Pelvic organ prolapse can be defined as the descent of the pelvic organs (the bladder, urethra, uterus, vagina, rectum, or small intestine) toward or through the vaginal or anal opening. It is considered a subjective disorder in that the severity of prolapse may not be correlated with the symptoms experienced. Some women with pelvic organ prolapse have no symptoms at all. It is primarily the ‘level of bothersome’ of these symptoms that guide treatment. Pelvic organ prolapse is not a disease, it is a functional problem.
Symptoms of Pelvic Organ Prolapse:
A bulge at the vaginal or rectal opening that can be seen or felt and that may change depending on position or activity (worse with coughing, lifting, straining with bowel movements, end of the day, prolonged standing/walking, etc.)
Heaviness or pressure felt in the perineal region (between the vagina and anus).
Incomplete emptying of or difficulty evacuating the bladder or bowels.
Difficulty initiating urination.
Discomfort during intercourse.
Pain is not typically a defining characteristic of prolapse, though some women may experience some.
Chronic constipation: Straining, pushing and sitting on the toilet for an extended period of time can contribute significantly to the development and worsening of pelvic organ prolapse.
Types of Prolapse
Prolapse is named by the organ which is descending into the vaginal canal including:
Cystocele (prolapse of the bladder): When the bladder tips backwards and pushes into the front wall of the vagina. It can make it harder to empty the bladder completely when you urinate. Incomplete bladder emptying can contribute to bladder infections. Some women with bladder prolapse also have urinary incontinence. If there is any straining with a bowel movement, it is a good idea to support the perineum (area between vagina and anus) with your hand (wrapped in toilet paper) to minimize the amount of downward movement of your bladder and other pelvic organs.
Rectocele (prolapse of the rectum): When the rectum tips forward into the back wall of the vagina. This can cause incomplete emptying because the stool gets stuck in the pocket of prolapsed bowels. Some women may need to push on the prolapse with their fingers or thumb inserted into the vagina (directed towards their back) to help empty their bowels (referred to as splinting). Changing the stool consistency, aiming for soft, formed stool and avoiding constipation, as well as learning correct evacuation postures and techniques can help relieve some of these symptoms.
Hysterocele (prolapse of the uterus): When the cervix and uterus collapse into the vagina. You may be able to feel the tip of the cervix, which feels harder than the surrounding tissues, somewhat like the tip of your nose.
Urethrocele (prolapse of the urethra): When the urethra (the tube that urine passes from the bladder to the outside of the body through) tips closer toward the vaginal opening.
Vaginal vault prolapse: When the top of the vagina, after a hysterectomy, descends toward the vaginal opening.
Enterocele (prolapse of the small intestine): When the small intestine descends into the lower pelvic cavity, pushing on the vagina.
Intercourse is safe and will not typically worsen a pelvic organ prolapse. If any discomfort is felt with intercourse, exploration of different sexual positions is recommended.
Even if you have pelvic organ prolapse, it is still important to maintain an active lifestyle. Recommendations can be made regarding the most suitable type of exercise for you. Low impact activities such as walking, biking, or swimming are best.
Perhaps even more important than the type of exercise you are doing is how you are doing it. Focusing on steady breathing instead of breath-holding is important so as to not unnecessarily increase intra-abdominal pressure. Keep moving in ways that do not increase your symptoms of pelvic pressure or bulge. If your symptoms are brought on, find ways to modify your exercise to avoid your symptoms being brought on.
Physiotherapy Treatment Management of pelvic organ prolapse can be very effective in helping to eradicate, minimize, or manage symptoms. Strategies that physiotherapists address include:
Inner core training and pelvic floor strengthening
Symptom management education
Pessary education and fitting (link)
If management through physiotherapy is not successful to the degree that a woman is satisfied with, corrective surgery may be considered, although most would agree that surgery is best left as a last resort.
Surgical Treatment for Prolapse
Some women choose to have surgery to manage their prolapse symptoms. The type of surgery needed depends on the organs that need to be repaired. In addition to lifting prolapsed organs, your surgeon might recommend removing the uterus (hysterectomy) or lifting the top of the vagina (vault suspension). Surgery for prolapse can also be combined with surgery for stress urinary incontinence.
Surgical risks include:
Infection at the surgical site
Bleeding and damage to surrounding structures (bladder and bowel)
Nerve injury related to your position during surgery