Vaginal prolapse and uterine prolapse

Normally, the body’s internal organs are so tightly bound together by connective tissue and muscles that they stay in place. However, the connective tissue in a woman’s pelvic floor can weaken for various reasons.

As a result, the uterus, urinary bladder, or rectum can prolapse. In some cases, the organs drop so far down in the pelvis that the vagina bulges through the vaginal opening or the uterus emerges from the vagina. Doctors refer to this as vaginal or uterine prolapse (genital prolapse).

Bladder prolapse is the most common condition. This is when the bladder pushes down and against the vaginal wall. However, because the organs are connected, they often descend together. Prolapse is treated primarily through pelvic floor exercises (also known as Kegel exercises), silicone supports (pessaries) or surgery.

Women who experience a mild weakening of the pelvic floor often do not have any symptoms at all. However, the following symptoms can occur if the organs prolapse further:

• feeling that something is pressing down
• foreign body sensation in the lower abdomen
• urinary incontinence, increased urinary urgency, or difficulty urinating
• pulling pain in the lower abdomen
• pain during sexual intercourse
• difficulty with bowel movements
• back pain and lower back pain
• pressure sores and bleeding in the vagina

Pain, pressure, and foreign body sensations occur especially when standing, walking, or having a bowel movement. When lying down, these symptoms often subside. It is a significant burden on women if their vagina and uterus protrude from the vaginal opening and visibly bulge outward.

Their sex life is also severely impaired. Many women with severe prolapse also have feelings of shame.

Organ prolapse is caused by excessively weak muscles and weak connective tissue in the pelvic floor. Doctors refer to this as pelvic floor weakness (pelvic floor insufficiency). In some women, weaker connective tissue is hereditary.

Other factors are:

• Vaginal birth: this can weaken and damage the pelvic floor. The risk of vaginal and uterine prolapse is not increased following a cesarean section.
• Age: muscles and connective tissue weaken with age. This can make the support structures in the pelvic floor less stable.
• Weight: women who are very overweight (obese) are at an increased risk of a vaginal prolapse and uterine prolapse.

Pressure on the pelvic floor may also weaken the connective tissue, for example through heavy lifting and carrying, chronic coughing or frequent constipation. However, few studies on this have been conducted to date. It is therefore unclear what impact these types of stresses have.

It is also unclear whether removal of the uterus increases the risk of prolapse. However, it is suspected that the bowel and bladder have less support after a hysterectomy and descend more easily.

About half of all women experience a slight weakening of the pelvic floor over the course of their lives. Approximately 3% of all women have a prolapse with symptoms present.

There are four different stages of vaginal and uterine prolapse. The stage depends on how far the bladder, uterus, or bowel have descended into the pelvis.

• Stage 1: the organs have prolapsed only slightly.
• Stage 2: the organs have prolapsed as far as the vaginal opening.
• Stage 3: the vagina or uterus protrude from the vaginal opening by up to 1 cm.
• Stage 4: vagina or uterus protrude substantially from the vaginal opening.

In most cases, the prolapse is slight. A slight prolapse may even recede after a few months or years. However, a pelvic organ prolapse can also progress slowly.

About half of women with mild pelvic organ prolapse (stage 1 or 2) also have urinary incontinence. Doctors refer to this type of incontinence as stress incontinence. The reason is that the bladder can no longer withstand the pressure that occurs, for example, when coughing, sneezing or exercising, and releases some urine unintentionally.

In contrast, those with a stage 3 or 4 prolapse tend to have more difficulty emptying the bladder. This is because more severely prolapsed organs can cause the urethra to bend.

Regularly exercising the pelvic floor strengthens the pelvic muscles and the pelvic floor. After childbirth, postnatal exercises can strengthen the pelvic floor again. It is sometimes also recommended that the woman should avoid lifting or carrying heavy objects so as to prevent excessive pressure on the pelvic floor. Pressure on the pelvic floor may be relieved by treating chronic cough and chronic constipation. However, there are insufficient studies to show whether these measures, or even weight loss, can actually prevent pelvic organ prolapse.

In the case of vaginal prolapse and uterine prolapse, a visit to the doctor is often prompted by general abdominal discomfort or bladder problems. Severe pelvic organ prolapse can be detected with a vaginal examination. Doctors can detect a mild prolapse by palpating the organs in the pelvis, from the outside and through the vagina.

In addition, the vagina is examined with a medical instrument (speculum). By palpating the bowel through the anus, doctors can assess the location of the organs in the back of the pelvis. These examinations are usually sufficient to detect a pelvic organ prolapse and determine its severity.

In addition, a cough stress test can be used to determine whether stress incontinence is present. This is the case if urine is passed when coughing vigorously.

If there are problems with urination, a post-void residual urine test can be performed. The patient first goes to the toilet and urinates to empty the bladder as much as possible. The doctor then uses an ultrasound device to check whether there is still urine in the bladder.

Treatment of vaginal prolapse and uterine prolapse largely depends on whether symptoms occur. The severity of the prolapse plays a secondary role.

Factors that will determine which type of treatment to use include:

• which symptoms are to improve and how burdensome they are
• the age of the patient
• whether the patient wants to have children in the future
• whether the patient wants to keep her uterus
• which organ has prolapsed and how far
• how well non-surgical treatments work
• whether urinary incontinence or other conditions are present

Treatment options for vaginal prolapse and uterine prolapse include:

• Pelvic floor exercises to strengthen the muscles
• Therapeutic pessaries: these consist of differently sized cups, cubes, or rings made of rubber or silicone. A pessary is inserted into the vagina to support the organs in the pelvis. These pessaries are not to be confused with pessaries used for contraception.
• Surgery: this involves lifting and stabilizing the organs in the pelvis. In some cases, removal of the uterus (hysterectomy) is also considered.

Some women with a pelvic organ prolapse can sufficiently alleviate their symptoms with pelvic floor exercises or a therapeutic pessary. If neither of these treatments helps, if the symptoms continue to worsen or if the uterus protrudes further from the vaginal opening, surgery may be an alternative. In general, the uterus remains intact after surgery.

The decision aid from gesundheitsinformation.de can help you choose an appropriate treatment for uterine prolapse.