Defined as the descent or herniation of pelvic organs from their normal position or attachment sites, pelvic organ prolapse is a condition which involves the uterus, vaginal apex, anterior vaginal wall, or posterior vaginal wall among other pelvic structures.

Many women, particularly older women, experience pelvic organ prolapse at some point in their lives, but the condition isn’t always severe enough to cause symptoms. It is estimated that 50% of all women have mild prolapse and 10% have moderate to severe prolapse. However, many women are reluctant to seek help from their doctors because of embarrassment, or they are unaware that the condition can cause problems and that treatment is readily available.

“Pelvic organ prolapse happens when the group of muscles and tissues that normally support the pelvic organs, called the pelvic floor, becomes weakened and are unable to hold the organs in place firmly. A number of factors can weaken your pelvic floor and increase your chance of developing pelvic organ prolapse. They include pregnancy and childbirth – especially if you had a long, difficult birth, or if you gave birth to a large baby or multiple babies; getting older and going through the menopause; being overweight or obese; having long-term constipation or a long-term condition that causes you to cough and strain; having a hysterectomy and occupations entailing heavy lifting,” explained Dr Jazlan Joosoph, obstetrician and gynaecologist at Raffles Hospital.

He highlighted further that some of the symptoms that patients experience may include a feeling of pressure or fullness in the pelvic area, low backache, painful intercourse, a feeling that something is falling out of the vagina, urinary problems such as leaking of urine or a chronic urge to urinate, constipation, and spotting or bleeding from the vagina.

Types of prolapses

There are a number of different types of prolapses, noted Dr Jazlan. The prolapse of a pelvic organ may occur independently or along with other pelvic organ prolapses. Prolapses are graded according to their severity; first, second or third degree prolapse.

The five main types of prolapses are:

1. Cystocele Prolapse

Anterior prolapse, also known as a cystocele, occurs when the supportive tissue between a woman’s bladder and vaginal wall weakens and stretches, allowing the bladder to bulge into the vagina. Anterior prolapse is also called a prolapsed bladder. Straining the muscles that support your pelvic organs may lead to anterior prolapse. Such straining occurs during vaginal childbirth or with chronic constipation, violent coughing or heavy lifting. Anterior prolapse also tends to cause problems after menopause, when estrogen levels decrease.

2. Enterocele Prolapse

This occurs when the back and front vaginal walls separate, allowing the small bowel to press against the vagina. This is more common after women have undergone a hysterectomy.

3. Rectocele Prolapse

This occurs when the back of the vagina weakens and the rectum prolapses into the vagina. This condition may cause a bulge which is very noticeable and uncomfortable for the sufferer. A posterior vaginal wall prolapse occurs when the thin wall of tissue that separates the rectum from the vagina weakens, allowing the vaginal wall to bulge.

Childbirth and other processes that put pressure on pelvic tissues can lead to posterior vaginal prolapse. A small prolapse may cause no signs or symptoms. If a posterior vaginal prolapse is large, it may create a noticeable bulge of tissue through the vaginal opening. This bulge may be uncomfortable, but is rarely painful. If needed, self-care measures and other nonsurgical options are often effective. Severe posterior vaginal prolapse might require surgical repair.

4. Uterine Prolapse

This occurs when the ligaments supporting the top of the vagina weaken, in turn causing other ligaments elsewhere to weaken, allowing the uterus to prolapse. This can have differing degrees of severity in terms of how low the uterus drops into the vagina. Uterine prolapse can occur in women of any age. But it often affects postmenopausal women who have had one or more vaginal deliveries. Mild uterine prolapse usually does not require treatment.

5. Vaginal Vault Prolapse

This type of prolapse may occur following a hysterectomy (surgical removal of the uterus). Because the ligaments surrounding the uterus provides support for the top of the vagina, this condition is especially common after a hysterectomy. In vaginal vault prolapse, the top of the vagina gradually falls toward the vaginal opening. This may cause the walls of the vagina to weaken as well. Eventually, the top of the vagina may protrude out of the body through the vaginal opening, ultimately turning the vagina inside out.

The five main types of prolapses
The five main types of prolapses

Diagnosis and treatment

Pelvic organ prolapse is typically diagnosed by a simple pelvic examination as part of a complete physical examination. Your doctor may use a speculum to examine the different parts of the vagina to determine which part of the vagina is prolapsing and to what extent; or a pelvic organ prolapse quantification known as a POP-Q, measurement system to assess severity of prolapse and track changes.

In addition, other exams or studies may help your doctor assess symptoms associated with prolapse such as urodynamics, cystoscopy, defecography, pelvic ultrasound, pelvic floor MRI and a CT scan of abdomen and pelvis.

The most appropriate treatment will depend upon the type of prolapse, the severity, the age of the woman, her state of health and her plans regarding childbearing, said Dr Jazlan.

Although a prolapse isn’t classified as life-threatening, it can cause pain and discomfort. Symptoms can usually be improved with pelvic floor exercises and lifestyle changes, but sometimes medical treatment is needed.

“There are a range of treatment options available for prolapse, and this may comprise non-surgical management options such as pessaries which are devices that provide structural support when placed in the vagina; behavioural modifications such as by performing targeted exercises that strengthen the pelvic floor muscles; and surgical options such as prolapse repairs which 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 to provide better bowel, bladder, and vaginal functions. In short, to improve quality of life.” concluded Dr Jazlan. MIMS