Prolapse

Far too many below-the-waist female health conditions remain shrouded in silence. Many women suffer in silence with health needs that remain unspoken, underrecognized, underacknowledged, and under addressed. Women are hungry for hope. Pelvic organ prolapse alone impacts 50% of women world-wide, yet POP awareness barely exists prior to diagnosis. Considering childbirth and menopause are the leading POP causes, the lack of open discussion regarding women’s most private health needs falls far short.

Tackling shortfalls in women’s health is not optional, it is essential. Building bridges among key stakeholders is critical to spark evolution in women’s health awareness,screening, practice, and policy. Patients and those who engage in women’s healthcare and advocacy must band together to stimulate forward momentum within the female health arena. It is imperative we explore and expand meaningful, real-world solutions to address insufficient women’s health awareness and eradicate health stigma. As all sectors band together to stimulate open conversation within the female health arena,the world at large will recognize the diverse and intrusive quality-of-life impacts of health stigma and silence to women’s lives.

I encourage women to talk out loud about their health journeys with their daughters, sisters, mothers, friends, and constituents. I encourage women to dance through the Women’s Health Pathway website to capture valuable insights to advance their health awareness. And I encourage women to explore the information shared on APOPS website if they are experiencing tissues bulging out of the vagina, chronic constipation, incontinence, or pain with intimacy. We must advance women’s health side by side.

Every Voice Matters,

Sherrie Palm, Founder Association for Pelvic Organ Prolapse Support www.pelvicorganprolapsesupport.org

Pelvic organ prolapse occurs when one or more of the pelvic organs (bladder, uterus, rectum, or small bowel) drop from their normal position and bulge into the vagina. This happens when the muscles and tissues that support these organs become weakened or stretched.

Types of Pelvic Organ Prolapse

Cystocele (Anterior Prolapse)

• The bladder drops down and presses against the front vaginal wall
• Most common type of prolapse
• May cause a bulge you can see or feel

Uterine Prolapse

• The uterus drops down into the vaginal canal
• In severe cases, may protrude outside the vagina
• Can occur even after hysterectomy (vaginal vault prolapse)

Rectocele (Posterior Prolapse)

• The rectum pushes against the back vaginal wall
• May create a bulge in the back wall of the vagina
• Can affect bowel movements

Enterocele

• Small bowel drops down and pushes against the upper vaginal wall
• Often occurs with other types of prolapse
• Less common than other types

Prolapse Severity Grades

Grade 1 (Mild)

• Organs have dropped slightly but remain inside the vagina
• May have minimal symptoms

Grade 2 (Moderate)

• Organs have dropped to near the vaginal opening
• May be visible during straining

Grade 3 (Severe)

• Organs protrude outside the vaginal opening
• Visible bulge beyond the vaginal opening

Grade 4 (Complete)

• Complete protrusion of organs outside the vagina
• Requires immediate medical attention

What’s happening in your body

Your pelvic organs are supported by a complex system of muscles, ligaments, and connective tissue called the pelvic floor. This “hammock” of support:

Pelvic floor muscles: Form the foundation of support, contracting and relaxing to control organ position

Ligaments and fascia: Connective tissues that hold organs in place

Vaginal walls: Provide structural support between organs

When this support system weakens or becomes damaged, organs can shift from their normal position and create a bulge or prolapse.

Risk Factors

Childbirth: Vaginal delivery can stretch and damage supporting tissues

Aging: Natural weakening of muscles and connective tissue

Hormonal changes: Reduced estrogen after menopause affects tissue strength

Chronic straining: From constipation, chronic cough, or heavy lifting

Genetics: Some women have naturally weaker connective tissue

Remember: Prolapse is very common, affecting up to 50% of women who have had children. Many women have mild prolapse without realizing it, and effective treatments are available for all grades of prolapse.

Prolapse symptoms vary depending on which organs are affected and the severity of the prolapse. Some women have no symptoms, while others experience significant discomfort that affects daily life.

Physical Symptoms

Visible or palpable bulge

• Feeling of “something coming down” in the vagina
• Visible bulge at the vaginal opening
• Sensation of sitting on a ball or balloon
• Bulge that worsens with standing, straining, or at the end of the day

Pelvic pressure and heaviness

• Feeling of fullness or pressure in the pelvis
• Aching or heaviness that worsens throughout the day
• Relief when lying down

Back and abdominal discomfort

• Lower back pain, especially after standing
• Abdominal discomfort or cramping
• Pain that improves when lying down

Bladder-Related Symptoms (Cystocele)

Urinary problems

• Difficulty starting urination
• Feeling of incomplete bladder emptying
• Need to lift or push the bulge to urinate completely
• Frequent urinary tract infections
• Urinary incontinence (leaking)

Changes in urination patterns

• Frequent urination
• Urgent need to urinate
• Getting up at night to urinate (nocturia)

Bowel-Related Symptoms (Rectocele)

Bowel movement difficulties

• Feeling of incomplete bowel evacuation
• Need to support the vaginal wall to have a bowel movement
• Constipation or straining during bowel movements
• Feeling of blockage in the rectum

Sexual and Relationship Symptoms

Sexual discomfort

• Pain or discomfort during intercourse
• Reduced sensation during intercourse
• Self-consciousness about the bulge
• Decreased sexual desire

Partner concerns

• Partner may feel the bulge during intercourse
• Anxiety about intimacy

Daily Life Impact

Activity limitations

• Avoiding exercise or physical activities
• Difficulty with prolonged standing or walking
• Problems with lifting or carrying
• Discomfort wearing tampons

Emotional symptoms

• Anxiety about the condition worsening
• Embarrassment or shame
• Feeling less feminine
• Social withdrawal

Symptoms That Worsen Throughout the Day

Many prolapse symptoms follow a pattern:

• Morning: Often minimal symptoms after lying down all night
• Afternoon: Symptoms become more noticeable
• Evening: Peak symptoms due to gravity and daily activities

When to See Your Doctor

Seek prompt medical attention if you experience:

• Sudden onset of severe pelvic pain
• Inability to urinate
• Severe constipation lasting several days
• Prolapse that cannot be gently pushed back in
• Signs of infection (fever, unusual discharge)

Schedule a routine appointment for:

• Any visible or palpable bulge
• Persistent pelvic pressure or heaviness
• Urinary or bowel symptoms
• Pain during intercourse
• Symptoms that interfere with daily activities

Remember: Even mild prolapse symptoms are worth discussing with your healthcare provider. Early intervention can prevent worsening and improve quality of life.

Understanding the causes and risk factors for pelvic organ prolapse empowers you to take preventive measures and make informed decisions about your pelvic health.

Primary Causes

Childbirth and pregnancy

• Vaginal delivery is the strongest risk factor
• Trauma during delivery can damage pelvic floor muscles and connective tissue
• Large babies (over 9 pounds) increase risk
• Prolonged labor or difficult deliveries (forceps, vacuum) add additional risk
• Even pregnancy without delivery can weaken pelvic support

Hormonal changes

• Estrogen helps maintain strength and elasticity of pelvic tissues
• Menopause reduces estrogen, leading to tissue weakening
• Postmenopausal women have significantly higher prolapse risk

Aging

• Natural weakening of muscles and connective tissue over time
• Decreased collagen production affects tissue strength
• Cumulative effects of lifetime activities

Risk Factors You Can Control

Chronic straining activities

• Chronic constipation: Regular straining increases abdominal pressure
• Chronic cough: From smoking or respiratory conditions
• Heavy lifting: Occupational or recreational heavy lifting
• High-impact exercise: Without proper pelvic floor training

Weight management

• Obesity: Extra weight increases pressure on pelvic organs
• Rapid weight gain: Can stretch supporting tissues
• Maintaining healthy weight: Reduces strain on pelvic floor

Lifestyle factors

• Smoking: Affects tissue healing and causes chronic cough
• Poor posture: Can affect pelvic alignment and muscle function
• Inadequate nutrition: Affects tissue health and healing

Risk Factors You Cannot Control

Genetic factors

• Family history of prolapse
• Inherited connective tissue disorders (Ehlers-Danlos syndrome, Marfan syndrome)
• Natural variations in tissue strength and elasticity

Medical conditions

• Previous pelvic surgeries (hysterectomy)
• Neurological conditions affecting muscle control
• Chronic respiratory conditions
• Connective tissue disorders

Demographic factors

• Race and ethnicity (varies by population)
• Advanced age
• Number of pregnancies and deliveries

Prevention Strategies

Strengthen your pelvic floor

• Regular Kegel exercises: Daily pelvic floor muscle training
• Professional assessment: Physiotherapy to ensure proper technique
• Progressive exercise programs: Gradually increasing intensity
• Core strengthening: Supporting muscles around the pelvis

Healthy lifestyle habits

• Maintain healthy weight: Reduces pressure on pelvic organs
• Prevent constipation: High-fiber diet and adequate hydration
• Proper lifting technique: Use legs, not back; engage core muscles
• Quit smoking: Reduces cough and improves tissue health

Exercise modifications

• Low-impact activities: Swimming, walking, cycling
• Proper form: Learn correct technique for exercises
• Gradual progression: Slowly increase exercise intensity
• Pelvic floor-friendly fitness: Pilates, yoga with modifications

Managing Risk Factors

During pregnancy

• Pelvic floor exercises throughout pregnancy
• Prepare for labor with pelvic floor physiotherapy
• Discuss delivery options with healthcare provider
• Maintain appropriate weight gain

After childbirth

• Early pelvic floor rehabilitation
• Gradual return to exercise
• Address constipation promptly
• Seek help for persistent cough

During menopause

• Consider hormone therapy if appropriate
• Maintain strong pelvic floor muscles
• Regular monitoring for prolapse development
• Calcium and vitamin D for bone health

Occupational considerations

• Use proper lifting techniques
• Take frequent breaks from standing
• Wear supportive garments if needed
• Modify work activities when possible

Remember: While some risk factors cannot be changed, many can be modified through lifestyle choices and preventive care. Early intervention with pelvic floor strengthening can be highly effective in preventing prolapse development or progression.

Medical terminology around prolapse can be overwhelming. This guide breaks down common terms you might hear when discussing pelvic organ prolapse with healthcare providers.

Types of Prolapse (Medical Terms)

Cystocele

• “Cysto” = bladder, “cele” = hernia or bulge
• Bladder prolapse pressing against the front vaginal wall
• “You have a grade 2 cystocele” = Your bladder has dropped moderately

Rectocele

• “Recto” = rectum, “cele” = hernia or bulge
• Rectal prolapse pressing against the back vaginal wall

Uterine Prolapse

• Uterus dropping down into the vaginal canal
• “Uterovaginal prolapse” = Uterus and vaginal walls prolapsing together

Enterocele

• “Entero” = intestine, “cele” = hernia or bulge
• Small bowel dropping down behind the uterus

Vaginal Vault Prolapse

• Top of the vagina dropping down after hysterectomy
• “Your vaginal vault has prolapsed” = The top of your vagina has dropped

Anatomical Terms

Pelvic Floor

• Group of muscles that support pelvic organs like a hammock
• “Pelvic floor dysfunction” = These muscles aren’t working properly

Levator Ani

• Main group of pelvic floor muscles
• “Levator ani avulsion” = These muscles have torn away from the bone

Fascia

• Connective tissue that helps support organs
• “Fascial defect” = Tear or weakness in the supporting tissue

Perineum

• Area between the vaginal opening and anus
• May be damaged during childbirth

Diagnostic Terms

POP-Q (Pelvic Organ Prolapse Quantification)

• Standardized system for measuring prolapse severity
• “Your POP-Q score is…” = Medical measurement of how far organs have dropped

Baden-Walker Classification

• Older grading system for prolapse severity
• Grades 0-4 from no prolapse to complete prolapse

Dynamic MRI

• Specialized scan that shows organ movement during straining
• “We’ll do a dynamic MRI” = Scan to see how organs move

Defecography

• X-ray study of bowel movements to diagnose rectocele
• Also called “evacuation proctography”

Treatment Terms

Pessary

• Device inserted into vagina to support prolapsed organs
• “We’ll fit you for a pessary” = Non-surgical support device

Anterior Repair (Anterior Colporrhaphy)

• Surgery to repair cystocele (bladder prolapse)
• “You need an anterior repair” = Surgery to fix bladder prolapse

Posterior Repair (Posterior Colporrhaphy)

• Surgery to repair rectocele
• May include perineoplasty (perineum repair)

Hysterectomy

• Surgical removal of the uterus
• May be recommended for severe uterine prolapse

Sacrocolpopexy

• Surgery using mesh to suspend the vagina to the sacrum (lower back bone)
• “Robotic sacrocolpopexy” = Minimally invasive version using robotic surgery

Sacrospinous Fixation

• Surgery attaching the vagina to ligaments in the pelvis
• Alternative to mesh procedures

Pelvic Floor Physical Therapy Terms

Biofeedback

• Using sensors to help you learn proper muscle contractions
• Visual feedback shows if you’re doing exercises correctly

Electrical Stimulation

• Using mild electrical pulses to help strengthen muscles
• “E-stim therapy” = Electrical stimulation treatment

Internal Assessment

• Physical therapist examines pelvic floor muscles internally
• Checks muscle strength, coordination, and tension

Kegel Exercises

• Pelvic floor muscle strengthening exercises
• Named after Dr. Arnold Kegel

Severity Descriptions

Asymptomatic

• Having prolapse but no symptoms
• “Your prolapse is asymptomatic” = You have prolapse but it’s not causing problems

Symptomatic

• Prolapse causing noticeable symptoms
• May require treatment

Recurrent

• Prolapse that returns after previous treatment
• “You have recurrent prolapse” = The prolapse has come back

Questions to Ask Your Doctor

• “Can you show me a diagram of what type of prolapse I have?”
• “What grade or stage is my prolapse?”
• “What does this mean for my daily activities?”
• “What are all my treatment options?”
• “Can you explain the surgical procedure you’re recommending?”

Remember: Don’t hesitate to ask for clarification on any medical terms. Understanding your specific type and grade of prolapse is crucial for making informed treatment decisions.