Pelvic organ prolapse

Bladder and bowel prolapse (vaginal prolapse)

Bladder and bowel prolapse is also known as ‘vaginal prolapse’ because the walls of the vagina become overstretched and bulge downwards towards the vaginal entrance. A prolapse may affect the front or back vaginal walls.

When the bladder bulges into the front wall of the vagina, it is called a ‘bladder prolapse (cystocele)’. When the rectum bulges into the back wall of the vagina, it is called a ‘bowel prolapse (rectocele)’. These conditions usually happen together.

Uterine prolapse

A uterine prolapse is when the uterus (womb) and cervix (opening to the uterus) drop down towards the vaginal entrance and may protrude outside the vagina.

Symptoms

The symptoms of a prolapse depend on the severity of the prolapse and your physical health.

Symptoms can include:

• an inability to completely empty your bladder or bowel when going to the toilet
• straining to get your wee flow started, or to empty your bowel
• a slow flow of wee that tends to stop and start
• a sensation of fullness or pressure inside your vagina
• a sensation of vaginal ‘heaviness’ or ‘dragging’.

Symptoms might also include:

• a feeling of bulging or swelling in your vagina
• the need to wee or poo quickly
• the inability to control your wee or poo (incontinence)
• lower back ache.

In severe cases, your vaginal wall or cervix may protrude outside your vaginal entrance.

Causes

Anything that puts pressure on your pelvic floor muscles can cause a prolapse.

For example:

• pregnancy and childbirth
• constipation or regularly straining when going to the toilet
• repetitive lifting of heavy weights – at the gym, at work, in the garden or even lifting children
• squatting for long periods of time
• being overweight or obese
• coughing caused by smoking and chronic lung diseases
• connective tissue disorders such as Ehlers Danlos syndrome and Marfan’s syndrome.

Note that being sexually active does not cause or worsen prolapse.

The risk of prolapse increases:

• with previous pelvic surgery
• after menopause – when oestrogen (the hormone that keeps pelvic floor muscles toned) decreases and the muscles weaken.

Diagnosis

Prolapse is usually diagnosed via a clinical examination. Your doctor will ask about your medical history and do a pelvic examination, and other tests if required.

The pelvic examination will determine:

• the severity of the prolapse
• how well the pelvic floor muscles are functioning
• which organs are part of the prolapse.

You may need other tests. For example:

• a pelvic ultrasound to check for any masses or cysts in the pelvic area
• assessment of bladder function (urodynamic studies) to check for different types of incontinence
• a bladder ultrasound to see if wee isn’t emptying completely from the bladder after going to the toilet
• a mid-stream urine test to rule out infection if there are bladder symptoms.

Degrees of prolapse

Gynaecologists with a special interest in prolapse (urogynaecologists) use a grading system called the POP-Q system to understand the stages of prolapse.

The stage of prolapse is defined by how much the uterus or vaginal walls are pushing down into the vagina.

There are four stages:

• Stage 1: The wall or organ drops into the upper part of the vagina.
• Stage 2: The wall or organ drops into the lower part of the vagina.
• Stage 3: The wall or organ protrudes from the vaginal opening.
• Stage 4: The wall or organ slips completely outside the vagina.

Treatment and management

There are different ways to treat and manage a prolapse. But without intervention the symptoms of prolapse usually worsen over time.

Treatment depends on the severity of the prolapse and how it affects your normal routine.

Your doctor will explain the problem and your treatment options so you can make an informed decision.

Prevention

Pelvic floor exercises and changes in your daily routine, along with weight management, may be all you need. Learn more about pelvic floor exercises and why they are important.

Mild and moderate prolapse

The most common pelvic organ prolapses are stage 1 and 2 prolapses. Regular sessions with a pelvic floor physiotherapist can help in most cases. You may require surgery, but you can try a pessary first.

Pessaries

Pessaries are devices that health professionals insert in the vagina to support the pelvic organs. They are a non-surgical way of managing prolapse. Pessaries are available in different shapes and sizes. The most common type is a pessary ring.

You can be taught to insert and remove some types of pessaries yourself, which may reduce the number of visits to your health professional.

Severe prolapse

Surgery is usually required to repair a severe prolapse, or when symptoms do not improve with physiotherapy.

Some women have a hysterectomy after a prolapse. But there are options to keep your uterus.

You may need surgery to repair your vagina. Your doctor may use dissolvable or permanent stitches to reinforce the connective tissues in the pelvis to better support the vagina. Mesh products are only recommended in certain situations – and only with your consent.

Surgery is usually done under general anaesthetic, but it may be performed with spinal anaesthesia.

It normally takes six to eight weeks to fully recover from surgery. You can do gentle exercise like walking but it’s important to avoid lifting and straining during your recovery time.

Discuss treatment options with your doctor. And learn about the risks and benefits of each option before deciding what’s best for you.

What you can do

There are different ways to help reduce the risk of a prolapse. These might also help you to recover well after a prolapse.

Diet

Try to:

• stay within a healthy weight range
• eat 30 g of fibre every day to prevent constipation
• drink six to eight glasses of fluid each day.

Going to the toilet

When you go to the toilet:

• avoid straining when you wee or poo
• use your hand to support the prolapse
• relax and take your time – try leaning forwards with your forearms on your thighs or putting your feet on a small stool when doing a poo.

Physical activity

Aim to do physical activity every day and try to:

• use lighter weights – avoid lifting anything heavier than 10 kg (including children)
• include core strengthening exercises
• do cardiovascular exercise such as walking, swimming or bike riding, rather than running, jumping or high-impact aerobics.

Pelvic floor exercises

Do pelvic floor exercises every day and remember to squeeze up pelvic floor muscles before lifting, coughing, laughing or sneezing.

If you have symptoms of a prolapse, make an appointment with a specially trained pelvic floor physiotherapist.

Learn more about pelvic floor exercises and why they are important.

When to see your doctor

It’s important to see your doctor as soon as possible if you notice any symptoms. Early treatment will prevent or reduce the severity of prolapse.

You should also ask your doctor about treatment options for any condition that causes coughing and sneezing, such as asthma, chest infections or hay fever. Repetitive sneezing and coughing may cause or worsen bladder prolapse.

If you have reached menopause, you can ask your doctor about hormone therapy to increase your levels of oestrogen. This may help to strengthen your vaginal walls and pelvic floor muscles.

This web page is designed to be informative and educational. It is not intended to provide specific medical advice or replace advice from your health practitioner. The information above is based on current medical knowledge, evidence and practice as at April 2023.