Vaginal Prolapse – Causes, Symptoms, Diagnosis, Treatment

Vaginal Prolapse – Causes, Symptoms, Diagnosis, Treatment

Vaginal prolapse is a condition where the vagina slips out of position. This is more common in women who have had multiple vaginal deliveries during childbirth, have gone through menopause, are smokers or are overweight. The chances of developing a prolapse also increase as you age.

Muscles, ligaments and skin, in and around the vagina, support and hold the female pelvic organs and tissues in place by acting as a hammock. However, pregnancy, childbirth, aging, and menopause, all contribute to the stretching and weakening of these pelvic floor muscles. The result can be a vaginal prolapse – where the pelvic organs, such as the uterus, rectum, bladder, urethra, small bowel, or even the vagina itself, fall out of their normal position. As a vaginal prolapse usually involves the vagina, plus another organ, it is often referred to as a Pelvic Organ Prolapse (POP).

Around 40% of us will be affected by a vaginal prolapse by the time we reach our 60’s, and this figure rises to 50% of us over 50. Although not life-threatening, it can cause severe pain and discomfort, especially in later stages if the prolapse becomes exposed outside of your vagina. So read on to learn about the causes, treatments and preventable measures.

As with most medical problems, it’s important not to put off treatment. Allowing your prolapse to go untreated for a long period of time leads to weakened pelvic muscles and damage to associated nerves – increasing the risk of a prolapse reoccurring. So avoid unnecessary delays and speak to your doctor if you have any concerns.

Types of Vaginal Prolapse

There are many different types of pelvic organ prolapse, each one has a different name depending on the pelvic organ affected:

  • Rectocele prolapse – A prolapse of the back wall of the vagina (the rectovaginal fascia). This occurs when the rectal wall pushes against the vaginal wall, creating a bulge into the vagina. The effects of this bulge may be more noticeable during a bowel movement.
  • Cystocele or bladder prolapse – When the front wall of the vagina weakens and allows the bladder to protrude into the vagina. If the urethra is also affected, it is called a urethrocele.
  • Enterocele or small bowel prolapse – Also known as a herniated small bowel, this occurs when the upper vaginal supporting muscle becomes weakened. Resulting in the front and back walls of the vagina to separate, allowing the small intestines to push against the vaginal walls.
  • Uterine prolapse – Weakening of the uterosacral ligaments at the top of the vagina can cause the uterus to fall and move downwards. Often, during a prolapsed uterus, both the front and back walls of the vagina start to weaken as well.
  • Vaginal vault prolapse – Around 15% of women who have had a hysterectomy (complete removal of the womb and cervix) suffer a vaginal vault prolapse. The uterus provides support for the top of the vagina, if it is no longer there then the top of the vagina can gradually fall towards the vaginal opening and the vaginal walls weaken. Eventually, the top of the vagina can protrude out through the opening of the vagina.

Stage

There are four main stages of pelvic organ prolapse, as graded using the Pelvic Organ Prolapse Quantification System (POP-Q). The example organ used here is the uterus:

  • First stage uterine prolapse – The uterus drops into the lower part of the vagina but cannot be seen from outside of the vagina.
  • Second stage uterine prolapse – The uterus drops as far as the opening of the vagina but is still not visible from the outside.
  • Third stage uterine prolapse – The cervix, the area between the opening of the uterus and the top of the vagina, is pushed to the outside of the vagina by the collapsing uterus.
  • Fourth stage uterine prolapse – The entire uterus and cervix has dropped so low that it has fallen out of the vagina and is entirely visible from the outside. This is known as a ‘complete prolapse’ or procidentia.

Causes of Vaginal Prolapse

There are a few risk factors that may lead to you experiencing a vaginal or pelvic organ prolapse:

  • Pregnancy – Around 50% of women who have carried a baby to full term will experience some kind of vaginal prolapse. This is in part due to the extra weight that the baby adds to the pelvic area, which can weaken the pelvic floor muscles. It is also thought to be caused by pregnancy hormones allowing vaginal tissues to stretch beyond their rebound limits. Multiple pregnancies will further increase your risk.
  • Childbirth – Again, around 50% of women who give birth vaginally will experience some level of prolapse. A large baby or a difficult birth where you’ve had to push a lot or forceps were used may increase your risk. More than one birth also increases your risk of experiencing a vaginal prolapse. Mothers who have delivered four babies vaginally are at 12 times greater risk than women who have not given birth vaginally.
  • Menopause – The change in hormones you experience during this time of your life, particularly the drop in estrogen, can cause your pelvic floor muscles to weaken. Effects can be worsened by the general loss of muscle tone associated with aging.
  • Bodyweight – Being overweight or obese can increase your chances of suffering a pelvic organ prolapse due to the weight on your pelvic area causing strain.
  • Genetics – If a family member has suffered a vaginal prolapse, then there may be a genetic reason that puts you at an increased risk.
  • Constipation – Continued straining to pass a stool will put extra pressure on the pelvic floor and could cause it to weaken.
  • Persistent coughing – Constant heavy coughing can add pressure to the pelvic floor. If you smoke and have a persistent smoker’s cough or if you have a lung condition that results in a cough, such as asthma or bronchitis, then you could be at a higher risk.
  • Heavy lifting – Repetitive heavy lifting, and lifting incorrectly, increases the pressure put on the pelvic floor.
  • Strenuous activity – Heavy, high impact exercises such as running or plyometric training (jump training) can cause the pelvic floor muscles to weaken.
  • Previous pelvic surgeries – A hysterectomy or previous vaginal prolapse surgery can weaken the pelvic floor muscles, and is likely to be part of the cause of any future pelvic organ prolapses.
  • Pelvic conditions – Heavy fibroids or a tumor somewhere in your pelvis can add weight to the area and weaken the pelvic floor muscles.
  • Hysterectomy – Up to 40% of women who have had a hysterectomy (the complete removal of the womb and cervix) suffer a vaginal vault prolapse. The uterus provides support for the top of the vagina, if it is no longer there, then the top of the vagina can gradually fall towards the vaginal opening and the vaginal walls weaken.
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Symptoms of Vaginal Prolapse

If you’re developing a vaginal or pelvic organ prolapse, then you may notice an odd feeling inside your vagina, like there’s something inside that is falling out. But it’s important to not feel embarrassed and speak to your doctor. In the early stages of pelvic organ prolapse, you may have no symptoms at all and it, therefore, may be diagnosed during a routine examination, such as a smear test.

As a prolapse advances, you may experience some or all of the following complaints:

  • a feeling of pressure inside the vagina, especially when sitting down
  • a dragging feeling inside the vagina, and/or feeling that something is going to fall out
  • vaginal bleeding, outside of menstruation
  • an excessively widened vagina, so much so that tampons don’t stay in place
  • noticeable tissue protruding from the vagina, that may also be painful and bleed
  • discomfort or pain during sex
  • loss of feeling or ‘tightness’ when having sex
  • pelvic or lower back pain
  • pain that reduces when you lay down and increases when you stand for a long time
  • persistent or frequent urinary tract infections (cystitis)
  • urinary stress incontinence – the inability to hold in urine when you cough, sneeze, laugh, exercise or lift heavy objects
  • a frequent need to urinate
  • difficulty passing urine
  • difficulty having a bowel movement – constipation and a feeling of not having fully emptied the bowel

With the number of different prolapse conditions and their close proximity to each other in the body, it can be difficult to know which symptoms point to which condition. Visiting your doctor to get a diagnosis is important and can help you decide which course of treatment is best for you.

Diagnosis of Pelvic Organ Prolapse

  • Plain Films – Plain films are usually not appropriate for the evaluation of pelvic prolapse. Barium defecography is in use at some places as a part of the assessment of pelvic floor dysfunctions, however, with the advent of newer and non-ionizing radiation imaging techniques like MR defecography, barium defecography has become largely obsolete.
  • Computed Tomography – Due to concern for radiation exposure and availability of MRI, which provides a better soft-tissue resolution, computed tomography (CT) is usually not appropriate for the evaluation of pelvic prolapse; however, one should look on the sagittal abdomen and pelvis images for a hint of pelvic floor prolapse by drawing a pubococcygeal line and see for overt prolapse and then recommend a dynamic MRI pelvis (MR Defecogram) for further evaluation.
  • Magnetic Resonance – Dynamic magnetic resonance imaging (MRI) provides an accurate assessment of pelvic prolapse. MRI provides a better anatomic detail compared to the transtibial ultrasound and is also useful as a preoperative tool. Furthermore, the MRI examination does not require bowel preparation and does not involve sensitive pelvic exposure. Despite its benefits, the MRI is not widely available, expensive, and contraindicated in patients with MRI incompatible devices or hardware.
  • Ultrasonography – Translabial ultrasound is a relatively inexpensive way of evaluating pelvic prolapse and is widely available. Besides, the ultrasound does not produce ionizing radiation and allows dynamic evaluation of the pelvic floor. However, the diagnostic quality of the ultrasound exam depends on the sonographer’s skill level and the interpreting radiologist’s familiarity with the examination.
  • Nuclear Medicine – Nuclear medicine studies are usually not appropriate for the evaluation of pelvic prolapse.
  • Angiography – Angiography is usually not appropriate for the evaluation of pelvic prolapse.

Treatments of Vaginal Prolapse

If you’re suffering from vaginal prolapse, speak to your doctor about what treatments may work for you. There are numerous different vaginal prolapse treatments that work and depend on your personal circumstances. Targeted pelvic floor muscle exercises are a popular choice for seeing a quick and effective improvement in your prolapse.

Surgery is considered as an option only when symptoms are severe and cannot be treated through other means, as there is a risk of further damage in the case of complications. Non-surgical treatments are also preferred when future children are desired, which can reduce the success of previous surgical procedures:

  • Pelvic floor exercises – These exercises help to strengthen the pelvic floor. Used in conjunction with an electronic pelvic toner, they could make all the difference.
  • Lifestyle treatments – You may be surprised how much difference losing weight, avoiding constipation, lifting properly, exercising differently, or giving up smoking can make.
  • Hormone treatment – Hormone supplements and topical estrogen creams can help boost the levels of the hormones you may be lacking through menopause or age that weaken the pelvic floor.
  • Wearing a vaginal pessary – A vaginal pessary will help to better support a pelvic organ prolapse. It’s a small device, usually made from silicone, that is placed inside the vagina to help support the vaginal wall and prevent other pelvic organs from collapsing further into it. Different shapes and sizes of vaginal pessaries suit different shapes and sizes of women. Your doctor can help you find the right one and help you change the pessary every four to six months. This is commonly the favored treatment for those unable to undergo surgery due to other medical conditions or those wishing to have children in the future. Pessaries can support even very severe prolapses..
  • vaginal pessaries – A pessary is a removable device inserted into the vagina to support the pelvic organs. Pessaries come in many different shapes and sizes. Pessaries are often the first treatment your doctor will try. Certain types of pessaries can treat both pelvic organ prolapse and urinary incontinence. A device made of rubber (latex) or silicone is inserted into the vagina and left in place to support the vaginal walls and pelvic organs. Vaginal pessaries allow you to get pregnant in the future. They can be used to ease the symptoms of moderate or severe prolapses and are a good option if you cannot or would prefer not to have surgery. Vaginal pessaries come in different shapes and sizes depending on your need. The most common is called a ring pessary.
  • Pelvic floor muscle therapy – Your doctor may show you how to do pelvic floor exercises or refer you to a physical therapist to do exercises to help strengthen the pelvic floor muscles. Pelvic floor muscle exercises can also help women who have pelvic organ prolapse as well as urinary incontinence.
  • Changing eating habits – If you have bowel problems, your doctor may recommend eating more foods with fiber. Fiber helps prevent constipation and straining during bowel movements.
  • Pelvic floor exercises – Doing pelvic floor exercises will strengthen your pelvic floor muscles and may well relieve your symptoms. A GP or specialist may recommend a program of supervised pelvic floor muscle training for at least 16 weeks before you move on to other treatments or surgery.
  • Rubber or silicone rubber device – fitted to the patient which is inserted into the vagina and may be retained for up to several months. Pessaries are a good choice of treatment for women who wish to maintain fertility, are poor surgical candidates, or who may not be able to attend physical therapy.[rx] Pessaries require a provider to fit the device, but most can be removed, cleaned, and replaced by the woman herself. Pessaries should be offered to women considering surgery as a non-surgical alternative.
  • Osteogen Therapy – If you have a mild prolapse and have been through menopause, your doctor may recommend treatment with estrogen to ease some of your symptoms, such as vaginal dryness or discomfort during sex. Oestrogen is available as:
    • a cream you apply to your vagina
    • a tablet you insert into your vagina
    • an estrogen-releasing vaginal ringHormone (estrogen) treatment

SURGICAL TREATMENT

While reconstructive surgery for POP is an option, it must be noted that there is a 30% recurrence rate for women choosing this route. Prolapse repairs can be done transvaginally, abdominally, laparoscopically, and/or robotically (when a scope is placed through the belly button). Ultimately, the purpose of the surgery is to correct the anatomy as well as provide better bowel, bladder, and vaginal function.

  • Cystocele Repair – This surgery repairs a prolapsed bladder or urethra (urethrocele)
  • Hysterectomy – This is complete removal of the uterus.
  • Rectocele Repair – A rectocele repairs the fallen rectum and small bowel (enterocele).
  • Vaginal Vault Suspension – Most commonly a laparoscopic procedure to repair the vaginal wall
  • Vaginal Obliteration – Closure of the vagina
    Fixation or suspension – using your own tissues (uterosacral suspension and sacrospinous fixation)—Also called “native tissue repair,” this is used to treat uterine or prolapse. It is performed through the vagina. The prolapsed part is attached with stitches to a ligament or to a muscle in the pelvis. A procedure to prevent urinary incontinence may be done at the same time.
  • Hysterectomy – This is the complete removal of the uterus and is often performed in a uterine prolapse emergency or when a uterine prolapse is severe. This can be performed through the vagina, or through the abdomen. The vaginal walls are then attached to healthy ligaments as support for the other organs. This surgery prevents any future pregnancies and is often followed by further pelvic organ prolapses as the uterus is no longer there to support the other pelvic organs, so it is important to consider other options before choosing a hysterectomy.
  • —Used to treat prolapse of the anterior (front) wall of the vagina and prolapse of the posterior (back) wall of the vagina. This type of surgery is performed through the vagina. Stitches are used to strengthen the vagina so that it once again supports the bladder or the rectum.
  • —Used to treat vaginal vault prolapse and enterocele. It can be done with an abdominal incision or with laparoscopy. Surgical mesh is attached to the front and back walls of the vagina and then to the sacrum (tail bone). This lifts the vagina back into place.
  • —Used to treat uterine prolapse when a woman does not want a . Surgical mesh is attached to the and then to the sacrum, lifting the uterus back into place.
  • Surgery using vaginally placed mesh—Used to treat all types of prolapse. Can be used in women whose own tissues are not strong enough for native tissue repair. Vaginally placed mesh has a significant risk of severe complications, including mesh erosion, pain, infection, and bladder or bowel injury. This type of surgery should be reserved for women in whom the benefits may justify the risks.
  • Uterine suspension sling / a uterine or vault suspension (without support) – These surgeries all include a repair where the prolapsed organs are stitched back into place. Most procedures use stitches that dissolve over 4-6 months. However, some procedures, such as the uterine suspension sling, use a synthetic mesh lining for additional support. Using a mesh lining is currently only recommended within the context of research, as current evidence into the safety of the procedure is insufficient.
  • Sacrocolpopexy or sacrospinous fixation – Often recommended when your condition is the result of a previous hysterectomy. A sacrospinous fixation involves the top of the vagina being stitched to the sacrospinous ligament, which is near the tail bone, for support. This procedure has a 70-80% success rate.
  • Obliterative surgery – This surgery can be considered an extreme option. The surgeon will narrow or close off the vagina to prevent prolapsed organs from prolapsing outside the vagina. This prevents sex intercourse and vaginal childbirth.
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or

  • Anterior (front) vaginal wall repair – Also known as anterior colporrhaphy, this is a treatment option for women whose bladder has slipped down and is pushing against the front wall of the vagina (a cystocele). It involves strengthening and tightening the connective tissue between the bladder and vagina in order to lift and support the bladder.
  • Posterior (back) vaginal wall repair – Also known as posterior colporrhaphy, this treatment is considered for women who have a rectocele. This is a prolapse that causes the lower part of the bowel (the rectum) to push against the back wall of the vagina. The surgery involves strengthening and tightening the connective tissue between the vagina and rectum in order to lift and support this part of the bowel.
  • Sacrocolpopexy and sacrohysteropexy – These procedures aim to correct prolapse in the middle of the pelvic floor – for instance, if the uterus (womb) has dropped down. Sacrocolpopexy involves attaching the top of the vagina to the sacrum or coccyx (tailbone) using synthetic mesh. In sacrohysteropexy, the cervix is attached instead. The womb doesn’t have to be removed.
  • Sacrospinous fixation – This is an alternative surgical approach to correcting prolapse in the middle of the pelvic floor. In order to lift the vagina back to a higher position, it is attached to ligaments in the pelvis.

Physiotherapy

Physical therapists play a major role in the nonsurgical management of POP. Along with pessary support, pelvic-floor muscle training (PFMT) is cited in highly credible reviews as a main nonsurgical option for women with POP.

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For all the information re retraining, these muscles see the physiotherapy section of Pelvic Floor Dysfunction and Kegel’s Exercises

In a study by Panman et al in 2016, examining the two-year effects of pelvic floor muscle retraining, it was demonstrated that in women aged 55 and greater with symptomatic mild pelvic organ prolapse, pelvic floor muscle retraining results in a significant decrease in pelvic floor symptoms when compared to watchful waiting (note: statistically significant but below the minimal clinically important difference). Additionally, it was found that pelvic floor muscle retraining was more effective in women who experienced increased pelvic floor symptom distress at baseline. Conversely, the same study found no difference in sexual functioning, quality of life, the function of the pelvic floor muscles or degree of prolapse.

A randomized control trial compared the effect of intravaginal vibratory stimulation (IVVS) with intravaginal electrical stimulation (IVES) in women with pelvic floor dysfunctions, unable to voluntarily contract the pelvic floor muscles. The results showed improvement with both techniques, with IVVS superior to IVES in improving pelvic floor muscle strength.

Pelvic floor muscle retraining included: (Kegel exercises diagram in illustration)

  • Explanation and description of the pelvic floor 
  • Instruction regarding how to contract and relax pelvic floor muscles 
    • If unable to perform this task, use feedback through digital palpation 
    • If insufficient control demonstrated, use my feedback or electrical stimulation 
  • General exercise program provided, subsequently modified for individual needs 
  • Taught correct technique for contracting pelvic floor muscles before and during increases in abdominal pressure 
  • Received information about washroom habits and lifestyle [rx]
  • If pelvic floor muscles were overactive, the focus was on relaxation rather than contraction 
  • Face-to-face contact with a physiotherapist as well as encouragement to maintain practice at home 3-5 times per week, 2-3 times per day.

 


How Can I Prevent a Vaginal Prolapse?

If you think you might be at risk of vaginal prolapse, there are steps you can take to prevent one:

  • Kegel exercises – Also known as pelvic floor exercises, you can do them quickly and easily at any point in the day as no one will know you’re doing them. They help to strengthen the pelvic floor muscles. You can make them even more effective by using an electronic toner.
  • Maintain your weight – Making sure you stick to a healthy weight will put less pressure on your pelvic floor muscles, giving you more chance of keeping them strong. The National Institute for Heath and Care Excellence (NICE) recommends keeping your BMI under 30.
  • Avoiding constipation – Eating a high fiber diet of fruits, vegetables, and wholegrain cereals will help your bowels stay regular, as will drinking plenty of water.
  • Avoid straining on the toilet – Straining on the toilet puts unnecessary pressure on the pelvic floor muscles. Using a toilet stool when you pass a bowel movement will help avoid straining as it puts your body in the optimum position for fully emptying your bowels.
  • Lift heavyweights (and children) safely – Lifting correctly will make all the difference to not only your back but your pelvic area too. The National Health Service (NHS) suggest holding the load close to your waist and avoid bending your back.
  • Avoid too much high impact exercise – High impact exercises are great for overall health. But if you’re worried about a prolapse, then gentler, lower impact exercise like swimming may be better for you.
  • Treat that cough – Persistent heavy coughing can cause a weakening in the pelvic floor muscles that may not become apparent straight away. Get medical help for a cough that lasts longer than a week or so.

Even if you’re young, of a healthy weight and have no plans to have a baby any time soon, these steps are still worth taking.

References

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