Prolapse literally means ‘to fall down’. A woman’s pelvic floor muscles and ligaments supports the pelvic organs (uterus, bladder and rectum). When the supporting muscles and ligaments are weakened, the pelvic organs can ‘fall down’ from their natural position into the vagina. Sometimes, a prolapse may protrude outside the vagina.
Half of women over 50 will have some symptoms of pelvic organ prolapse and by the age of 80, more than one in ten will have had surgery for prolapse.
What are the symptoms of prolapse?
○ You may not have any symptoms at all and may only find out that you have a prolapse after a routine vaginal examination e.g. Cervical Screening Test.
○ Some women may feel heavy, dragging feeling or a lump ‘coming down’ the vagina. You may also have backaches.
○ If your bladder has prolapsed into the vagina, you may:
Need to pass urine more frequently
Have difficulty in passing urine
Feel your bladder is not emptying properly
Leak urine when coughing, laughing or lifting heavy objects
○ If you have a bowel prolapse, you may experience lower back pain, constipation or an incomplete bowel emptying. You may need to push back the prolapse to allow stools to pass.
○ Sex may be uncomfortable.
What causes prolapse?
○ The most common causes is the weakening of the pelvic floor after a pregnancy and giving birth, particularly if you have a large baby and a prolonged labour. You’re more likely to develop a prolapse in later life if you’ve had multiple births.
○ Prolapse is more common as you get older, particularly after menopause, even if you’ve never given birth before.
○ Being overweight, constipation, chronic coughing (eg. poorly controlled asthma or smoking), or prolonged heavy lifting can strain your pelvic floor and cause prolapse.
○ If you have close family members who’ve had prolapse, you’re at a higher risk.
Different types of prolapse
○ Anterior wall prolapse (cystocele) - when the bladder bulges into the front wall of the vagina.
○ Posterior wall prolapse (rectocele) - when the bowel bulges into the back wall of the vagina
○ Uterine prolapse - when the uterus hangs down into the vagina. Usually the uterus may protrude outside the body. This is also known as procidentia.
○ Vault prolapse - after a hysterectomy, the top of the vagina may bulge down. This happens to one in ten women who have had a hysterectomy to treat their original prolapse.
What can be done to prevent prolapse?
Keeping a healthy lifestyle with regular exercise and incorporating pelvic floor muscle exercises. Pelvic floor muscle exercises may help to strengthen the supporting muscles. A pelvic floor physiotherapist will be able to provide exercise advice.
It is much better to prevent prolapse than trying to fix it. Making lifestyle changes may also help.
Losing weight if you’re overweight
Managing chronic cough
Avoiding constipation
Avoiding heavy lifting
Treatment options for prolapse
Pessary
A pessary is a plastic or silicone device that fits into the vagina to help support the pelvic organs and hold up the uterus. It is a good non-surgical option and if you’re thinking about having children in the future. A pessary is more likely to help a uterine prolapse or an anterior wall prolapse. Pessaries comes in various types and sizes and your gynaecologist will be able to recommend the best one for your situation.
Fitting the right pessary is important and may take more than one attempt. They should be changed, cleaned and reinserted regularly. If you have soreness while changing the pessary, you may use some estrogen cream. Occasionally, pessaries may cause inflammation and you have unexpected bleeding, please see your doctor.
Surgery
Surgery to repair vaginal prolapse may be necessary to alleviate symptoms and making sure your bladder and bowels work normally. Depending on your type of prolapse, symptoms, age, health, wish for sexual intercouse and if you’re planning to have (more) children, there are different surgical operations available. Surgery can be performed through the vagina or through the abdomen, your gynaecologist will discuss this with you.
Possible operations include:
○ Pelvic floor repair if you have prolapse of the anterior or posterior walls of the vagina. This is usually done through your vagina so you do not need a cut in your abdomen.
○ Operations that aim to lift up and attach your uterus or vagina to a bone towards the bottom of your spine or a ligament within your pelvis (sacrocolpopexy or sacrospinous fixation). This may also be done via laparoscopic ‘keyhole’ surgery.
○ Hysterectomy (removal of the uterus) is sometimes performed for uterine prolapse.
○ Closing off your vagina (colpoclesis) may be considered if you’ve have several operations previously that has been unsuccessful.
If you’re still planning to have children, you may want to delay surgery until your family is complete. There are risks with any type of operations and your gynaecologist will discuss this with you. As a patient, feel comfortable asking as many questions as you like.
Dr Adeline Chan is a female gynaecologist in Sydney, servicing the Western Sydney and Hills District region.
Arete Health is an obstetrics and gynaecology practice in Sydney. Please call the rooms at 02 9629 3559 for any enquiries or if you wish to make an appointment.