Vaginal prolapse Factsheet

Vaginal prolapse (often known as pelvic organ prolapse or POP) happens when your muscles and ligaments that support your pelvic organs are weakened, allowing your uterus, urethra, bladder or rectum to slip down into your vagina.

It is thought that half of women over 50 have some degree of prolapse, and although it’s not dangerous, it can have a negative impact on your quality of life.

There are a few different types of vaginal prolapse:

– Cystocele or urethrocele prolapse is when your bladder falls down into your vagina. Cystocele is the most common type of prolapse. It is twice as common as a rectocele and three times as common as a uterine prolapse.
– Rectocele is when the wall separating your rectum and vagina weakens, allowing your rectum to bulge into your vagina.
– Uterine prolapse happens when your uterus (womb) drops down into your vagina.
– 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.

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 occurs when your muscles and ligaments of your pelvic floor are weakened, this can happen after childbirth and when estrogen levels drop during the perimenopause and menopause.

What causes vaginal prolapse?

Childbirth itself 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.

When you reach the menopause (and during the perimenopause) your estrogen levels drop, and your vaginal tissue becomes less elastic. All the surrounding tissue becomes increasingly fragile and more prone to a prolapse occurring.

Other risk factors for prolapse are 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.

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 obviously feel really 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. This is also the least common, and help is usually sought before a prolapse reaches this point.

How would I know if I have a prolapse?

The symptoms you experience will depend on which organ has prolapsed. You may not experience any symptoms at all, 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
– a 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

Getting a diagnosis

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.

What can I do about it?

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.

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 NHS Pelvic Floor 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 (biofeedback). This is a small device which 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, it is designed to support your prolapse and is usually first fitted by a doctor or a women’s health specialist in order 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.

Vaginal estrogen and HRT

Vaginal estrogen helps to replace the falling levels of estrogen that happens during the perimenopause and menopause, right where it’s often needed – your vagina and surrounding areas – and it comes in the form of a pessary, cream, gel or a ring that is inserted into your vagina. These are all prescription items so you will need to see your doctor or women’s health specialist to access these treatments.

You may also benefit from taking Hormone Replacement Therapy (HRT), which is replacement estrogen for your whole body, and you can discuss this with your health professional at the same time. Estrogen can help reduce the hormonal effects of the menopause on your genitals and urinary function such as tissue thinning and dryness, muscle weakening, and urinary incontinence, as well provide many other benefits to your physical health and emotional wellbeing, and HRT also reduces the risk of diseases in the future such as osteoporosis and heart disease. It is safe to use vaginal estrogen preparations and take HRT alongside.

Surgery

If none of these treatments help, you may want to consider a surgical solution for your prolapse that can be carried out through your vagina or laparoscopically, through small incisions in your tummy. It is always important to have your pelvic floor muscles in good shape (through strengthening exercises) prior to surgery, as this will help your recovery. Surgery aims to correct your prolapse but it does not strengthen your pelvic floor muscles.