A prolapse occurs in a woman when one of the pelvic organs (ie the bladder, uterus, rectum or intestines) loses its supports and “falls” down into the vagina. A prolapse is a form of hernia into the vagina.
What can prolapse?
- The bladder sits in front of the vagina and a bladder prolapse into the vagina is called a “cystocele”.
- The rectum sits behind the vagina and rectal prolapse into the vagina is called a “rectocele”.
- The uterus sits at the top of the vagina and can prolapse resulting in uterine prolapse.
- After a hysterectomy (removal of the uterus), the intestines sitting on top of the vagina can prolapse into the vagina causing an “enterocele” or vaginal vault prolapse.
Why does a prolapse develop?
Prolapse is due to a weakness in the usual supporting tissues and muscles of the pelvis. Factors that predispose to weakening of these tissues include:
- Childbirth with vaginal delivery
- Conditions that cause increased pressure on the pelvic floor, e.g.
- Chronic cough
- Chronic constipation
- Heavy lifting and straining
- Abnormalities of the connective tissues
What are the symptoms of prolapse?
Many women with less severe (low grade) prolapse have no symptoms and if this is the case, no further treatment is necessary. The less severe forms of prolapse may only be evident on a vaginal examination by a doctor and can occur without any symptoms.
Women with more severe forms of prolapse may experience:
- a sensation of a vaginal lump which may be associated with a feeling of discomfort or pressure
- a visible lump protruding from the vagina, especially at the end of the day or with more strenuous activity
- if the prolapse is continually protruding from the vagina, vaginal discharge and bleeding can occur
- difficulties in passing urine with poor urine flow and a sensation of incomplete emptying of the bladder (in the case of a large cystocele)
- urinary incontinence
- difficulties in emptying the bowel (in the case of a large rectocele or enterocele)
- the need to press on the prolapse with a finger in the vagina to help the passage of urine or bowel actions
- problems with sexual intercourse
Does prolapse cause urinary incontinence?
- The underlying weakness of the pelvic floor muscles and tissues that causes prolapse also causes stress urinary incontinence (i.e. the loss of urine with activity, cough, straining), and hence the two conditions are often found together. In this situation surgical repair of the prolapse and surgery for the stress incontinence can be performed together.
- It may sound strange but more severe degrees of prolapse can actually hide problems with stress urinary incontinence. This is due to the fact that a large prolapse can kink the urethra (the tube which drains urine from the bladder) and hide the problem of urinary incontinence. When the prolapse is repaired (or pushed back into position with a pessary), urinary incontinence can sometimes be “unmasked”. It is important to look for this hidden form of urinary incontinence particularly with a larger prolapse as it helps determine if surgical treatment for incontinence will also be needed. A trial with a vaginal pessary for prolapse is another useful way of checking for hidden incontinence.
What can be done to prevent further prolapse?
The following measures are thought to help prevent worsening of prolapse and recurrence of prolapse after surgical treatment:
- Maintain a healthy weight
- Avoid heavy lifting and straining
- Have chronic cough and constipation investigated and treated
- Stop smoking
- Perform regular pelvic floor physiotherapy
When is treatment needed for prolapse?
The two main reasons to have surgery for prolapse are:
- Bothersome symptoms – i.e. a woman will decide herself when the symptoms caused by the prolapse are bothersome enough to warrant treatment
- Complications related to the prolapse e.g. blockage of the flow of urine or rarely of the kidneys, incomplete emptying of the bladder. These complications are uncommon.
For the vast majority of women with prolapse, the decision to have treatment is elective, i.e. a woman decides if she needs treatment based on her symptoms.
What treatments are available for prolapse?
- Not all women with prolapse require treatment and observation with ongoing review and performance of pelvic floor physiotherapy is all that may be required
- Non-surgical management of prolapse with a vaginal pessary. A pessary is a small plastic device inserted into the vagina to support the prolapsed tissue and return it to its correct position.
- Prolapse surgery. There are many different operations available for prolapse which vary according to the type and severity of prolapse, whether the uterus is present, and both the woman’s and surgeon’s preference. Operations can be performed both through the vagina and through the abdomen. There is no one surgery that is effective in all women. It is important that the surgery is individualized to the woman.
Which treatment is the right one?
The correct treatment for any individual can only be determined after thorough evaluation of the prolapse and consideration of multiple factors including prolapse severity, symptom severity, desire for further children or a woman’s preference in retaining the uterus, previous surgery performed for prolapse, and consideration of the potential risks and complications of any treatment.