Pelvic Organ Prolapse

Pelvic Organ Prolapse

What is it?

Pelvic organ prolapse is when the bladder, uterus and/or rectum start pushing into a women’s vagina. This can cause bulging of the vaginal walls and can be more severe so that a woman may actually start seeing the bulging inside of her vagina at the entrance to her vagina or even beyond the entrance of the vagina. Pushing of the bladder into the vaginal walls is called a cystocele. Bulging of the rectum into the vaginal walls is called a rectocele. Falling down of the uterus (uterine prolapse) may result in a woman seeing her cervix (the opening of the uterus) at or beyond the entrance of the vagina. The top of the vagina can also fall down after the uterus is gone (after hysterectomy) and is called vaginal vault prolapse.

What are the causes?

Pelvic organ prolapse is mostly caused by vaginal childbirth. It may worsen after menopause or with increasing weight. Hysterectomy and chronic constipation may also worsen prolapse. Women often feel pressure in their pelvis or see the bulge in their vagina but pelvic organ prolapse usually does not cause severe pain unless the patient is unable to urinate.

How is it treated?

Pelvic organ prolapse is very common and does not predispose the woman to cancer and usually does not interfere with sexual intercourse. Usually it does not need to be treated except to correct bothersome bulging or pressure.

The non-surgical treatment is placement of a pessary in the vagina to hold the loose organs up. Pessaries come in many shapes and sizes and must be fit by a trained health care provider. When a pessary is in the vagina and is fit correctly, it should not fall out and it should not be sensed by the woman. A pessary must be taken out periodically to clean it. How often depends on the kind of pessary placed, the menopausal status of the woman and how well the vagina has tolerated the pessary being in place. Pessaries left in the vagina without periodic checking can irritate the vaginal walls and cause bleeding or can even cause holes in the vaginal walls.

There are many options for surgical correction of pelvic organ prolapse. Many options involve removing the uterus (hysterectomy) when it is falling down as well. In addition, pelvic organ prolapse is associated with leaking of urine (incontinence) because vaginal childbirth predisposes to both conditions. Any incontinence associated with coughing, laughing or sneezing (stress incontinence) can also be fixed at the time of surgery. An Important aspect of surgery is to correct all of the defects (cystocele, rectocele and uterine prolapse) at the same time because correction of one defect while leaving other minor defects alone can cause those minor defects to get worse. Some surgeries involve the placement of mesh in or around the vagina. There are several ways this can be done (sacrocolpopexy or suburethral sling) that have been done for many years and have low risks of problems with the mesh. Other, newer procedures done with mesh can have more problems with scarring of the vagina and erosion of the mesh into the vagina causing bleeding. It is important that these procedures are performed by a specialist in this area (urogynecolgist).