In women, the pelvic floor supports the vagina and pelvic organs. The pelvic floor is made up of muscles, connective tissue, and ligaments. This can weaken due to age, chronic straining, and stress from vaginal childbirth. When this happens, the pelvic organs can descend into the vagina – this is called a pelvic organ prolapse.
The severity of the prolapse is graded according to how far down it descends into the vagina.
- Grade 1: There is mild descent of the bladder into the vagina.
- Grade 2: The bladder descends to within 1cm of the level of the vaginal opening.
- Grade 3: The bladder descends by > 1cm below the level of the vaginal opening.
- Grade 4: There is a complete protrusion of the bladder out of the vagina.
Is the bladder the only organ that can prolapse into the vagina?
No. The vagina consists of a front (anterior) wall, a back (posterior) wall, a roof and an opening at the bottom. A weakness in any of these components can result in prolapse of the related nearby organs into the vagina.
- Front wall: The bladder sits here and a prolapse here is also called a cystocele.
- Back wall: The small bowel and rectum are located here and herniations of these organs are called an enterocele or a rectocele respectively.
- Roof (apex): The uterus (womb) can herniate, and this is called a uterine prolapse. In patients with previous hysterectomy, the top of the vagina can also prolapse (vault prolapse).
How common is it?
About 30%-40% of women will have some kind of vaginal prolapse in their lifetime. Some may not cause any symptoms. It is more common with age and in women after menopause, childbirth, or a hysterectomy (surgical removal of the womb). Many women do not seek medical attention and choose to live with it for fear of embarrassment.
Women may describe a dragging sensation or pressure in the vagina. Some can feel a lump protruding out of the vagina. Some describe painful intercourse. Voiding symptoms such as difficulty emptying the bladder may be described. This can sometimes cause recurrent bladder infections.
Very rarely, a prolapse may be large enough to block the ureters (tubes that drain the kidneys to the bladder), causing kidney damage.
There may be associated urinary incontinence with physical exertion (female stress urinary incontinence).
If there is a prolapse of the back wall (enterocele or rectocele), bowel symptoms like constipation or difficulty emptying the bowel may be described. Sometimes, manual reduction of the prolapse with the hands (splinting) is described to ease with passing of urine or opening of the bowels.
A physical examination is essential in making a diagnosis. This is always done with care and consideration, in the presence of a female chaperone if needed. You may be asked to bear down to show the prolapse.
A urodynamics study (bladder function test) is sometimes used to assess for any other bladder storage or voiding problems. Incontinence can sometimes be masked by a prolapse and you may be asked to cough and bear down to look for leakage with and without the prolapse being pushed back. This will help the surgeon decide whether an incontinence surgery has to be done at the same time as the prolapse surgery.
A cystoscopy (look inside the bladder with a tubelike camera) is sometimes done, especially if the patient also complains of the frequent need to urinate, blood in the urine or bladder pain.
Treatment is only indicated if the patient is symptomatic.
- A vaginal pessary may be preferred instead of surgery in some women, especially if the prolapse is mild with minimal symptoms. This is a device that is placed into the vagina to help support the prolapsed organ. It needs to be changed regularly every few months. This may also be appropriate for those who are not sexually active or those who are too frail to have surgery.
- Lifestyle modifications like losing weight, avoiding heavy-impact activities, or straining can help prevent the prolapse from worsening.
- Pelvic floor exercises can help strengthen the muscles of the pelvic floor and can be part of the treatment for mild to moderate prolapse.
- Oestrogen therapy helps strengthen the muscles and tissues in the vagina and also prevents infection especially if a pessary is used. There are some risks of being on oestrogen therapy and you must discuss this with your doctor.
Prolapse repair is usually done under general anaesthesia or spinal anaesthesia. The surgery can be done transvaginally (from a vaginal incision) or transabdominally (from an abdominal route).
A vaginal incision is made where the defect is and the prolapsed area is repaired and strengthened with stitches (colporrhaphy). Transvaginal mesh is NOT used during this repair. Success rates are 70% - 90% (anterior cystocele repair) and 75% - 96% (posterior rectocele repair).
Some stitches may be placed at the top of the vagina to fix it to strong ligaments in the pelvis to treat apical prolapse (sacrospinous ligament fixation). The success rate is 80% - 90%.
In some cases, a concurrent sling procedure is done to treat stress urinary incontinence.
Some women may choose to have the uterus removed (hysterectomy).
This can be done using keyhole surgery or an open abdominal incision.
A small piece of synthetic graft (mesh) is usually used to reinforce the repair by attaching it to the sacrum (bottom of the spine) and the uterus / vagina. The mesh is then covered with a layer of tissue (peritoneum) to prevent the bowel from sticking to it. This surgery is called transabdominal sacrocolpopexy (in those with no uterus) or sacrohysteropexy. The success rate is 80% - 90%.
Read A/Prof Gani’s publication - systematic review on the Surgical Management of apical pelvic organ prolapse:
Download A systematic review of the surgical management of apical pelvic organ prolapse - PDF (978 Kb)
Read Australian Commission on Safety and Quality in Health Care’s publication:
Download Treatment options for pelvic organ prolapse - PDF (1200 Kb)