Pelvic Organ Prolapse

PELVIC ORGAN PROLAPSE

Pelvic organ prolapse occurs when the pelvic floor muscles and connective tissue weaken or tear, causing one or more of the organs inside the pelvis to slip from their normal positions and bulge into the vagina. The pelvic organs consist of the uterus, vagina, bowel, and bladder. Usually, the muscles and connective tissues in the pelvis support these organs and hold them in place.

Similar to a hernia, pelvic organ prolapse develops as soon as pelvic support fails but may not cause symptoms of a “bulge” until many years later.

As many as one in three women will develop prolapse in her lifetime, and close to 15 percent will have surgery. However, because there is a perceived stigma related to the symptoms of pelvic floor disorders, many women are reluctant to discuss them, even with their doctors, because of embarrassment.

The urogynecologists at the Northwestern Medicine Women’s Integrated Pelvic Health Program (IPHP) perform comprehensive diagnostic evaluations and offer an array of appropriate treatment options for women with pelvic organ prolapse, and most women are candidates for both conservative and surgical options. The IPHP team is committed to providing individualized care for every patient. All surgeons are fellowship-trained and either board-certified or board-eligible specialists in the field of Urogynecology and Reconstructive Pelvic Surgery.

The Women’s IPHP is a national leader in pelvic organ prolapse treatment and research. Our transdisciplinary team works together to create new treatments and innovations to address each woman’s pelvic floor symptoms.

Types of Pelvic Organ Prolapse

To evaluate a woman for pelvic organ prolapse, a urogynecologist will review her medical history and perform a pelvic examination, measuring the degree of prolapse. A staging system is applied to the exam findings, and a stage ranging from one to four is assigned. Below you will find descriptions of four types of pelvic organ prolapse, depending on the location of the support defect. It is possible, even likely, that a woman develops more than one type:

Anterior vaginal wall prolapse (cystocele): The front wall of the vagina sags downward or outward, which allows the bladder to drop from its normal position and bulge into the vagina or past the vaginal opening.

Posterior vaginal wall prolapse (rectocele): The weakened vaginal wall and perineum allow the rectum to bulge into the vagina or past the vaginal opening.

Uterine Prolapse: Weakening of the supports of the uterus and upper vagina allows the uterus to slide down into the vaginal canal or past the vaginal opening.

Vaginal Vault Prolapse: Weakening of the upper support of the vagina in a woman who has previously undergone a hysterectomy. This allows the top, or “roof,” of the vagina to descend into the vaginal canal or past the vaginal opening.

Symptoms

If a woman has pelvic organ prolapse, she may have one or more of the following symptoms:

Protrusion of tissue, or bulge, from the vaginal opening
Pelvic pressure
Urinary symptoms such as a slow urinary stream or the need to push up on the vaginal bulge to accomplish bladder emptying
Bowel symptoms, such as difficulty moving the bowels, a feeling of stool being trapped near the opening of the anus, or the need to press on the vaginal bulge to empty the bowel

If you have symptoms of pelvic organ prolapse, it is important that you consult with your primary care physician or obstetrician-gynecologist for a complete physical examination of the genitourinary and nervous systems. If other causes of your symptoms are ruled out, referral to a urogynecologist for further evaluation and treatment is appropriate.

Causes and Diagnoses

There are several factors that may cause damage to the pelvic floor, including:

Pregnancy and childbirth: As many as one in three women who have given birth develop prolapse. Pregnancy and vaginal delivery can damage the pelvic muscles and nerves, allowing pelvic organs to descend. This can occur more commonly in women who have delivered a large baby, have required forceps during delivery, or have had many babies. Symptoms of prolapse resulting from this damage to the pelvic tissues can occur shortly after pregnancy but often take many years to develop.
Aging and menopause: Pelvic organ prolapse becomes more common with age, as loss of estrogen and other changes that occur with aging can weaken the pelvic floor muscles and supportive structures.
Health conditions: Certain health conditions that involve repeated straining, including obesity, chronic coughing, and constipation, can weaken and injure the pelvic floor muscles and connective tissue over time.
Genetics/family history: The strength of your connective tissues is determined by your genetics. If your mother had pelvic organ prolapse, you are more likely to develop it.

In addition to a thorough medical history and physical examination, your urogynecologist may perform some or all of the following supplementary tests:

3D pelvic ultrasound: An ultrasound performed through the vagina that looks at the anatomy of the pelvic floor muscles and the position of your organs.
Postvoid residual urine volume: Immediately after you void, a small catheter is passed through the urethra into your bladder to empty the remaining urine. This urine is measured and sent for analysis to evaluate for bacteria and blood.
Urodynamics: Urodynamics tests how the bladder functions. Some women with prolapse also have lower urinary tract symptoms such as difficulty passing urine, urinary incontinence, or frequent urination. Urodynamics can reveal information about why this is happening.

Treatments

There are a variety of therapies, both surgical and non-surgical, that effectively treat pelvic organ prolapse and eliminate bothersome symptoms. Each patient is encouraged to consider her treatment goals and values and choose the treatment best suited to her. Options include:

Active Monitoring

Pelvic organ prolapse is not life-threatening, which means that if you do not experience discomfort, you may simply monitor its progress over time. It may stay the same size, or it could worsen as the years pass.

Lifestyle Changes

Some lifestyle changes can help reduce symptoms of pelvic organ prolapse, including:

Eliminating constipation and straining with bowel movements
Losing weight
Treating medical conditions that cause excessive coughing
Quitting smoking: Use of tobacco doubles the risk for developing pelvic floor disorders

Pelvic Floor Physical Therapy

Pelvic floor physical therapy helps rehabilitate the muscles of the core, which include the pelvic floor muscles, the abdominal muscles, the back muscles, and the diaphragm, and to optimize their function. Your physician will evaluate your pelvic floor muscles at your initial consultation and provide a referral if necessary. Learn about our Pelvic Health Physical Therapy Program.

Pessary Therapy

A pessary is a small device that is inserted into the vagina to mechanically support the pelvic organs above the pelvic floor muscles, eliminating the protrusion of tissue from the vagina. Pessaries carry minimal risk, as long as they are removed and cleaned regularly. Most patients can do this themselves, but those who cannot are seen in our office for pessary management by our advanced practice nurses. Women may choose this option if they have not completed their families, if they have medical problems that make surgery unacceptably risky, or if they personally wish to avoid surgery. Learn more about pessary therapy.

Surgery for Pelvic Organ Prolapse

Women desiring definitive treatment of pelvic organ prolapse may opt for a minimally invasive surgical repair. There are a few different surgical options, and a woman may benefit from one type of surgery more than another based on her age, prior surgical history, the severity of prolapse, overall health, and personal treatment goals. Your surgeon will help you determine which surgery is best for you.

Pelvic prolapse surgery almost always involves repair of the vaginal apex, which is the uppermost portion of the vagina and includes the cervix or the vaginal cuff (in women who have undergone hysterectomy). Apical suspensions can be performed using one of three approaches:

Laparoscopic or robotic reconstructive surgery (sacrocolpopexy): Four small (5–8 mm) incisions are made in the abdomen, and the top of the vagina is attached to a strong ligament along the sacral spine using a synthetic material. Patients can go home from the hospital on the day of surgery with minimal pain and recovery time.

Vaginal reconstructive surgery (uterosacral ligament suspension, sacrospinous ligament suspension): An incision is made in the vagina, and stitches are used to attach the top of the vagina to strong ligaments in the pelvis. These surgeries are often referred to as “native tissue repairs” as they are performed using only sutures and a woman’s own tissues. Similar to laparoscopic and robotic procedures, patients usually go home from the hospital on the day of surgery with minimal pain or recovery time.
Vaginal closure surgery (colpocleisis): This procedure is most appropriate for women who do not engage in vaginal intercourse and do not intend to have vaginal intercourse in the future. A colpocleisis shortens the vagina by sewing together the inside vaginal walls. It has the highest success rates and the quickest recovery of all prolapse surgeries, so it can be a good option in women who would like a quicker surgery or are too ill to have reconstructive procedures.

In women who have not undergone hysterectomy, all three surgical procedures can be performed with removal of the uterus, fallopian tubes, and/or ovaries. Some women prefer to keep the uterus in place, and this can be offered in most cases.

Women with pelvic organ prolapse often have urinary incontinence as well, and some are at risk of developing this problem after treatment for prolapse. For this reason, urinary testing is commonly performed before surgery for prolapse so that both problems can be treated at the time of surgery.

Surgical Decision Making

Because decisions about surgery for prolapse are complex and personal, it is important to understand that you are not alone. Our team offers a shared decision-making approach in which the ultimate choice of procedure is made during a discussion between you and your surgeon. During your consultation, you’ll receive an introduction to your surgical options and will be provided access to a computer-based module that provides educational materials and asks about your values and treatment goals. The results of your experience with this module serve as a starting point for your next discussion with your surgeon. This provides an ideal opportunity for all of your questions to be answered and for you to choose the best surgery for you.

Recovery After Surgery

Most women who undergo prolapse surgery will go home from the hospital on the day of surgery. Your physical activity will not be restricted, and you may return to your usual activities and exercise as soon as you feel up to it. Our team has published research showing that women who are able to resume physical activity as soon as they are ready have better surgical outcomes and quality of life than those whose activities are restricted after surgery. Learn more about the Northwestern Medicine Enhanced Recovery After Surgery (ERAS) program.

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If you're suffering from a pelvic floor disorder, you don't have to live with the symptoms. To learn about treatment options, call 312.694.7337 to schedule an appointment with one of our urogynecologists.

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Treatment Options

Learn about common treatment options for pelvic organ prolapse:

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NORTHWESTERN MEDICINE ERAS PROGRAM

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Northwestern Medicine
Urogynecology & Reconstructive Pelvic Surgery