Pelvic Organ Prolapse
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What is Pelvic Organ Prolapse?
Pelvic organ prolapse (POP) is common, and it can happen at any stage of a woman's life. It occurs when one or more of the pelvic organs move downwards from their normal anatomical position and bulge (herniate) into the vagina.
The pelvic organs including the bladder, urethra, uterus, vaginal walls, rectum and small bowel are supported by a complex system of muscles, connective tissues, ligaments and the surrounding structures of the pelvis.
When this support system changes, a prolapse may develop.
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Prolapse is not your fault and you are not alone.
Some women have a prolapse without experiencing any symptoms and may only discover it during a pelvic examination. Others may experience a noticeable vaginal bulge, pressure, heaviness, dragging, bladder or bowel changes, discomfort or changes in sexual function.
Importantly, the size or stage of a prolapse does not always correspond to how much it affects you.
A relatively small prolapse can cause significant symptoms for one woman, while another woman may have a more advanced prolapse with very few symptoms.
Your symptoms and quality of life matter.
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What are the different types of pelvic organ prolapse?
Prolapse is usually described according to the part of the vaginal wall or pelvic organ involved. It is also possible to have more than one type at the same time.
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Anterior vaginal wall prolapse
This is commonly referred to as a cystocele and occurs when the bladder and the front wall of the vagina bulge downwards.
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It may be associated with:
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A feeling of vaginal pressure or a bulge
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Urinary leakage
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Urinary urgency or frequency
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Difficulty emptying the bladder
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A feeling that the bladder has not completely emptied.
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A urethrocele describes downward movement of the urethra and its supporting tissues. It may occur alongside an anterior vaginal wall prolapse.
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Cystourethrocele
This describes prolapse involving both the bladder and urethral support.
Posterior vaginal wall prolapse
A rectocele occurs when the rectum pushes forward into the vagina, creating a bulge in the posterior vaginal wall..
It may be associated with:
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Constipation
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Difficulty emptying the bowel
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A feeling of incomplete bowel emptying
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Needing to change position or use gentle pressure to help empty the bowel.
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A uterine prolapse occurs when the uterus and cervix descend towards or into the vaginal canal.
After a hysterectomy, the top of the vagina is called the vaginal vault or vaginal apex. This area can also descend and is known as vaginal vault or apical prolapse.
An enterocele occurs when the small bowel and its surrounding tissues descend into the upper vagina. It may occur alongside other forms of prolapse.
It is quite common for more than one compartment of the vagina to be affected.
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How is prolapse graded or staged?
You may have heard prolapse described as Grade 1, 2, 3 or 4. Clinical practice has largely moved away from using these terms because they do not describe prolapse with enough precision.
Specialist assessment commonly uses the POP-Q system (Pelvic Organ Prolapse Quantification).
POP-Q measures specific points within the vagina in relation to the hymen. This allows clinicians to document the location and extent of prolapse more objectively and to monitor changes over time.
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POP-Q is generally described as Stage 0 to Stage 4:
Stage 0: No prolapse is demonstrated.
Stage 1: The leading edge of the prolapse remains more than 1 cm above the hymen.
Stage 2: The leading edge is within 1 cm above or below the hymen.
Stage 3: The prolapse extends more than 1 cm beyond the hymen but does not represent complete vaginal eversion.
Stage 4: There is essentially complete eversion of the vagina, sometimes referred to as complete uterine or vaginal procidentia depending on the anatomy involved.
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These stages describe anatomical position. They do not, on their own, tell us how much the prolapse is affecting your life.
A woman with Stage 1 or Stage 2 prolapse may have significant symptoms, while another woman with Stage 3 prolapse may experience relatively little difficulty.
This is why a proper assessment considers both the physical findings and the woman experiencing them.
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Why does pelvic organ prolapse happen?
There is rarely one single cause.
Pelvic organ prolapse is considered multifactorial, meaning that several factors may contribute to changes in pelvic support.
These can include:
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Dysfunctional breathing
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Pregnancy and childbirth
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Vaginal birth and birth-related injury
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Increasing age
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Changes associated with menopause
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Genetic or connective-tissue characteristics
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Previous pelvic surgery
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Persistent constipation and straining
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Chronic coughing
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Increased abdominal pressure
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Higher body weight
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Repeated heavy lifting or high physical loads
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Previous pelvic floor dysfunction.
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Some women may develop prolapse despite having done everything they could to look after their pelvic floor.
Prolapse is not simply a matter of having a “weak pelvic floor”.
The pelvic floor is part of a much larger support system involving muscles, connective tissue, fascia, ligaments, nerves and the way the whole body manages pressure and movement.
This is why an individual assessment is so important.
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What symptoms can prolapse cause?
Some women have no symptoms at all.
When symptoms are present, they can include:
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Vaginal and pelvic symptoms
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A feeling of pressure, heaviness or dragging
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A sensation that something is coming down
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Feeling or seeing a bulge at the vaginal opening
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Symptoms that become worse later in the day or after prolonged standing
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Pelvic or vaginal discomfort.
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Bladder symptoms
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Prolapse can sometimes be associated with:
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Stress urinary incontinence
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Urinary urgency
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Increased frequency
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Difficulty starting the urine stream
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Difficulty emptying the bladder completely
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Recurrent urinary symptoms.
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Bowel symptoms
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Some women experience:
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Constipation
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Difficulty emptying the bowel
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Incomplete bowel emptying
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The need to change position or use gentle pressure to assist bowel emptying
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Bowel leakage or difficulty controlling wind.
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Sexual symptoms
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Prolapse can affect sexual wellbeing in different ways.
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Some women experience:
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Discomfort during sex
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A feeling of pressure or bulging
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Reduced confidence
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Concerns about how their body looks or feels
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Changes in sexual function.
These symptoms are personal and deserve to be discussed without embarrassment.
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How is pelvic organ prolapse assessed?
A good prolapse assessment should look beyond simply asking, “How far has it descended?”
Your healthcare professional may ask about:
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Vaginal bulging or pressure
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Bladder function
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Bowel function
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Sexual function
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Pelvic pain
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Your physical activity and lifestyle
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Previous pregnancies and births
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Previous pelvic surgery
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Your personal goals and concerns.
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A pelvic examination may then be performed to identify which areas of the pelvic support system are affected and to document the degree of prolapse.
Where appropriate, clinicians may use the POP-Q system to document the anatomical findings.
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If your symptoms do not match what is seen during an examination, further assessment may sometimes be appropriate. In some women, symptoms may be more apparent when standing, squatting, coughing or straining.
Routine imaging is not normally required simply to diagnose a prolapse when it can be identified clinically.
The important point is that your symptoms, examination findings and goals should all be considered together.
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Does every prolapse need treatment?
No.
If a prolapse is not causing troublesome symptoms, treatment may not be necessary.
However, if your prolapse is affecting your comfort, bladder or bowel function, exercise, work, relationships, sex or confidence, there are treatment options that may help.
The aim is not simply to make an examination look “normal”.
The aim is to help you achieve the **best possible function, comfort and quality of life for you.**
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What treatments are available?
There is no single treatment that is right for every woman.
Current clinical guidance supports shared decision-making, taking into account your symptoms, the type and stage of prolapse, your health, lifestyle, future pregnancy plans, previous surgery and importantly what matters to you.
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Treatment options can include:
1. Watchful waiting and self-management
If your symptoms are mild or not troublesome, you may choose observation and regular review.
Understanding your prolapse and learning how to manage pressure, bowel function, physical activity and pelvic floor function can be very empowering.
2. Pelvic floor muscle training
For women with symptomatic Stage 1 or Stage 2 prolapse, NICE recommends considering a supervised pelvic floor muscle training programme for at least 16 weeks as a first treatment option. (See the resources page for suggested programs and reliable trainers)
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Pelvic floor rehabilitation is not simply about doing more squeezing exercises.
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A specialist pelvic health professional can assess:
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Whether you can correctly contract and relax the pelvic floor
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Muscle strength and endurance
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Coordination
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Breathing and pressure management
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How your pelvic floor responds to movement and exercise
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Bladder and bowel habits
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Constipation and straining
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How your pelvic floor works during everyday activities.
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The goal is to help you use your pelvic floor effectively and functionally not simply to make it stronger.
If pelvic floor training is beneficial, continuing the programme can help maintain those benefits.
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3. Lifestyle and pressure management
Depending on your circumstances, your healthcare professional may discuss:
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Preventing and treating constipation
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Avoiding unnecessary straining
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Managing a chronic cough
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Maintaining a healthy body weight where appropriate
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Modifying heavy lifting or high-impact activities when these aggravate symptoms
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Improving breathing and pressure-management strategies
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Maintaining general physical fitness.
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You should not automatically stop exercising because you have a prolapse.
In many cases, the goal is to help you exercise safely and confidently, rather than avoid movement altogether.
4. Vaginal oestrogen
For some women experiencing menopause-related vaginal or genitourinary symptoms, a clinician may recommend local vaginal oestrogen.
This can help improve vaginal tissue symptoms and may be particularly useful when managing prolapse and pessary use.
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Whether it is appropriate for you should be discussed with your healthcare professional.
5. Vaginal pessary
A pessary is a medical device placed inside the vagina to provide support to the vaginal walls and/or pelvic organs.
Pessaries are an established non-surgical treatment option for symptomatic prolapse and may be used alone or alongside pelvic floor muscle training.
Contact Gaynor Morgan (Pelvic Angel) for individual training or if you are a medical professional for CPD pessary training.
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There are many different pessary designs and sizes.
A ring pessary is commonly used, but it is not suitable for everyone. Other designs may be more appropriate depending on the type and stage of prolapse and the individual's anatomy.
Finding the right pessary can sometimes take more than one fitting and sometimes you may need 2 different types or sizes throughout the day, depending on your activities.
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This does not mean you have failed or that pessaries do not work for you.
It may simply mean that a different size or design is needed.
Pessary care should be individualised. Some women can learn to remove, clean and reinsert their pessary themselves, while others require ongoing clinical support.
Potential problems can include increased vaginal discharge, bleeding, discomfort, difficulty removing the pessary or expulsion. Regular review and appropriate pessary care are important because serious complications can occur if a pessary is neglected.
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6. Surgery
Surgery is one treatment option for pelvic organ prolapse, but it is not automatically required because a prolapse has been diagnosed.
Current NICE guidance recommends offering surgery when symptoms have not improved with, or when a woman has declined, non-surgical treatment.
If surgery is being considered, the decision should be based on shared decision-making and should include discussion of the expected benefits, possible complications, changes to bladder, bowel and sexual function, and the possibility of recurrent prolapse.
You have the right to understand your options before making a decision.
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Can prolapse get improve/reduce/reverse?
Yes, symptoms/prolapses can change over time.
Some women find that their symptoms remain stable, some experience improvement, while others notice progression.
Some women have managed to fully reverse their prolapses.
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Treatment does not always mean that the prolapse will completely disappear.
Instead, treatment may help to:
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Reduce symptoms
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Improve pelvic floor function
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Improve bladder or bowel function
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Provide physical support
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Improve confidence with exercise and daily activities
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Improve quality of life.
For some women, a combination of approaches works best.
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You do not have to navigate prolapse alone
Being told you have a prolapse can be frightening particularly if you have been told that an organ has “dropped”.
But a prolapse diagnosis does not mean that you are broken, that you must stop exercising, or that surgery is inevitable.
There are many ways to manage prolapse, and the right approach depends on you.
If you are unsure what type of prolapse you have, your symptoms do not seem to match your diagnosis, your pessary is uncomfortable or repeatedly falls out, exercise is making your symptoms worse, or you simply want to understand your options, seeking advice from a clinician experienced in pelvic health can be extremely valuable.
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At Pelvic Angel, my aim is to help women understand what is happening in their bodies, understand the options available to them, and feel confident asking the right questions of their healthcare professionals.
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You deserve to understand your prolapse and you deserve choices.
The information on this website is provided for education and does not replace an individual assessment or diagnosis from an appropriately qualified healthcare professional. If you have new, severe or unexplained symptoms, difficulty passing urine or stool, significant bleeding, severe pain, or a sudden change in your prolapse, seek appropriate medical assessment.
