prolapse. Prolapse of the vagina occurs only in woman who have had a hysterectomy.
A cystocele develops when the bladder drops down and protrudes into the front wall of the vagina. A cystocele may cause stress incontinence or overflow incontinence. After urination, the bladder may not feel completely empty. Sometimes urinary tract infections develop because of retained urine. Because the nerve to the bladder or urethra can be damaged, woman who have these disorders may develop urge incontinence. An enterocele develops when the small intestine and the lining of the abdominal cavity [peritoneum] bulge downward between the uterus and/or the rectum, if the uterus has been removed, between the bladder and the rectum. An enterocele often causes no symptoms, but some woman have a sense of fullness or pressure or pain in the pelvis. Pain may also be present in the lower back.
A rectocele develops when the rectum drops and protrudes into the back of the vagina. A rectocele can make a bowel movement difficult and may cause constipation.
What Causes Pelvic Organ Prolapse?
Anything that produces strain, stretching, or nerve damage to the pelvic floor can lead to pelvic organ prolapse.
A number of different factors contribute to the weakening of pelvic muscles over time, but the two most significant factors are thought to be pregnancy and aging (menopause). Pregnancy is believed to be the main cause of pelvic organ prolapse, whether the prolapse occurs immediately after pregnancy or 20 years later. A vaginal delivery may weaken or stretch some of the supporting structural muscles in the pelvis. The delivery may damage nerves, leading to muscle weakness. Certain situations in pregnancy and birth further increase the likelihood of an extent of damage, such as a large baby, a long labor and the use of forceps or extractive devices. The aging process with already damaged pelvic floor muscles further weakens the pelvic muscles. The natural reduction in estrogen at menopause also causes muscles to become less elastic.
Woman who are overweight or have large fibroids are at an increased risk of prolapse due to the extra pressure this creates in their abdominal area. Chronic coughing from smoking, asthma or bronchitis, straining during bowel movements and heavy lifting also contribute to pelvic floor disorders. Other causes include hysterectomy, nerve diseases, connective tissue disorders, degenerative neurologic conditions and prior pelvic surgery.
Genetics may also play a role in pelvic organ prolapse. Connective tissues may be weaker in some women naturally, placing them at increased risk.
What Are the Symptoms of Pelvic Organ Prolapse?
Some women notice nothing at all, but others report these symptoms with pelvic organ prolapse:
Symptoms depend somewhat on which organ is drooping. Many times the patient will feel a protrusion or "bulge" from the vagina and heaviness and pressure in the pelvic and vaginal region. This is especially common after being on their feet all day or If the bladder prolapses, urine leakage may occur. If it is the rectum that has prolapsed, constipation and painful intercourse often occur. Uterine and vaginal vault prolapse are also accompanied by a low backache and uncomfortable intercourse.
How Is Pelvic Organ Prolapse Treated?
Treatment of pelvic organ prolapse depends on how severe the symptoms are. Treatment can include a variety of therapies including:
Surgical Treatment of Pelvic Organ Prolapse:
Most of the surgical treatments for prolapse aim to lift the prolapse organ back into place. Hysterectomy for uterine prolapsed is the only treatment that removes the prolapsed organ all together. The choice of surgery depends on the type of prolapse you have, your age, and whether or not you want to keep your uterus or have children in the future, whether you are sexually active, the skill of your surgeon and your personal preferences. It is very common to have more than one type of prolapse at the same time and each one should be taken into consideration when planning. Your doctor may give you a series of bladder tests before your operation even if you do not have bladder symptoms. This is because your prolapse may be masking stress incontinence by pushing up against your urethra and preventing urine from leaking. Repairing your prolapse may fix one condition but leave you with another: incontinence. Your urologist may recommend another procedure to prevent incontinence.
As with all surgery, the degree of success depends on many factors. While surgical treatment may be successful for one woman, it may be very disappointing results for another. The surgical treatments that you choose may repair your prolapse, but they may not relieve all of your symptoms, and in some cases they may make your symptoms worse or cause other problems. Statistics show that one in three women have a surgical repair go on to have additional surgery.
Can Pelvic Organ Prolapse Be Prevented?
Many risk factors for pelvic organ prolapse are out of your control. These include:
But you can reduce the likelihood you will have problems. Try these steps: