Prolapse


There are many different types of prolapse, including 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 and muscles that support the pelvic organs, causing those organs to 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 (see below) or uterine prolapse.
Bowel prolapse (also called rectocele) When the bowel bulges forward into the back vaginal wall.

diagram of female pelvic floor

Risk factors for 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 or urine
  • repetitive lifting of children/grandchildren
  • repetitive lifting of heavy weights at work or in the gym
  • excess weight
  • smoking and chronic lung diseases with coughing.

Women who have had pelvic surgery may also be at increased risk of prolapse.

Postmenopausal women

Postmenopausal women are more susceptible to 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 may also stretch, which may allow the bladder or bowel to bulge into the vagina.

Symptoms

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

The symptoms can include:

  • an inability to completely empty the bladder or the bowel when going to the toilet
  • straining to get urine flow started, or to empty the bowel
  • a slow flow of urine that tends to stop and start
  • a sensation of fullness or pressure inside the vagina
  • a sensation of vaginal heaviness or dragging
  • a bulge or swelling felt in the vagina
  • bladder or bowel urgency or incontinence
  • lower back ache.

In severe cases, the vaginal wall or cervix 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
  • the function of the pelvic floor muscles
  • whether the prolapse involves just the bladder, and/or the uterus or bowel.

Tests

Tests that may be done include:

Test What it assesses
Pelvic ultrasound Whether there are any masses or cysts in the pelvic area.
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).

Mid-stream urine test Rules out infection if there are bladder symptoms.

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 prolapse is graded by how much the organ or vaginal wall is pushing down into the vagina. The three stages are:

Stage What happens
Stage 1 The wall/organ protrudes a little way into the vagina.
Stage 2 The wall/organ protrudes close to the vaginal opening.
Stage 3 The wall/organ 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 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.

Being sexually active does not cause or worsen prolapse.

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
  • Sessions with a pelvic floor physiotherapist to learn the best exercise technique to strengthen the pelvic floor muscles
  • Surgery may be required
  • 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 prolapse. This is done in the gynaecologist's consulting room.
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 hold the bladder and urethra in place.
  • The length of time the operation takes will depend on 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 and straining. Walking for exercise is best during this time.

What you can do to prevent and manage prolapse

Action What to do Why you need to do it
Lifting Avoid lifting heavy objects (more than 10kg) – this includes children and grandchildren! To avoid straining and pushing the prolapse down
Weight range Keep within a healthy range. Being overweight has been shown to worsen prolapse.
Fibre Eat recommended daily fibre intake of 30g. To help prevent constipation, because even one instance of straining can worsen the prolapse.
Fluid Drink between 6 and 8 glasses of fluid each day. Not drinking enough fluid can make stools hard, dry and difficult to pass, which can cause straining.
Toilet habits

Avoid straining on the toilet for either bowels or bladder.

Using your hand to support the prolapse can help.
Sit down and relax, leaning forwards, forearms on thighs. Putting your feet apart on a small stool can help when emptying bowels. Take your time and don't hurry.
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 and worsening the prolapse.
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 can help reduce symptoms of prolapse.
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 Seek a prescription for hormone therapy, such as a cream, pessary or a vaginal tablet. Helps vaginal walls and pelvic floor muscles to offer more support.

Last updated 26 September 2018 — Last reviewed 04 August 2018

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 August 2018.

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