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Pelvic Organ Prolapse

Pelvic organ prolapse occurs when the normal support of the vagina is lost resulting in “sagging” or dropping of the bladder, urethra, cervix and rectum. As the prolapse of the vagina and uterus progresses, women can feel bulging tissue protruding through the opening of the vagina.

Causes and Risk Factors
By studying large numbers of women with and without prolapse, researchers have been able to identify certain risk factors that are believed to predispose, cause, promote or worsen prolapse. The strength of our bones, muscles and connective tissue are influenced by our genes and our race. Some women are born with weaker tissues and are therefore at risk to develop prolapse. Caucasian women are more likely than African American women to develop prolapse. Loss of pelvic support can occur when any part of the pelvic floor is injured during vaginal delivery, surgery, pelvic radiation or back and pelvic fractures during falls or motor vehicle accidents. Hysterectomy and other procedures done to treat prolapse are also associated with future development of prolapse. Some other conditions that promote prolapse include: constipation and chronic straining, smoking, chronic coughing, and heavy lifting. Obesity like smoking is one of the few modifiable risk factors. Women who are obese have a 40-75% increased risk of prolapse. Aging, menopause, debilitating nerve and muscle diseases contribute to the deterioration of pelvic floor strength and the development of prolapse.

Incidence
We do not know exactly how common pelvic organ prolapse is because most of the research has been on women who come seeking health care. Nearly half of all women between the ages of 50 and 79 have some form of prolapse. The lifetime risk that a woman will have surgery for the correction of prolapse or urinary incontinence in the United States is about 11%. We also know that as many as one third of these women will undergo repeat corrective surgery for these conditions. Approximately 200,000 procedures for correction of pelvic prolapse are performed each year in the United States. We believe that is just the tip of the iceberg as many women mange their prolapse without surgery.

Symptoms
Some loss of support is a very common finding on physical exam in women, many of whom do not have bothersome symptoms. Those who are uncomfortable often describe the very first signs as subtle - such as an inability to keep a tampon inside the vagina, dampness in underwear, or discomfort due to dryness during intercourse. As the prolapse gets worse, some women complain of:

  • A bulging, pressure or heavy sensation in the vagina that worsens by the end of the day or during bowel movements
  • The feeling that they are “sitting on a ball”
  • Needing to push stool out of the rectum by placing their fingers into the vagina during bowel movement
  • Difficulty starting to urinate, a weak or spraying stream of urine
  • Urinary frequency or the sensation that they are not emptying their bladder well
  • The need to lift up the bulging vagina or uterus to start urination
  • Urine leakage with intercourse

Treatment
After being diagnosed with pelvic organ prolapse of any type, a woman generally has three options:

  • No treatment – watch how things go
  • Wear a pessary for support
  • Surgery to correct the prolapse

Prolapse generally does not have to be treated if it is not causing bothersome symptoms. The goals of treatment should include improvement of your quality of life. So if the prolapse is not causing discomfort or interfering with the things that a woman enjoys doing, it may not require treatment. One exception to this rule occurs with severe prolapse, which can block the flow of urine and cause recurrent urinary tract infections or even kidney damage. This is an infrequent situation which can be checked for at the time of a physical exam. Since the symptoms associated with prolapse often progress very gradually, the adaptive changes in physical or social activities may go unnoticed until they are extreme.

The decision to seek treatment for prolapse is often based on how bothersome the symptoms are from the prolapse. Symptoms that may lead a woman to seek treatment include:

  • Discomfort (usually pressure, fullness, or pain)
  • Bleeding from the exposed skin that rubs on pads or underwear
  • Urinary symptoms of leakage, difficulty starting the stream of urine, frequent urinary tract infections
  • Difficult bowel movements – the need to strain or push on the vagina to have a bowel movement

Work with your physician or urogynecologist to develop the most appropriate treatment plan that takes into consideration your overall health, lifestyle and personal goals. A Urogynecologist can recommend a variety of therapies to relieve symptoms of prolapse, urinary or fecal incontinence, or other pelvic floor disorder symptoms. He or she may advise conservative (non-surgical) or surgical therapy depending on your preference, the severity of your symptoms and your general health. Conservative options include medications, pelvic exercises, behavioral and/or dietary modifications and vaginal support devices (also called pessaries). Biofeedback and Electric Stimulation [hyperlink to glossary] are two newer treatment modalities that your Urogynecologist may recommend. Safe and effective surgical procedures for correction of incontinence and prolapse are also available.


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