Pelvic Organ Prolapse (POP)


Watch a video animation about Pelvic Organ Prolapse (POP).

Symptoms

  • Bulge in the vaginal opening
  • Perception of something “falling out”
  • Pelvic pressure, lower back pain
  • Urinary stress incontinence
  • Difficulty emptying bladder (urinary retention)
  • Pain with sex
  • Difficult evacuation of the rectum, splinting
  • Pain that increases during long periods of standing
  • Recurrent urinary tract infections

Contributors to Prolapse

  1. Childbirth
  2. Time
  3. Straining
    • Frequent heavy lifting
    • Long term coughing (smoking, severe allergies)
    • Long term constipation
  4. Excess Weight/Obesity
  5. Menopause/Lack of Estrogen in the Vaginal
  6. Sometimes prior Hysterectomy

Prolapse Severity (Grading System)

  • 1st Degree: Mild 
— Only a small portion of the organ or wall droops into the vagina. This amount is almost never perceived.
  • 2nd Degree: Moderate
 — The prolapsing part is halfway down the vaginal
  • 3rd Degree: Severe — 
The prolapse is within 1 cm inside to 1 cm beyond the entrance of the vagina. This is the most common amount of prolapse for a woman to first notice her prolapse.
  • 4th Degree: Extreme/Complete — 
The prolapsing organ or wall protrudes more than 1 cm beyond the vaginal opening.

The vagina and other pelvic organs are attached to the pelvis by connective tissue. This connective tissue help form walls around the vagina which helps to ensure there is normal urinary and bowel voiding. This tissue can fail as the pelvic muscles become weak and this allows for the bladder or rectum to bulge into the vaginal wall and creating a prolapse.

Options for treating prolapse:

  • Pessary Placement Trial — the non surgical option

    Vaginal Pessaries

    Watch a video.

    Pessaries are rubber devices, similar to contraceptive diaphragms, which are used to either lift the bladder or uterus. One design treats urinary incontinence. They are a non-surgical treatment option for prolapse or urinary incontinence. More than half of the women who are fitted with a pessary will continue to use it successfully on a long-term basis.

    Typical pessary users are women who:

    • Would like to avoid surgery
    • Have mild symptoms and want or need to avoid surgery for the moment
    • Have health problems that make the risks of surgery too great
    • Need to delay surgery and are uncomfortable from their incontinence or prolapse
    • Need vaginal support and incontinence help during exercise

    Learn more about Vaginal Pessaries.

  • Kegel’s – this group of pelvic muscles exercises enhances any prolapse treatment and strengthens the muscles to help support the fascia

    Kegel Exercises

    Kegal Instructions / PDF format

    Kegel exercises are frequently discussed in childbirth classes or written about in magazine articles. Unfortunately, because pelvic muscles are hidden from view, it is difficult to know if you are doing them correctly. Some tips that can help you find the right muscles include:

    • Try to stop your urinary stream. If you succeed then you have identified the right muscles to exercise. This is a learning tool. DO NOT STOP YOUR URINE FREQUENTLY as there is concern that this may create problems with bladder emptying.
    • Imagine you are going to pass gas, then, squeeze the muscles that would prevent that gas from escaping from your rectum. Exercising the muscles around the rectum will also strengthen those around the vagina and under the bladder.
    • Use a hand mirror to look at your vaginal opening and the perineum (the muscle wall between the vagina and rectum). You should see the perineum lift up when you contract your pelvic muscles.
    • While lying or sitting, place one finger inside your vagina. Squeeze as if you were trying to stop urine from coming out. You should feel your finger lifted and squeezed if you are correctly contracting your pelvic muscles.
    • Do not hold your breath while exercising.
    • Remember not to tighten your stomach and back muscles or squeeze your legs together. These should be relaxed as you isolate and contract just your pelvic muscles.
    • You don’t have to do this alone! If you are just not sure that you are doing the exercises correctly ask your doctor or their nurse at a pelvic exam to check if your squeeze is working the right muscles.
    • GET A PERSONAL TRAINER FOR YOUR PELVIC FLOOR! Some physical therapists have special expertise in Pelvic Floor Muscle Rehab. They assess pelvic, back and abdominal strength, your gait and your posture. These all effect how your pelvic muscles work. Once you learn the right tips from your trainer, you an continue having more success at home!
    • Recommended Pelvic Floor Routine
    • Start by pulling in and holding a pelvic muscle squeeze for 3 seconds then relax for an equal amount of time (3seconds).
    • Do this for 10 repetitions three times a day
    • Increase your contraction hold by 1 second each week until you are contracting for a 10 second squeeze.
    • Remember to rest and breathe between contractions.
    • When you start, do the exercises while lying down. As you get stronger; do an exercise set sitting and standing.

    Information adapted from the American Urogynecologic Society

  • Anterior Colporrhaphy – cycsocele repair

    This operation uses strong stitches to recreate support of the anterior vaginal wall under the bladder. It supports the bladder like a shelf. It essentially corrects a hernia or ballooning of the weak wall. The stitches melt after our own tissue has healed 6 weeks later. This operation is done exclusively through the vagina and generally patients stay over 1 night at the hospital or return home the same day. There is generally very little discomfort. It is most important to limit walking, lifting and exercise the first 6 weeks so the new support can heal strong for long-term success.

  • Posterior Colporrhaphy – rectocele repair

    This operation uses strong stitches to support the posterior vaginal wall between the vagina & lower colon/rectum. The weak wall bridges and this operation corrects the bulging hernia to give the wall strength. Many women have a sense of evacuating their stool more completely after this operation, relief of pelvic pressure or low back pain, and resolution of visible or palpable bulge at the vaginal entrance. This operation is done through the vagina and often involves an overnight stay. There is generally very little discomfort. It is most important to limit walking, lifting and exercise the first 6 weeks so the new support can heal strong for long-term success.

  • Enterocele Repair

    This operation uses permanent stitches to close off the weak area where intestines slip down through and bulge in the vagina. It is most important to limit walking, lifting and exercise the first 6 weeks so the new support can heal strong for long-term success.

  • Uterosacral Ligament Copopexy / Uterine Colpopexy (uterine prolapse repair)

    This operation is performed robotically and helps tighten stretched out support ligaments of the uterus and vagina. It is excellent for when mild to moderate prolapse occurs to help correct uterine prolapse and avoid needing hysterectomy or mesh. It is most important to limit walking, lifting and exercise the first 6 weeks so the new support can heal strong for long-term success.

  • Sacrospinous Ligament Fixation (Vaginal or uterine prolapse repair)

    This operation is a vaginal operation that supports the top of the vagina to deep pelvic ligaments with permanent stitches. It is most important to limit walking, lifting and exercise the first 6 weeks so the new support can heal strong for long-term success.

  • Robotic Sacrocolpopexy (vaginal, uterine or severe cystocele repair)

    This operation is currently considered the Gold Standard treatment for recurrent cystocele or severe global prolapse. This procedure highlights how robotic instruments can really help surgeons perform complex surgery laporascopically. It uses permanent strong stitches and abdominal mesh to support the top of the vagina or uterus to strong ligaments on the front of the sacrum or tailbone. This generally offers the most long term support for women who have severe recurrent prolapse, when done robotically, it offers support with very little discomfort. It is most important to limit walking, lifting and exercise the first 6 weeks so the new support can heal strong for long-term success.

  • Hysterectomy/Supracervical Hysterectomy (uterine prolapse treatment)

    This operation removes the uterus or top portion of the uterus (leaving the cervix in place to connect support stitches too) when support can be achieved better without the uterus or when there are other reasons the uterus needs to be removed. This can be done vaginally, robotically, laparoscopic or abdominally – depending on the specific prolapse situation for the patient. When used to treat prolapse, generally other procedures are done concurrent with the hysterectomy. It is most important to limit walking, lifting and exercise the first 6 weeks so the new support can heal strong for long-term success.


Types of Prolapse

Cystocele occurs when the bladder falls or descends from its normal position. The most common symptom associated with cystocele is pelvic pressure in completely emptying the bladder. This can be associated with bladder infections. Large cystoceles can cause the bladder to overfill and allow small amounts of urine to leak. Leakage is most common during activity such as exercising or bouts of coughing/sneezing. A Cystocele is the most common prolapse to occur, and the most common to recur late in life.

Urethrocele usually occurs in conjunction with a cystocele. Both of these conditions result in, among other things, involuntary loss of urine, particularly when there is increased pressure in the abdomen, caused by walking, jumping, coughing, sneezing, laughing, or sudden movements.

Rectocele happens when the rectal wall bulges into or out of the vagina. Rectocele usually occur as a result of injuries sustained during childbirth. With a weakened or bulging rectum, bowel movements become more difficult. Often women need to press in the vagina to help complete the bowel movement. This is known as "splinting".

Enterocele is the bulging of small intestines down into the vagina. This often occurs along with a rectocele.

Vaginal vault prolapse occurs years after hysterectomy. It is when the top of the vaginal falls down, creating a bulge and pressure at the vaginal entrance.

Uterine prolapse occurs when the uterus falls or is displaced from its normal position. There are varying degrees of severity depending on the descent. This produces a general felling of heaviness and fullness, or a sense that the uterus is falling out.