Prolapse: Uterine and vaginal prolapse
Prolapse is a gynaecological hernia. When the walls of the vagina become lax, the organs that they should be supporting bulge into the vagina, creating the sensation of a lump hanging down. There are many types of prolapse, which differ according to which organ is affected. The uterus is supported at the top of the vagina, and when the ligaments in this wall loosen, the uterus bulges downward. This condition is called uterine prolapse. Other types of prolapse include prolapse of the bladder into the front wall of the vagina (cystocele), that of the rectum into the back wall (rectocele), and that of the small intestine into the top of the vagina (enterocele). A combination of the last two is known as a recto-enterocele.
Causes of prolapse
The common causes of prolapse are childbirth, loss of hormones at menopause, being overweight and chronic illnesses which create a lot of pressure inside the abdomen (such as chronic lung disease, which causes considerable congestion and coughing). It is less common in women who have not had babies, and most common in those who have had difficult vaginal deliveries, but there is evidence to indicate that women who have had caesarean sections also develop vaginal wall weakness. This is thought to be due to pregnancy hormones, which allow the tissues to stretch beyond their rebound limits, and also the weight of an ever-growing womb containing the baby. Prolpase can also be exacerbated by the loss of muscle tone commonly associated with aging.
Those who suffer from uterine prolapse often report a sensation of heaviness or pulling in the pelvis, with a feeling of "sitting on a small ball". It can also be accompanied by low backache and, in moderate to severe cases, protrusion from the vaginal opening. Uterine prolapse may also cause difficult or painful sexual intercourse.
Lax bladder support leads to a "reservoir effect" where the bladder is not completely emptied when the urine is passed. The remaining urine then irritates the bladder, leading to bladder spasms, which causes urgency and is sometimes severe enough to produce an involuntary leakage. The lowering of the neck of the bladder with prolapse can result in stress incontinence, which involves the leakage of urine into the urethra as a response to any sudden pressure, often followed by a contraction of the bladder causing even more leakage. A lax and irritable bladder may also leak during intercourse, due to the pressure exerted upon it.
Those who suffer from rectal prolapse complain of a sensation of bulging in the vagina when they strain to open their bowels. There is in effect an "S-bend" effect in the vagina, where faeces move into the reservoir created by the prolapse. Despite the urgency to open the bowels, very little bowel motion is likely to occur, as the reflexes tend to be lost due to this pouch effect. Constipation and irritable bowel syndrome may result from this. When the small intestine is also prolapsed, patients complain of a tangible bulge and a dragging or "balloon like" sensation in the upper vaginal wall. This may also make intercourse painful.
Prolapse is usually diagnosed by a pelvic examination.
It is usual practice to send patients to physiotherapy sessions to help with their symptoms. Logic suggests that when the elasticity of the vaginal walls has been exceeded, the physiotherapy exercises would not allow the tightening to occur to any significant effect. However, some women do report improvement in bowel and urinary symptoms to some extent because of these exercises.
When the prolapse is troublesome, soft rubber ring pessaries are available. The effect of these is to hold the walls of the vagina away from the centre and hence tighten the "hammock" of tissues that hold the organs. These rings are changed regularly, and are often used along with topical estrogen creams. When the prolapse involves the womb or the top of the vagina, or when there is no womb from a previous hysterectomy, another device called a shelf pessary is inserted, which effectively "dams up" the prolapse. Again, use of hormone creams help keep these devices in place on a long-term basis.
When these pessaries are not effective or uncomfortable and unacceptable, surgery is the next step. Vaginal repairs can be performed where the prolapse is reduced and supporting sutures inserted. Various other materials have been used to provide longer lasting repairs in the form of nylon mesh, etc. but it is now more commonly practiced to use animal tissue grafts to support the repairs, with good results. Pig material is now widely used successfully, with very few side effects. Patients should discuss possible treatment options with their doctor.
National Library of Medicine (US): Uterine prolapse
[accessed July 2007]
Bladder and Bowel Foundation (b&bf)
(formerly Incontact and the Continence Foundation)
Helpline: 0845 345 0165
This factsheet has been produced by Women's Health Concern and reviewed by members of our Medical Advisory Panel. It is for your information and advice and should be used in consultation with your own medical practitioner.
Updated: March 2010.
Women's Health Concern is an independent charity and receives no government funding.
Registered Charity No. 279651
Email advice: advice[at]womens-health-concern.org (NB: please type @ instead of [at] in your email)