Roughly half of women over age 50 have pelvic organ prolapse, a condition in which the uterus, bladder, small intestine, or rectum bulges into the vaginal wall or drops down through the vagina. But unlike with other common health conditions, many women don’t talk about it — even with their doctors. For some, this may stem from embarrassment, but in other instances, it’s because they think it’s just something they need to deal with as they age.
“Women will say to me, ‘I thought this was normal because I had kids.’ But it’s not normal. Not everyone who has had a vaginal delivery or is over 65 has urinary incontinence or pelvic organ prolapse,” says Dr. Emily Von Bargen, a Harvard Medical School instructor in Obstetrics, Gynecology, and Reproductive Biology. Pelvic organ prolapse is treatable, and it’s not something women have to live with, says Von Bargen.
|Pelvic organ prolapse conditionsNormal positions of pelvic organsCystocele and urethroceleRectoceleUterine prolapseAnatomy illustrations by Scott Leighton|
Symptoms of prolapse
Pelvic organ prolapse occurs when the bowl-shaped structure of muscles and ligaments inside the pelvis weakens and allows one or more organs to shift downward and to bulge into the vagina. Often this happens without any symptoms, and the woman isn’t even aware that it has occurred. But in some instances, this shift compresses structures in the pelvis that can lead to urinary problems or constipation. Women may notice pelvic discomfort or feel a bulge in the vagina. Sex may be painful.
These problems can be triggered by the strain of pregnancy or childbirth. While pelvic organ prolapse often occurs after vaginal birth, it can also follow a cesarean. Other risk factors for pelvic organ prolapse are older age, being overweight, and having a condition that causes frequent coughing, which puts downward pressure on the pelvis. You may also be more likely to experience pelvic organ prolapse if your mother or another close relative had the problem.
Different types of pelvic organ prolapse
The particular symptoms of prolapse are often determined by where the problem is occurring, either in the front of the pelvis (anterior) or in the back (posterior).
- Anterior vaginal wall prolapse is the most common type of pelvic organ prolapse. Loose tissues toward the front of the pelvis allow the bladder to slip down (cystocele), sometimes compressing the urethra, the tube that carries urine from the bladder out of the body (urethrocele).
- Posterior vaginal wall prolapse may involve the small intestine (enterocele) or the rectum (rectocele). Rectocele is different from rectal prolapse, where the rectum protrudes through the anus.
- Uterine prolapse, where the uterus and cervix descend, is another common condition.
- Apical prolapse, also known as vaginal vault prolapse, is sagging of upper part of vagina in women who have had a hysterectomy.
Not everyone who has pelvic organ prolapse is bothered by it. Your gynecologist may discover prolapse when performing a pelvic exam. If you don’t notice it, there’s no reason to be concerned or to treat the condition. Prolapse is almost never dangerous. One rare exception is if a woman has a condition called complete uterine prolapse, where the organ drops down through the vagina, extending a few inches outside the vaginal opening. In this position it can pinch the urethra, which can hamper urination and lead to kidney problems. It does need medical treatment, says Dr. Von Bargen.
Treating pelvic organ prolapse
Women who are bothered by pelvic organ prolapse symptoms should seek medical evaluation. Choosing among the various treatment options is often a matter of personal preference.
“Women will ask me, ‘What would you recommend that I do if I were your mother?'” says Dr. Von Bargen.
It’s not a question she can answer. Each option brings pros and cons, and deciding among them is highly individual. Some women want to get rid of the problem as quickly as possible and opt for surgery, while others want to avoid the risks of surgery and prefer other methods.
Treatment options for pelvic organ prolapse include the following:
Pelvic floor physical therapy. This approach strengthens the pelvic muscles so that they can better support the organs and hopefully reverse or minimize the prolapse. If you opt for this approach, you will work with a physical therapist who specializes in helping women strengthen the pelvic floor. “When pelvic organ prolapse is not super advanced, pelvic physical therapy can move it by a centimeter or more,” says Dr. Von Bargen. This may be enough to relieve symptoms. But the downside is that this isn’t an instant cure; it takes time. Most often women need to go to physical therapy once a week for eight to 12 weeks to see a difference. The process may or may not be covered by insurance.
Pessary. A pessary is a support device that resembles a birth control diaphragm (although a pessary is not designed to prevent pregnancy). It is inserted into the vagina and supports the structures inside the pelvis that are dropping. But it’s not a cure. If you remove the device, the prolapse will come back. A pessary can be used in different ways. For older women who aren’t comfortable taking the device in or out, it can be inserted by a doctor and left in for three to six months at a time, says Dr. Von Bargen.
|A pessary is a removable device that can provide temporary support for pelvic organs.|
Some types of pessaries must be removed for sexual intercourse. For this and other reasons, some women prefer what doctors call a self-managed device, which they take in and out themselves. This allows a woman to use it as needed — for example, during exercise. Others may wear it all day and remove it at night. “If prolapse is bothering you all the time, you can leave it and only take it out one night a week,” says Dr. Von Bargen. This is done because vaginal discharge sometimes builds up around the device, and removing the pessary periodically allows it to clear. A pessary will not cause a vaginal infection, such as bacterial vaginosis or a yeast infection, but the discharge may be a nuisance, she says.
Surgery. Some women either don’t have success with or prefer not to try physical therapy or a pessary, and instead opt to have the problem fixed surgically.
The goal of prolapse surgery is to tighten the ligaments and muscles that are causing the pelvic organs to drop. Your surgeon will reinforce the weakened tissues using a specialized mesh or using your own tissues.
There are a number of surgical techniques used to do this, and the surgery may be done differently depending on the type of prolapse that you have.
A hysterectomy, which removes the uterus, may or may not be part of pelvic organ prolapse surgery. But a hysterectomy alone does not fix prolapse. “The uterus is an innocent bystander,” says Dr. Von Bargen. “The real problem is the laxity of the ligaments that suspend the vaginal walls.” When technically possible, there are advantages to leaving the uterus in place, such as reduced blood loss, a shorter surgery, and faster recovery, says Dr. Von Bargen. However, the surgeon may need to remove the uterus to reach the structures that require tightening, or a woman may have other reasons for having a hysterectomy.
If a woman is no longer sexually active, and has no desire to be, she may opt for what doctors call an obliterative surgical procedure, which essentially narrows or closes off the vagina permanently to keep the organs in place.
Bible verses for today’s meditation and inspiration: Matthew E. McLaren
“Finally, brothers and sisters, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable–if anything is excellent or praiseworthy–think about such things.” – Philippians 4:8
“Therefore I tell you, whatever you ask for in prayer, believe that you have received it, and it will be yours.” – Mark 11:24
“Anxiety weighs down the heart, but a kind word cheers it up.” – Proverbs 12:25
“Who of you by worrying can add a single hour to your life?” – Luke 12:25
“For I know the plans I have for you, declares the Lord, plans for welfare and not for evil, to give you a future and a hope.” – Jeremiah 29:11
“If you, then, though you are evil, know how to give good gifts to your children, how much more will your Father in heaven give good gifts to those who ask him!” – Matthew 7:11
“A cheerful heart is good medicine, but a crushed spirit dries up the bones.” – Proverbs 17:22
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