There are several different types of pelvic organ prolapse. Pelvic organ prolapse occurs when ligaments and connective tissue in the pelvic area become weak or damaged and can no longer support the pelvic organs. The womb (uterus) is the only organ that actually falls into the vagina. When the bladder and bowel slip out of place, they push up against the walls of the vagina. While prolapse is not considered a life threatening condition, it may cause a great deal of discomfort and distress. There are a number of different types of prolapse that can occur in a woman's pelvic area, and these are divided into three categories according to the part of the vagina they affect:

• front wall
• back wall or
• top of the vagina

It is common to have more than one type of prolapse. Clicking the image below will take you to an animation of the different types of prolapse.

Prolapse of the anterior (front) vaginal wall
Cystocele (fallen bladder)
When the bladder falls down into the vagina, it called a cystocele. When the bladder prolapses, it falls towards the vagina and creates a large bulge in the front vaginal wall, which may cause discomfort and difficulty emptying the bladder, or even pocketing of stool tht may later leak.

Uterine and vaginal vault prolapse (apical or top)
Uterine prolapse (fallen uterus)
Uterine prolapse is when the womb drops down into the vagina. It is the second most common type of prolapse, and is classified into three grades depending on how far the womb has fallen. This condition may cause discomfort and problems with difficulty having bowel movements.

Vaginal vault prolapse (fallen/ bulging vagina)
In women who have previously had a hysterectomy, it is still possible for the vagina itself to fall down even though the uterus is no longer present. This is called a post-hysterectomy ("after hysterectomy") vaginal prolapse.

Enterocele (bulging of small bowels)
An enterocele occurs when a space between the vagina and rectum opens and a portion of the small bowel bulges through.

Prolapse of the posterior (back) vaginal wall
Rectocele (bulging rectum)
If the rectum falls, it is called a rectocele. This condition may cause discomfort and difficulty having bowel movements.

Back To Top

Physical Symptoms:

• Difficult bowel movements, constipation, liquid stools
• Like having a tampon that is about to fall out or a lump outside the vagina
• Lower backache
• Painful intercourse (dyspareunia)
• Pelvic pressure, pulling/stretching groin pain
• Something bulging or falling out from the vagina
• Urine leakage, frequency, chronic urinary tract infections, difficulty urinating

Women with pelvic organ prolapse can experience all, some or none of these symptoms. Each woman's experience depends on the type of prolapse, the severity of the symptoms and the individual herself.

Emotional Symptoms:
Women with pelvic organ prolapse often feel alone, isolated and depressed. They may feel embarrassed by this condition and, because the condition is generally not discussed, do not seek treatment. Women may feel embarrassed by their body and choose to hide their condition from their partners, leading to reduced intimate contact.

Back To Top

When Should I Get Help?

• If you have any concern at all about any condition with your body, you should always contact your doctor.
• If you feel a bulge or lump on the outside of your vagina.
• If you have lower back pain or increased pelvic pressure that interferes with your daily activities.
• If you have irregular vaginal spotting or bleeding.
• If you experience frequent urinary incontinence, urinary tract infections, difficulty urinating, frequent urination or any of the symptoms listed here that interfere with your daily routine.
• If sexual intercourse is painful or difficult.

How Will I Be Evaluated?
Thorough Explanation of Your Symptoms:

When You See Dr. Ashby, Urogynecologist for the Pelvic Control Center, You Will Have a Health History Taken. Some of the Questions You May Be Asked Are:

• What types of symptoms you are having?
• Do you have any type of chronic disease such as asthma, bronchitis, etc?
• Did you have any vaginal births?
• Do you smoke?
• Do you do heavy lifting or stand on your feet for long periods of time?

Pelvic Exam
To find out if you have pelvic organ prolapse - descent of any of the pelvic organs such as the bladder, cervix, vagina or rectum - Dr. Ashby, Urogynecologist for the Pelvic Control Center, will do a pelvic exam. This is usually done while you lie on an exam table, or sometimes while you are standing. The doctor may ask you to push down or cough to see the full extent of the prolapse. A pelvic exam may be performed where a speculum in inserted into your vagina. A rectal exam also might be performed to check the strength of these muscles, which can weaken with age or childbirth. The doctor also will likely ask you to do a Kegel (pelvic floor contraction of the muscles that you use to stop the flow of urine). If you do have pelvic organ prolapse, the doctor will determine which organs are involved and how severe the prolapse is.

What Are The Stages of Pelvic Organ Prolapse?

• Stage 0 means that there is no prolapse. The pelvic organs - like the vagina, bladder and rectum - are perfectly supported by the ligaments in the pelvis.
• Stage 1 means that there is virtually no prolapse. The pelvic organs are very well supported by the ligaments in the pelvis.
• Stage 2 prolapse means that the pelvic organs are not as well supported by the ligaments and have begun to fall down. In Stage 2 prolapse, the organs are still inside the vagina.
• Stage 3 prolapse, the pelvic organs are beginning to bulge to or beyond the opening of the vagina.
• Stage 4 prolapse, the pelvic organs are completely outside of the vagina.

Most women who have had children vaginally have Stage 1 or 2 pelvic organ prolapse, and it is normal if they don't have any symptoms. On the other hand, women with Stage III or IV prolapse generally feel a bulging sensation and may have problems with urination or bowel movements.

Other Tests As Part Of The Evaluation

Post-void Residual Test
A PVR is done to determine how much urine is left behind after you urinate. It is normal for the bladder not to empty itself completely; often, a small amount of urine remains. Even though you may have voided 10 minutes earlier, urine may still be collected from your bladder. The post-void residual test consists of you first emptying your bladder; within 15 minutes, a catheter is placed in your bladder to determine the amount of urine left behind. Most women have a post-void residual between 0-60 cc. A PVR is done to determine if you have any urinary retention, which can be a sign of an underlying condition. Most doctors will conduct follow-up studies if the PVR is over 100 cc.

Urinalysis
This test is done to determine if you have an infection or other substances found in the urine. It is usually performed at the beginning of any type of bladder test. A clean catch of urine is obtained and then a test strip is dipped into the urine. Results are usually obtained within minutes. If you have a high white blood cell count, it could indicate a bladder infection. For follow-up, doctors also may send your urine out to a laboratory to be cultured; this is a more sensitive test.

Bladder Testing (Urodynamics)
Urodynamic testing is a series of bladder tests that are done in order to observe how your lower urinary tract reacts under certain conditions. It is usually done to see if you have problems with loss of urine (urinary incontinence) or to figure out what type of incontinence you may have. Cystometry - sometimes also referred to by the general term "urodynamics" - consists of filling your bladder with sterile water, then observing the pressure and how your bladder reacts under these conditions. When the test begins, the physician inserts a small soft catheter in your bladder and hooks a tube to a bag of sterile water. Your bladder is then filled to around 250 cc (approximately one cup), which most women can hold without needing to urinate. A second catheter, which is connected to a machine or computer, also is inserted. This catheter measures the pressures within your bladder. Once the bladder is filled, you will be asked to cough and strain in order to see how much urine you leak. Also, many women will leak if their bladder is full and they cannot get to the bathroom in time.

Back To Top

Lifestyle Modifications
There are many simple things you can do to help with your prolapse or to try to stop it from getting worse. Try not to stand on your feet for long periods of time. Heavy lifting can make a prolapse get worse, so try not to lift things that are heavier than 10-15 pounds. Straining to have a bowel movement can also make a prolapse worse. Try to keep your bowel movements soft (the consistency of toothpaste). This can be done with a high-fiber diet, or with fiber supplements, such as Metamucil or Citrucel.

Pessaries



A pessary is a small device made of plastic or silicone that is placed inside the vagina to hold the uterus or the walls of the vagina up and inside your body. Pessaries come in many shapes and sizes, and can be fitted for each individual woman to best suit your needs. Some are shaped like a ring, a dish, a donut, a mushroom or a cube. A woman can remove and replace her own pessary, or she can visit the doctor every few months to have it removed and cleaned. It is usually safe to keep a pessary in the vagina for three to four months at a time. Some women are sexually active with a pessary in place. Other women prefer to remove the pessary to have sex. A pessary can be an excellent choice for women who cannot or do not wish to have surgery to correct their prolapse. It is important to return to the doctor for scheduled visits to make sure that there are no pressure sores in the vagina as a result of the pessary.

Back To Top

What Keeps The Pelvic Organs From Falling Out?
Pelvic organs are supported by both muscles and ligaments. The pelvic organs include the uterus, bladder, vagina and bowel. These organs are at the bottom of the abdomen and so the pelvis must bear the weight of the contents of the abdomen. This is somewhat like having a box where the pelvic floor is located. Those structures at the bottom of the pelvis must carry the weight of the contents of the box while the sides and the top have relatively less weight placed upon them.

Muscles
Muscles are what hold the vagina, rectum and urethra closed, as well as support the organs. As is true with the muscles in your back, these are not muscles you think about controlling. The body simply has them adjust to keep just the right amount of tension to hold things in place. For example, muscles hold the rectum and anus closed and it is only during times such as those in which gas is pushed down that we actually think about those muscles and contract them. The rest of the time, muscles are controlled automatically by the body.

Ligaments
Ligaments are fibrous tissues that connect bones together. They are slightly elastic and when under tension can lengthen. The ligaments in the pelvis are normally strong enough to hold the organs in place, however, they can also be damaged and weakened. Age, chronic smoking and some diseases also can cause ligaments to weaken in some women in the same way that skin is affected as we age. Moreover, some women are born with different strengths of ligaments. Women born with weak ligaments are more likely to have problems with prolapse than those born with stronger ligaments. For example, if a large adult was to try to sit on a small children's swing, the swing may break. Similarly, if the muscles and ligaments are stressed beyond their limits, they may fail. Chronic coughing, working in a job where lots of heavy lifting is needed and probably obesity all put unusual pressures on the pelvic floor. These may not damage the pelvic floor in all women but in those who are predisposed to this condition. All of these factors can lead to weakening and breakage of the ligaments that help hold the pelvic organs in place.

Both the ligaments and muscles work together in women with normal support to prevent the vagina and uterus from falling out. The following drawing shows an area like the vagina that is inside the space and helps show how ligaments help to hold the pelvic organs in place. The two red bands are like the ligaments that hold and keep the pelvic organs/ vaginal area from being pushed downward.

Back To Top

The pelvic organs rest on the muscular floor of the pelvis, which is something like a trap door. If you were standing on a trap door and the door dropped down, you would fall through unless you had something to hold onto. Similarly, when the pelvic floor opens due to muscle and nerve damage, the organs begin to fall downward. Ligaments catch the falling organs and hold them in place, but this puts a lot of stress on the ligaments, and eventually the ligaments can fail as well. As a result, pelvic organ prolapse occurs, and the organs fall or bulge out through the vaginal opening.

Imagine that the vagina is somewhat like a finger of a glove, which is tucked inside the rest of the glove. In this way, the vagina is surrounded by an enclosed area. If the pressure in that area is increased, the vagina tends to be pushed downward. In women with normal support, the muscles and ligaments prevent the vagina from protruding outward. But in women with damaged support, the vagina is not held in place, and the organs push downward causing the vagina to bulge or fall out through the opening.

Because there are many different factors that can lead to pelvic organ prolapse, a different pelvic organ may fall down.

Does Childbirth Cause Prolapse?
During vaginal delivery, a woman's muscles have to stretch in order for the baby to come through the vagina. Vaginal delivery may cause a ligament to break as the baby's head comes through the pelvic floor. When this occurs, the muscle does not contract as it normally would. (This is similar to a spinal cord injury when people lose their ability to control the muscles that are not connected to the spinal cord and brain.) In most women, the damage is minor, but in others, enough muscle may be lost to the point that it can no longer hold up the pelvic organs.

Are There Other Causes Of Prolapse?

• Menopause: Decreased estrogen, such as during menopause, also may contribute to pelvic organ prolapse. During menopause, estrogen levels, collagen and certain connective tissue proteins decline.
• Obesity: Obesity contributes to an increased pressure in the abdomen so women who are overweight tend to have a higher rate of pelvic organ prolapse.
• Chronic Cough: Chronic coughing caused by smoking, asthma or chronic bronchitis put increased pressure on the abdomen and pelvis. Smoking alone reduces collagen and can increase the chances of a connective tissue tear.
• Prior Pelvic Floor Surgery: Prior surgery may cause damage to the support of the pelvic organs.
• Neurologic Diseases: Diseases affecting the nervous system such as Parkinson's, multiple sclerosis or a spinal cord injury also increase the chances of developing pelvic organ prolapse.
• Ethnicity/Race: Pelvic organ prolapse is more common in women of Caucasian and Hispanic background.

Back To Top