Prolapse & bladder weakness


There are many different types of prolapse including vaginal, uterine, bladder and bowel prolapse. Causes of prolapse, symptoms, tests used to diagnose prolapse, and management and treatment of prolapse are discussed.

What is prolapse?

Prolapse is caused by a stretching of the ligaments that support the pelvic organs, causing those organs to stretch and 'drop down'. The word prolapse literally means to 'fall out of place'.

There are different types of prolapse including:

Types of prolapse What happens
Vaginal prolapse

The walls of the vagina become overstretched and bulge downwards towards the vaginal entrance. The bulging can be:

  • the front vaginal wall with the bladder in front of it
  • the back vaginal wall with the rectum immediately behind
Uterine prolapse The uterus (womb) and cervix (opening to the womb) drop down towards the vaginal entrance and may protrude outside the vagina.
Bladder prolapse (also called cystocele) The bladder causes a bulge in the vaginal wall. A cystocele usually occurs because of a weakening of the pelvic floor muscles, which support the uterus, bladder and bowel. A cystocele can occur by itself or it may happen along with other abnormalities such as a rectocele or uterine prolapse.
Bowel prolapse (also called rectocele) When the bowel bulges forward into the back vaginal wall.

female pelvic floor

Causes of prolapse

A prolapse can result from anything that puts pressure on the pelvic floor such as:

  • pregnancy and childbirth
  • regularly straining on the toilet to pass bowel motions
  • repetitive lifting of children
  • repetitive lifting of heavy weights at work or in the gym
  • excess weight
  • Smoking and chronic lung diseases with coughing

Postmenopausal women

Postmenopausal women are more susceptible to a prolapse. The trigger is a loss of oestrogen during menopause. This hormone helps to keep the pelvic floor muscles, which support the vagina and bladder, well toned. Once oestrogen levels drop after menopause, these muscles become thinner, weaker and less elastic. The vaginal skin stretches, which may allow the bladder to bulge backwards into the vagina.

Symptoms

The symptoms of a prolapse depend on individual factors such as the severity of the prolapse, level of physical activity and any other associated prolapse.

The symptoms include:

  • stress incontinence: leaking urine when:
    • coughing
    • sneezing
    • laughing
    • standing up
    • running
    • walking
  • inability to completely empty the bladder or the bowel after going to the toilet
  • straining to get urine flow started
  • a slow flow of urine that tends to stop and start
  • a sensation of fullness or pressure inside the vagina
  • a bulge or swelling felt in the vagina

In severe cases, the vagina and bladder may protrude outside the vaginal entrance.

Diagnosis

A prolapse is diagnosed by a medical history check and a physical examination. The physical examination will determine:

  • how severe the prolapse is
  • what condition the pelvic floor muscles are in
  • whether the prolapse involves just the bladder or whether the vagina and/or the uterus are also involved

Tests

Tests that may be done include:

Test What it assesses
Pelvic ultrasound Whether any masses or cysts are causing the problem rather than a prolapse.
Urodynamics: a test of bladder function Different types of incontinence, particularly stress or urge incontinence.
Bladder ultrasound
  • Residual urine (urine left in the bladder after passing urine)
  • Whether any masses or cysts are causing the problem rather than a prolapse
Mid-stream urine test Whether a bladder infection is causing the problem.

Degrees of prolapse

Gynaecologists with a special interest in prolapse use a grading system called the POP-Q system to measure the degree of prolapse in centimetres.

A cystocele (bladder prolapse) is graded by how much of the bladder has fallen into the vagina. The three stages are:

Stage What happens
Stage 1 The bladder protrudes a little way into the vagina.
Stage 2 The bladder protrudes so far into the vagina that it is close to the vaginal opening.
Stage 3 The bladder protrudes out of the vagina.

Management & treatment

Without intervention the symptoms of prolapse usually worsen over time. However, there is a lot you can do to strengthen your pelvic floor muscles to improve the symptoms.

Before a prolapse occurs, there may be a slackening in the walls of the vagina, so awareness of this weakening and preventing it from getting worse are vital.

Treatment will depend on the severity of the prolapse and the degree it interferes with a woman's lifestyle. In some women, strengthening the pelvic floor muscles and modifying daily activities may be all that is required. Some women can benefit from a physiotherapy program and others will need more intensive treatment.

Level of prolapse Management and treatment
Prevention and mild cases of prolapse Lifestyle changes and preventive measures such as pelvic floor exercises.
Moderate cases
  • Lifestyle changes
  • A session with a pelvic floor physiotherapist to learn the best exercise technique to strengthen the pelvic floor muscle
  • Surgery may be necessary
  • For women who are not able to have surgery or who wish to delay surgery, a ring pessary can be inserted high into the vagina to support the bladder
Severe cases
  • Surgery is usually required to repair a severe prolapse
  • There are different surgical techniques available. Current techniques may involve the use of supporting mesh, tissue graft or a tape to support the bladder and urethra in place.
  • The length of time the operation takes will depend upon the particular operation. Some operations are day procedures
  • The surgery is usually done under general anaesthesia
  • Full recovery usually takes around six weeks, during which time you need to avoid lifting, straining or over exercising

What you can do to prevent and manage prolapse

Action What to do Why you need to do it
Lifting Avoid lifting heavy objects (over 10kg) – this includes children and grandchildren! To avoid straining
Weight range Keep within a healthy weight range. Being overweight is known to worsen symptoms.
Fibre Take recommended daily fibre intake of 30g. To help prevent constipation because one instance of straining because of constipation can worsen the prolapse.
Fluid Drink between 6-8 glasses of water each day. Not drinking enough water makes stools hard, dry and difficult to pass which can cause straining.
Toilet habits Avoid straining on the toilet for either bowels or bladder. Because one instance of straining can worsen the prolapse.
Physical activity
  • Exercise daily
  • Use lighter weights
  • Opt for core strengthening on an exercise ball and cardiovascular exercise such as walking, swimming or bike riding rather than running, jumping or high impact aerobics
  • To help keep your bowels regular
  • To avoid straining
Pelvic floor exercises
  • Do pelvic floor exercises daily
  • Always squeeze up pelvic floor muscles before lifting, coughing, laughing or sneezing
  • If you have symptoms of a prolapse, have a private consultation with a specially trained pelvic floor physiotherapist
To strengthen the muscles supporting the pelvic organs because stronger pelvic floor muscles help reduce symptoms of stress incontinence.
Seek medical advice Seek medical advice for any condition that causes coughing and sneezing such as asthma, chest infections and hay fever. Repetitive sneezing and coughing may cause or worsen cystocele.
Medication Hormone therapy such as a cream, pessary or a vaginal tablet. Can help postmenopausal women tone the muscles supporting the vagina and bladder.

Last updated 20 July 2017 — Last reviewed 15 January 2014

** Currently under review **

This web page is designed to be informative and educational. It is not intended to provide specific medical advice or replace advice from your health practitioner. The information above is based on current medical knowledge, evidence and practice as at January 2014.

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