Prolapse – in the ‘nether region’ – the unspoken condition.
Lots of women experience symptoms of prolapse, but few ever talk about it. Pelvic organ prolapse is the bulging of one or more of the pelvic organs into the vagina. Basically, it kinda means that your vagina is falling out! It can range from feeling a bit uncomfortable to totally unacceptable. Today, I will try to explain the reasons and causes of this condition and just what can be done.
The organs of the pelvic floor include the uterus(womb), vagina, bowel and bladder.
Symptoms of prolapsed may include:
- a sensation of a bulge or something coming down or out of the vagina, which sometimes needs to be pushed back
- discomfort during sex
- problems passing urine – such as slow stream, a feeling of not emptying the bladder fully, needing to urinate more often and leaking a small amount of urine when you cough, sneeze or exercise (stress incontinence)
Some women with a pelvic organ prolapse don’t have any symptoms and the condition is only discovered during an internal examination for another reason, such as a cervical screening. Pelvic organ prolapse isn’t life-threatening, but it can affect your quality of life. It’s important to see your GP if you have any of the symptoms of a prolapse, or if you notice a lump in or around your vagina.
Types of prolapse
If pelvic organ prolapse is confirmed, it will usually be staged to indicate how severe it is. Most often, a number system is used, ranging from one to four, with four indicating a severe prolapse.
Pelvic organ prolapse can affect the front, top or back of the vagina. The main types of prolapse are:
- anterior prolapse (cystocele) –where the bladder bulges into the front wall of the vagina
- prolapse of the uterus and cervix or top of the vagina –which can be the result of previous treatment to remove the womb (hysterectomy)
- posterior wall prolapse (rectocoele or enterocoele) –when the bowel bulges forward into the back wall of the vagina
It’s possible to have more than one of these types of prolapse at the same time.
Why does prolapse happen?
Prolapse is caused by weakening of tissues that support the pelvic organs. Although there’s rarely a single cause, the risk of developing pelvic organ prolapse can be increased by:
- your age – prolapse is more common as you get older
- childbirth, particularly if you had a long or difficult labour, or gave birth to multiple babies or a large baby – up to half of all women who have had children are affected by some degree of prolapse
- changes caused by the menopause – such as weakening of tissue and low levels of the hormone oestrogen
- being overweight, obese or having large fibroids (non-cancerous tumours in or around the womb) or pelvic cysts – which creates extra pressure in the pelvic area
- previous pelvic surgery – such as a hysterectomy or bladder repair
- repeated heavy lifting and manual work
- long-term coughing or sneezing – for example, if you smoke, have a lung condition or allergy
- excessive straining when going to the toilet because of long-term constipation
Certain conditions can also cause the tissues in your body to become weak, making a prolapse more likely, including:
- joint hypermobility syndrome – where your joints are very loose
- Marfan syndrome – an inherited condition that affects the blood vessels, eyes and skeleton
- Ehlers-Danlos syndrome – a group of inherited conditions that affect collagen proteins in the body
Can a prolapse be prevented?
There are several things you can do to reduce your risk of prolapse, including:
- doing regular pelvic floor exercises
- maintaining a healthy weight or losing weight if you’re overweight
- eating a high-fibre diet with plenty of fresh fruit, vegetables, and wholegrain bread and cereal to avoid constipation and straining when going to the toilet
- avoiding heavy lifting
If you smoke, stopping smoking may also help to reduce your risk of a prolapse.
Treating a pelvic organ prolapse
There are several treatment options available for a pelvic organ prolapse, depending on your circumstances.
The treatment most suitable for you depends on:
- the severity of your symptoms
- the severity of the prolapse
- your age and health
- whether you’re planning to have children in the future
You may not need any treatment if your prolapse is mild to moderate and not causing any pain or discomfort.
Self care advice
If your prolapse is mild, there are some steps you can take that may help improve it or reduce the risk of it getting worse.
This may include:
- doing regular pelvic floor exercises
- losing weight if you’re overweight, or maintaining a healthy weight for your build
- eating a high-fibre diet with plenty of fresh fruit, vegetables and wholegrain bread and cereal to avoid constipation and straining when going to the toilet
- avoiding heavy lifting and standing up for long periods of time
If you smoke, giving up will help, because coughing can make a prolapse worse.
Pelvic floor exercises
The pelvic floor muscles are a group of muscles that wrap around the underside of the bladder and rectum. Having weak or damaged pelvic floor muscles can make a prolapse more likely. Recent evidence suggests that pelvic floor exercises may help to improve a mild prolapse or reduce the risk of it getting worse. Pelvic floor exercises are also used to treat urinary incontinence (when you leak urine), so may be useful if this is one of your symptoms.
To help strengthen your pelvic floor muscles, sit comfortably on a chair with your knees slightly apart. Squeeze the muscles eight times in a row and perform these contractions three times a day. Don’t hold your breath or tighten your stomach, buttock, or thigh muscles at the same time.
When you get used to doing this, you can try holding each squeeze for a few seconds (up to 10 seconds). Every week, you can add more squeezes, but be careful not to overdo it and always have a rest inbetween sets of squeezes.
Specialist physiotherapists, who can teach you how to do pelvic floor exercises with bio-feedback are extremely helpful. It usually takes at least three months before you notice any improvement but this treatment is non-invasive and teaches you skills for life.
A vaginal ring pessary is a device inserted into the vagina to hold the prolapse back. It works by holding the vaginal walls in place. Ring pessaries are usually made of latex (rubber) or silicone and come in different shapes and sizes. Ring pessaries may be an option if your prolapse is more severe, but you would prefer not to have surgery. The pessary may need to be removed and replaced every four to six months.
Ring pessaries can occasionally cause vaginal discharge, some irritation and possibly bleeding and sores inside your vagina. Other side effects include:
- passing a small amount of urine when you cough, sneeze or exercise (stress incontinence)
- difficulty with bowel movements
- interference with having sex, although most women can have intercourse without any problems
- an imbalance of the usual bacteria found in your vagina (bacterial vaginosis)
These side effects can usually be treated.
Surgery may be an option for treating a prolapse if it’s felt the possible benefits outweigh the risks. Surgery for pelvic organ prolapse is relatively common. It’s estimated that 1 in 10 women will have surgery for prolapse by the time they’re 80 years old.
These procedures are outlined below.
One of the main surgical treatments for pelvic organ prolapse involves improving support for the pelvic organs. This may involve stitching prolapsed organs back into place and supporting the existing tissues to make them stronger. Pelvic organ repair may be done through cuts (incisions) in the vagina. If you’re planning to have children and have a prolapse, your doctors may suggest delaying surgery until you’re sure you no longer want to have any more children. This is because pregnancy can cause the prolapse to recur.
Surgery for pelvic organ prolapse may not always be successful and the prolapse can return. For this reason, synthetic (non-absorbable) and biological (absorbable) meshes have been introduced to support the vaginal wall and/or internal organs. The majority of women treated with mesh respond well to this treatment. However, there are reports of complications associated with vaginal meshes. These are mostly regarding persistent pain, sexual problems, mesh exposure through vaginal tissues and occasionally injury to nearby organs, such as the bladder or bowel.
Your gynaecologist will discuss all the pros and cons of the mesh with you and don’t be afraid to ask questions – for example
- What are the alternatives?
- What are the chances of success with the use of mesh versus use of other procedures?
- What if the mesh doesn’t correct my problems?
- If I have a complication related to the mesh, can it be removed and what are the consequences associated with this?
- Do you know what happens to the mesh over time?
If the womb (uterus) is prolapsed, then removing it during an operation called a hysterectomy often helps the surgeon to give better support to the rest of the vagina and reduce the chance of a prolapse returning. Methods to elevate and support the uterus without removing it do exist, but these need to be discussed with your doctor.
There is underwear that can help the early stages of prolapse especially if urinary incontinence is only an issue during sporting activities. There are running shorts and leggings from EVB sports (available online and in sports shops) and there is a pelvic strap called a V2 supporter that can also help during activity. The main message today is NOT to suffer in silence. Chat to your Pharmacist in Grant’s Pharmacy or your GP and you can improve your quality of life enormously. Grant’s Pharmacy is located in Wexford town, in Enniscorthy town, in Arklow town – all beside Pettitts and in Gorey town opposite the GPO. Find us on Facebook. If anyone wishes me to include an article about a topic they would like to know more about, please email me (Leonie Grant) at firstname.lastname@example.org. I would love to hear from you.