This page has been written and reviewed by Miss Zainab Khan MD FRCOG, Consultant Urogynaecologist and specialist pelvic floor surgeon. Miss Khan has published peer-reviewed research on pelvic floor surgical outcomes in BJU International, Neurourology and Urodynamics, and the Archives of Gynaecology and Obstetrics. She offers private pelvic organ prolapse consultations at Ashtead Hospital, Spire St Anthony's Hospital (Sutton), and Parkside Hospital (Wimbledon). To book a consultation: +44 (0)7859 896 297 or epsomurogynaecology@gmail.com.
Miss Khan assesses pelvic organ prolapse using the validated POP-Q (Pelvic Organ Prolapse Quantification) system, which provides a standardised, objective measurement of prolapse stage. Assessment includes a detailed clinical history, pelvic examination in the dorsal and standing positions, and assessment of associated urinary, bowel, and sexual symptoms.
Investigations that may be arranged at the time of consultation or subsequently include:
1) Pelvic ultrasound — to assess the uterus, ovaries, and bladder
2) Urodynamic studies — where concurrent urinary incontinence or voiding difficulty is present
3) MRI of the pelvic floor — in complex or recurrent prolapse cases
4) Flexible cystoscopy — where bladder symptoms require direct visualisation
Pelvic organ prolapse remains a prevalent condition, especially among women over the age of 50.
The overall prevalence of pelvic organ prolapse is estimated to be in the range of 30-50%. Approximately one in two women over the age of 50 is affected by this condition.
Pelvic organ prolapse involves the descent of pelvic organs, such as the urinary bladder, uterus, rectum, or the top of the vagina, from their normal position through the genital hiatus. This descent can lead to various symptoms and may impact a woman's quality of life.
Surgery for prolapse repair is a common intervention, with approximately 11-12% of women requiring such surgery during their lifetime.
Surgical procedures aim to restore the normal position of the pelvic organs and alleviate symptoms associated with prolapse.
Pelvic organ prolapse is primarily attributed to the weakening of the pelvic floor. Several factors contribute to this weakening, and understanding these causes is crucial for both prevention and treatment.
As individuals age, the pelvic floor undergoes changes. The loss of connective tissue and hormonal changes associated with menopause contribute to the weakening of the pelvic floor muscles.
Childbirth is a significant factor in pelvic organ prolapse. Prolonged and difficult labour, as well as delivering large babies, can cause trauma to the pelvic floor muscles. This trauma may lead to stretching or damage, resulting in pelvic organ descent over time.
Excess weight, particularly obesity, puts sustained pressure on the pelvic floor. The increased load on these muscles can lead to pelvic floor weakening and contribute to the development of pelvic organ prolapse.
Persistent and chronic coughing can create continuous stress on the pelvic floor muscles. Conditions such as chronic obstructive pulmonary disease (COPD) or habitual smoking may lead to repeated coughing, contributing to pelvic floor weakness.
Regular and prolonged straining due to constipation can negatively impact the pelvic floor. The increased intra-abdominal pressure during straining may weaken the supporting structures of the pelvic organs.
Regular and heavy lifting, especially without proper techniques, can strain the pelvic floor muscles. Jobs or activities that involve consistent heavy lifting may contribute to pelvic organ prolapse.
Certain connective tissue disorders, such as hypermobility syndrome, Marfan syndrome, and Ehlers-Danlos syndrome, are associated with general laxity in connective tissues, including those in the pelvic floor. This inherent weakness increases the risk of pelvic organ prolapse.
Pelvic organ prolapse can range from being asymptomatic to causing a variety of symptoms. These symptoms often depend on the specific pelvic organs involved and the severity of the prolapse. Common symptoms include:
1) Dragging Sensation/Pressure in the Vagina:
Women with pelvic organ prolapse may experience a sensation of heaviness, pressure, or dragging in the vaginal area. This can be particularly pronounced during activities such as standing or walking.
2) Vaginal Bulge or Lump:
A noticeable bulge or lump in the vaginal area is a common symptom of pelvic organ prolapse. This may be felt or seen and is often more prominent during activities that increase intra-abdominal pressure, such as coughing or lifting.
3) Vaginal Discomfort:
Discomfort, aching, or a feeling of fullness in the vagina can be associated with pelvic organ prolapse. This discomfort may vary in intensity and may be exacerbated by certain activities.
4) Urinary Symptoms:
Prolapse can affect the bladder, leading to urinary symptoms. Common urinary symptoms include:
a) Frequency of Passing Urine: Increased urge to urinate or having to go to the bathroom more frequently.
b) Difficulty Emptying the Bladder: Incomplete emptying of the bladder, leading to a sense of retained urine.
c) Urinary Incontinence: Leakage of urine, especially during activities that increase intra-abdominal pressure.
5) Bowel Symptoms:
Prolapse involving the rectum can cause bowel-related symptoms, such as:
a) Difficulty with Bowel Movements: Straining during bowel movements or a feeling of incomplete emptying.
b) Constipation: Difficulty passing stools, often accompanied by a sensation of pressure.
6) Pain During Intercourse:
Some women with pelvic organ prolapse may experience pain or discomfort during sexual intercourse. This can be related to the changes in pelvic anatomy and the pressure on surrounding tissues.
7) Psychological and Emotional Distress:
Pelvic organ prolapse can impact a woman's quality of life and emotional well-being. It may lead to psychological distress, including feelings of embarrassment, self-consciousness, or a negative impact on body image and sexual function.
Pelvic organ prolapse can involve different pelvic organs, resulting in various types of prolapse.
Common types include:
1) Cystocoele (Anterior Prolapse):
Descent of the bladder into the vaginal space.
2) Rectocele (Posterior Prolapse):
Descent of the rectum into the vaginal space.
3) Uterine Prolapse:
Descent of the uterus into the vaginal space.
4) Enterocele:
Herniation of the small intestine into the vaginal space.
5) Vaginal Vault Prolapse:
Descent of the upper part of the vagina.
Non-surgical options can be equally effective in managing pelvic organ prolapse. Some of the options are listed below.
PFMT, also known as Kegel exercises, focuses on strengthening the muscles that support the pelvic organs. This non-surgical approach is considered effective, particularly for mild grades of prolapse. It involves individualised training to ensure that each patient understands how to contract and exercise the specific muscles involved.
Pessaries are devices made of rubber (latex) or silicone that are inserted into the vagina. These devices are designed to provide support to the vaginal walls and pelvic organs. They are most suitable for women with minor stages of prolapse, especially those who have not completed their family or choose to avoid surgical repair due to personal preferences or the presence of medical co-morbidities.
Pessaries offer a conservative and non-invasive option for managing pelvic organ prolapse. They are left in place to provide continuous support and can be an effective solution for relieving symptoms associated with prolapse.
1) Anterior and Posterior Colporrhaphy:
These are traditional surgical procedures addressing prolapse of the anterior (bladder) and posterior (rectum) vaginal walls. Surgeons repair and strengthen weakened tissues to restore normal support.
2) Uterine Suspension Procedures:
For uterine prolapse, procedures such as sacrospinous ligament suspension or uterosacral ligament suspension may be performed. These techniques involve attaching the uterus to nearby ligaments, providing additional support.
3) Vaginal Mesh Procedures:
Vaginal mesh procedures involve using synthetic or biological mesh to support the pelvic organs. However, the use of mesh has been a topic of controversy due to concerns about complications and safety. In some regions, regulatory agencies have restricted or banned the use of vaginal mesh for pelvic organ prolapse.
4) Sacrocolpopexy:
Sacrocolpopexy is a more extensive procedure where a mesh is used to suspend the vaginal vault or cervix to the sacrum (tailbone). It provides strong and durable support and is often recommended for recurrent or more severe prolapse.
5) Hysterectomy:
In cases where the uterus is contributing to prolapse, a hysterectomy may be performed, either as part of a prolapse repair surgery or as a separate procedure.
6) Laparoscopic and Robotic-Assisted Surgeries:
Minimally invasive approaches, such as laparoscopic and robotic-assisted surgeries, are becoming more common for pelvic organ prolapse repair. These techniques often result in shorter recovery times and less postoperative pain.
7) Vaginal Obliterative Procedures:
In cases where fertility is no longer a concern, some women may opt for vaginal obliterative procedures, such as colpocleisis. This involves closing the vaginal canal, providing support and alleviating symptoms.
1) What surgical options are available for pelvic organ prolapse?
There are several surgical options, including anterior and posterior colporrhaphy, uterine suspension procedures, vaginal mesh procedures (with considerations), sacrocolpopexy, hysterectomy, laparoscopic and robotic-assisted surgeries, perineorrhaphy, and vaginal obliterative procedures like colpocleisis.
2) How do I know which surgery is right for me?
The choice of surgery depends on factors such as the type and severity of prolapse, the specific pelvic organs involved, overall health, and individual preferences. Your healthcare provider will assess your condition and discuss the most suitable options for your situation.
3) Are these surgeries performed using minimally invasive techniques?
Yes, many pelvic organ prolapse surgeries can be performed using minimally invasive approaches, such as laparoscopic or robotic-assisted surgeries. These methods often result in shorter recovery times and less postoperative pain.
4) What are the potential risks and complications of these procedures?
Risks and complications can vary depending on the specific surgery. Common considerations include infection, bleeding, injury to nearby structures, and in some cases, recurrence of prolapse. Your surgeon will discuss potential risks and benefits during the preoperative consultation.
5) How long is the recovery period after pelvic organ prolapse surgery?
Recovery times can vary, but minimally invasive procedures often lead to shorter recovery periods compared to traditional open surgeries. It's essential to follow postoperative care instructions provided by your healthcare team for optimal recovery.
6) Will I still be able to have children after undergoing pelvic organ prolapse surgery?
The impact on fertility depends on the specific surgery. Procedures like sacrocolpopexy and vaginal obliterative procedures may impact fertility. If fertility is a concern, it's crucial to discuss this with your healthcare provider before choosing a surgical option.
7) How likely is it that the prolapse will recur after surgery?
Recurrence rates can vary based on factors like the type of surgery, the severity of the initial prolapse, and individual health. Your healthcare provider will discuss the likelihood of recurrence and steps to minimise such risks.
8) Will the surgery impact my sexual function?
The impact on sexual function can vary depending on the type of surgery and individual factors. Your healthcare provider will discuss potential effects on sexual function during preoperative consultations.