Pelvic Organ Prolapse

‍Introduction

Pelvic organ prolapse (‘prolapse’) describes a lump or bulge in the walls of the vagina. This is caused by a pelvic organ (bladder, uterus, or bowel) moving down in the pelvis. As these organs move down, they push on the soft skin of the vaginal walls, causing them to stretch and curve out into the vaginal canal. This causes symptoms of ‘something coming down/ falling out’ or a feeling of heavy pressure in the vagina. This bulge may be felt inside the vagina or seen on the outside the vagina. Women may describe it as a pink coloured lump, which can be a similar size to an egg or small orange.

A prolapse can be mild and asymptomatic, or it can be severe, causing symptoms and affecting your daily life. Prolapses are extremely common; affecting 1 in 3 women.

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What is a Prolapse?

The picture below shows a side view of a normal female pelvis (without any prolapse). As well as showing the three pelvic organs in their original positions. It also shows the pelvic floor muscles sitting underneath them.

The pelvic floor muscles and ligaments (strong fibrous connective tissues) help support the pelvic organs and keep them in place.

When the muscles are weak, and the internal ligaments are overstretched, the support to the pelvic organs is compromised. These organs can move downwards resulting in a prolapse.

The terms used to describe a prolapse are often confusing. You may have been told you have a vaginal prolapse, or a pelvic prolapse. These are generic umbrella terms that describe a prolapse of any one of the three pelvic organs. Alternatively, you may have been told that you have a bladder prolapse; also known as an anterior wall prolapse, an anterior prolapse, a cystocele, or a urethrocele. You can also have a bowel prolapse; known as a posterior wall prolapse, a posterior prolapse, or a rectocele. Physiotherapy treatment for a prolapse is the same, regardless of the organ that has shifted position.

Common Types of Prolapse

Anterior Wall Prolapse / Cystocele / Bladder Prolapse

Normal Pelvis

Anterior Wall (Bladder) Prolapse

In these pictures you can see that the bladder has shifted down in position. Part of the bladder is putting pressure on the soft skin of the vaginal wall, creating a bulge just inside the entrance to the vagina. This picture shows a mild to moderate prolapse. As a prolapse becomes more severe, the bulge becomes larger and moves further down the vagina.

Posterior Wall Prolapse / Rectocele / Bowel Prolapse

Normal Pelvis

Posterior Wall (Bowel) Prolapse

These pictures show how the bowel has shifted position. The bowel exerts pressure onto the vaginal skin, creating a bulge inside the vagina. The bowel can also push down on the skin between the vagina and the anus (the perineum). This creates a sense of “heaviness” or “pressure” which can either be felt inside the vagina, or the perineum, depending on the individual’s anatomy.

Uterine Prolapse

Normal Pelvis

Uterine Prolapse

These pictures show how the uterus has shifted downwards. The picture shows a moderate uterine prolapse. When severe, the uterus moves further down the vaginal canal. The uterus is in the middle of the pelvis and firmly attached to the bladder and bowel on each side. Because of this, the uterus can pull on the bladder and bowel as it descends making it possible to get a degree of bladder and bowel prolapse with a uterine prolapse.

After a hysterectomy, women can still have a prolapse in the middle of the pelvis. This is called a vaginal vault prolapse. Although the uterus has been removed, the top of the vagina can still move down and prolapse for a “vault prolapse”.

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Causes of Prolapse

Pregnancy and childbirth – this is the most common factor, especially with a difficult vaginal delivery, although women who have had a caesarean section can also be affected.
Obesity/ being overweight – body weight is held up by the pelvic ligaments and pelvic floor. Any extra weight in this area puts a stretch and strain on these supporting structures, weakening them.
Heavy lifting – when you lift anything heavy, the weight is transferred inside the body. This internal strain weakens the structures supporting the pelvic organs.
Having a family history of prolapse – this may be due to inheriting a more flexible type of collagen which is not as sturdy and supportive as other types.
Menopausal changes – menopause causes a decrease in oestrogen in the blood stream. The tissues in the pelvis need the oestrogen to stay healthy. When oestrogen levels fall then the tissues are no longer as strong and healthy.
Constipation – pushing and straining on the toilet cause a direct downward pressure onto the pelvic organs. This causes a lengthening and weakening of the support structures.
Chronic cough – coughing causes the diaphragm (the structure under your lungs) to move downwards suddenly and forcefully. This downward pressure of the diaphragm causes a downward push onto the pelvic organs. Over time, with a chronic cough, this repeated pressure causes a strain on supporting structures.
Previous pelvic surgery – if you have already had an operation to repair a prolapse (or have had a hysterectomy) then your risk of developing a prolapse in the future is increased.
Aging – over time, pelvic ligaments lengthen and stretch. This is part of a gradual aging process that affects the whole body. Over time, many structures in the body may not be as tight as they originally were. Gravity causes a constant downward pressure on our bodies. As time goes on, the structures inside our pelvis move downwards in response to gravity over time.

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How Can I Help Myself?

Pelvic organ prolapse is not a life threatening condition, and many women do not know that they have a prolapse until it is noticed at a routine check-up or smear test. Many women have very minor bladder or bowel involvement.

You have several options as to what to do next:

You can do nothing and wait and see how your symptoms change over time.
Manage the symptoms yourself by adopting lifestyle changes and improving your pelvic floor muscle support. This is generally the preferred option as research suggests that this can control your symptoms and prevent your prolapse from worsening over time. Physiotherapy focuses on this stage. Please see below for more details. You may want to try our self-management app getUBetter. Our new Pelvic Health Module is designed to give you the knowledge and confidence to manage your symptoms and live a healthier life.
Speak to your GP about a vaginal pessary which supports the vaginal walls. A pessary is a device that a gynaecologist, GP, or specialist nurse inserts into the vagina. It stays in place and is changed approximately every 6 months. This is often, but not always, accompanied by vaginal oestrogen.
Speak to a gynaecologist about surgery. Many gynaecologists may prefer you to have tried all the above options before surgery is considered.

Information on pessaries and surgery is on the “help with your diagnosed condition” section. There are links to patient information leaflets from other organisations.

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Lifestyle Changes

All recommended lifestyle changes have one goal: to reduce the downward pressures through your pelvis.

If you are overweight then consider losing weight. Extra weight causes a continuous pressure on any prolapse present.

Consider reducing the amount of heavy lifting you do. Heavy lifting increases pressure in your abdomen which pushes down on your pelvic floor. If you have to lift, then tighten your pelvic floor muscles before and during the lift, and remember to breathe.

If you spend long periods of time on your feet, and find that your prolapse symptoms are worse at the end of the day, consider adding regular seated breaks to your day. This will give your pelvic support structures a chance to recover.

High-impact exercise, such as weight-lifting and very vigorous gym activities can overload your pelvic support structures. If your exercise causes symptoms then change them for a less demanding type of exercise (e.g. yoga, swimming, pilates). If you are currently exercising at a high level and have no prolapse symptoms then you are safe to continue but monitor how your body feels. If you have any increase in symptoms then it is wiser to change or modify your activity type sooner rather than later. Make strengthening the pelvic floor muscles an essential part of your exercise regime.

Persistent coughing or sneezing increases the downward pressure on your pelvis, puts pressure on the pelvic floor muscles, weakening them over time. In addition, nicotine is a bladder irritant and is strongly associated with bladder symptoms (especially urinating very frequently, or experiencing a sudden desperate urge to urinate). If your cough is due to smoking then consider stopping. If your chronic coughing or sneezing is due to a medical condition then consider reviewing your treatment and medication with your GP.

During the menopause, the level of oestrogen in your blood decreases. Decreased oestrogen is associated with weakness of the pelvic floor muscles, and supporting tissues. This can lead to worsening symptoms. Many women find that HRT is useful. If, after discussing with your GP, you find that HRT tablets/ patches/ gel are not suitable for you, then a very low dose of oestrogen can also be taken instead. This is in the form of a tablet (or cream) that is inserted into the vagina on a regular basis. Taken like this, it can directly help the tissues that need it.

Avoid straining to open your bowels, due to constipation as this puts pressure on the prolapse and worsens your symptoms. If your stool type is hard then consider increasing your fluid intake and ensuring a healthy diet high in fibre. It is important to stay hydrated to minimise constipation further or discuss this with your GP if you are still struggling. In the meantime, you may find it beneficial to alter your position on the toilet seat.

Toilet positions - Bladder & Bowel Community

Stick your bottom out when you go to sit down on the toilet. Sit fully on the toilet (do not ‘hover’). Try to relax as this helps the anus open more fully.
Place your feet apart and raised-up on a stool/ support. Experiment with how far apart you need to have your feet. Most people prefer to have them quite far apart, depending on their height and build. To achieve this, it might be useful to take your underwear down past your knees – or even take them off entirely.
Bend forwards and rest your arms comfortably on your legs. Try not to slump entirely, keep your head facing forward rather than down. This maintains a gentle curve in the base of your spine.
Keep your tummy and abdominal muscles relaxed. Avoid holding your breath and work on breathing naturally.
Relax your mouth and jaw muscles.
A slight bearing down will help the stool to open the back passage for the bowel movement. Many women may find it helpful to use their fingers to apply pressure to empty the bowels more fully and effectively. Some women support the perineum (the area of skin between the anus and the vagina). Other women find it more useful to apply pressure just inside the vagina, pushing towards the back passage. Either one of these areas can work well, but some women find one position more effective than the other. Putting a finger inside the rectum to hook out a stool is not generally recommended.

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Pelvic Floor Exercises

The pelvic floor muscles are at the base of your pelvis and are important for supporting your pelvic organs, bladder and bowel continence, and sexual enjoyment.

To exercise these muscles, imagine that you are trying to stop yourself from passing wind at the same time as trying to stop passing urine. You should feel a squeeze and a lift inside the vagina. Do not hold your breath. Do not clench your buttocks or hold your breath. If you find this difficult or feel a vaginal bulging when you try to tighten your pelvic floor muscles – get help from a specialist physiotherapist.

Long Squeezes

Tighten your pelvic floor, hold, and then relax fully. How long can you hold the squeeze?
Repeat until the muscles tire. How many times can you repeat the squeezes?

Short Squeezes

Quickly tighten your pelvic floor muscles, then immediately let them go again. How many times can you do this quick squeeze before the muscles tire?

This level becomes your baseline level of exercise. For example, you might be able to hold for 5 seconds, repeat 4 times and do 8 quick squeezes. This is your individual exercise program. It reflects how strong you are right now and the level to which you should be working. This program should be attempted three times a day. Over time, see if you can do a little more. Eventually, aim to do 10 long squeezes, holding each for 10 seconds, followed by 10 short squeezes.

Remembering to do your exercises daily is a challenge. Try to associate it with another activity so you will remember. Or there are apps which help to remind you and chart your progress. Squeezy is an app that has been developed by physiotherapists working in the NHS.

You may find it takes time to be able to do the exercise properly. It may take 6-8 weeks to get the technique right. You may struggle with relaxing other muscles at the same time, or you may struggle with breathing normally. You may also find that you are able to do the exercises correctly in one position (e.g. lying on your side) but if you change position then you can’t get the muscles to work in quite the same way. All this is very common at this stage. Women will often be frustrated in this time period as you may not see any improvement in symptoms despite doing exercises every day. But it is important to persevere. Build up your exercise regime over time. If your muscles were weak, you should notice an improvement in your symptoms in 3-5 months.

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