Vaginal prolapse: what you need to know

Also known as a pelvic organ prolapse, this common condition particularly affects women who have experienced childbirth or menopause, but other women can have a prolapse

Although around a half of women have some degree of pelvic organ prolapse [1], many are unaware they have it and some feel embarrassed or reluctant to talk about it despite it having a negative impact on their quality of life.

Your pelvic floor muscles are a bit like a trampoline, stretching from your pubic bone at the front, to your coccyx (tail bone) at the back, and between your bones that you sit on from side to side. They form the floor of your pelvis and support your pelvic organs, as well as controlling your bladder, bowel and sexual functions.

Vaginal prolapse happens when these muscles and ligaments that support your pelvic organs are weakened, allowing your uterus, urethra, bladder or rectum (or part of them) to slip down into your vagina or outside of your vagina.

There are a few different types of vaginal prolapse:

– Cystocele or urethrocele prolapse is when your part or all of your bladder and/or urethra bulges into the front wall of your vagina. It is sometime referred to as an anterior vaginal wall prolapse. This is the most common type of prolapse. It is twice as common as a rectocele and three times as common as a uterine prolapse. It is called cystourethrocele when the urethra is involved.
– Rectocele is when the wall separating your rectum and vagina weakens, allowing part of your rectum to bulge into your vagina. This is also sometimes referred to posterior vaginal wall prolapse. When part of the small bowel bulges into the back wall of your vagina, this is called an enterocele.
– Uterine prolapse happens when some or all of your uterus (womb) drops down into your vagina. In some women, the entire uterus protrudes completely outside the body, which is called a procidentia.
– Vaginal vault prolapse can happen when you have had a hysterectomy and the top of your vagina (where your cervix and uterus were) descends down into the lower part of your vagina.

What causes vaginal prolapse?

Childbirth is the most common cause of prolapse. A prolapse can happen following whatever type of delivery you have had, but it is more likely to happen if you have a long and difficult birth or if you had forceps or ventouse (suction) delivery. Having large babies or having lots of babies is also a risk factor. Prolapse can also occur during pregnancy.

During perimenopause and menopause, your hormone levels (oestradiol, progesterone and testosterone) drop, and your vaginal tissue can become less elastic. All the surrounding tissue can become increasingly fragile and can be more prone to a prolapse occurring.

Other risk factors for prolapse include constipation, hysterectomy, weight gain, heavy lifting, excessive coughing, fibroids, hypermobility and the risk can also increase as you age and if you have family members with prolapse.

What are the grades of vaginal prolapse?

Prolapse is often graded using an assessment tool called POPQ (pelvic organ prolapse quantification system). This is the grading system that your doctor or women’s health specialist may use to diagnose the grade of the prolapse:

Grade 1
At this stage you may not even know you have a small prolapse, this could be picked up on a routine cervical examination, for example.

Grade 2
This is when your bladder or bowel falls down far enough to be at the opening of your vagina.

Grade 3
This is when your pelvic organs begin to bulge out of your vaginal opening. It can feel uncomfortable or painful at this point.

Grade 4
This is the most severe form of prolapse and is when your entire bladder or uterus comes out of your vagina, called a procidentia. This is also the least common, and treatment is usually sought before a prolapse reaches this point.

What are the symptoms of a prolapse?

The symptoms you experience will depend on which organ has prolapsed. You may not experience any symptoms at all – according to NICE, in primary care in the UK, 8.4% of women report a vaginal bulge or lump [1] or you may notice some of the following:

– a heavy feeling of fullness or pressure in your vagina
– a bulge at the opening of your vagina
– a feeling like you’re sitting on an egg or a ball
– lower back ache that feels better when you lie down
– the need to urinate more frequently than usual
– having trouble completely emptying your bowel or bladder
– frequent bladder infections and/or constipation
– leaking urine when you cough, sneeze, laugh, have sex, or exercise
– pain or discomfort during sex
– vaginal bleeding

How is a prolapse diagnosed?

Vaginal prolapse can usually be diagnosed through a pelvic examination. Your doctor may also want to test your bladder function and refer you for an ultrasound, MRI or CT scan to take a closer look at your pelvic organs.

How can a prolapse be treated?

Vaginal prolapse is treatable, and mild cases can improve with simple lifestyle changes, such as losing weight, treating constipation by eating a healthy diet with plenty of vegetables and fibre, and avoiding heavy lifting.

Pelvic floor exercises

Performing regular pelvic floor exercises can help strengthen your muscles, and your doctor may refer you to a pelvic floor physiotherapist who can devise a programme of strengthening exercises. There are various apps to help you with pelvic floor exercises – a good one is the Squeezy App.

You may also benefit from biofeedback, which uses an electrode to show when you’re contracting the correct muscles, or electrical stimulation machines if you need some extra help to get started with doing the exercises. These tools are often used in clinical settings, but you can use the Elvie Trainer at home. This is a small device that you insert into your vagina – it connects to your smartphone to give you a five-minute programme of exercises and allows you to track your progress.

Vaginal pessaries

A vaginal pessary is a removable device that is inserted into your vagina and designed to support your prolapse. It is usually first fitted by a healthcare professional to find the correct size and shape of pessary that will work best for you. After the initial fitting, you can usually be taught how to put it in and take it out yourself. Most pessaries are made of soft plastic or silicone and come in a variety of shapes and sizes to fit all vaginas and different types of prolapse.

While a pessary isn’t a cure, it does mean that you won’t be bothered by troublesome symptoms. Pessaries can be used for short periods or for as long as you like, they can easily be put in and taken out, so if it suits you, you can just wear them for sports or important events.

A recent trial has shown that when women self-manage a vaginal pessary (versus receiving clinic-based care) for pelvic organ prolapse they experience fewer complications and maintain their quality of life [2]. It’s hoped that self-management will be rolled out more widely across the UK.

Vaginal hormones and HRT
Replacing falling hormone levels during perimenopause and menopause with vaginal hormones can help reduce the discomfort you may experience from having a prolapse. It can be taken in the form of a pessary, cream, gel or a ring that is inserted into your vagina.

Using vaginal hormones – oestradiol, oestriol, prasterone – can replace the missing hormones in these tissues and can improve and reduce prolapse in many women. These can be used regardless of whether or not you take HRT.

A review of oestrogen therapy for treating pelvic organ prolapse in postmenopausal women found that using vaginal oestrogen alongside pessaries was associated with fewer adverse vaginal events compared with pessaries alone, and vaginal oestrogen alongside surgery was associated with reduced postoperative urinary tract infections compared with surgery alone [3].

HRT, which is replacement hormones for your whole body, can help reduce some of the symptoms associated with pelvic organ prolapse, including the thinning and dryness of genital and urinary tissue, muscle weakening, and urinary incontinence, plus relieve other symptoms of perimenopause and menopause. HRT also reduces the risk of future diseases such as osteoporosis and heart disease. It is safe to use vaginal hormone preparations and also take HRT and testosterone.

RELATED: 10 FAQ about HRT

Surgery
If none of these treatments help, you may want to consider a surgical solution for your prolapse. Approximately 1 in 10 women have pelvic floor surgery to correct their prolapse [1]. There are different types of surgery available for prolapse – your gynaecologist can help advise what’s best for you. It is important that your pelvic floor muscles are in good shape (through strengthening exercises) prior to surgery, as this will help your recovery.

Surgery aims to correct prolapse but it does not strengthen your pelvic floor muscles. Approximately 25-30% of women who have surgery for prolapse will develop another prolapse in the future [4]. This can be due to weakness in the pelvic support, so strengthening these muscles is key.

RELATED: Pelvic floor and hormones

References

NICE: Urinary incontinence and pelvic organ prolapse in women: management (NG123)
Hagen, Suzanne et al. (2023), ‘Clinical effectiveness of vaginal pessary self-management vs clinic-based care for pelvic organ prolapse (TOPSY): a randomised controlled superiority trial’, eClinicalMedicine, 66, 102326 DOI: 10.1016/j.eclinm.2023.102326
Taithongchai A, Johnson EE, Ismail SI, Barron-Millar E, Kernohan A, Thakar R. Oestrogen therapy for treating pelvic organ prolapse in postmenopausal women. Cochrane Database of Systematic Reviews 2023, Issue 7. DOI: 10.1002/14651858.CD014592.pub2.
RCOG: Pelvic organ prolapse