Pelvic Organ Prolapse

What is pelvic organ prolapse?

Pelvic organ prolapse is a condition in which one or more of the organs in the pelvis slip down from their normal position and press into or out of the vagina. The pelvic organs include the bladder, the uterus (womb), the rectum (the last part of the bowel), and the top of the vagina itself. These organs are normally held in place by the pelvic floor, a group of muscles, ligaments, and connective tissue that stretches like a hammock across the bottom of the pelvis. When this support weakens or is damaged, the organs can drop, or prolapse, from their usual place.

Doctors describe prolapse by which organ is involved and how far it has moved:

• Anterior vaginal wall prolapse (cystocele): the bladder bulges into the front wall of the vagina. This is the most common type.
• Posterior vaginal wall prolapse (rectocele): the rectum bulges into the back wall of the vagina.
• Uterine prolapse: the uterus drops down into the vagina.
• Vaginal vault prolapse: the top of the vagina sags down, which can happen after the uterus has been removed (hysterectomy).
• Enterocele: a section of small bowel pushes against the upper part of the vagina.

Pelvic organ prolapse affects women, and it becomes more common with age, particularly after menopause. Many women who have given birth vaginally have some degree of prolapse, although a large number have no symptoms and never need treatment. It is not a cancer and it is not usually dangerous, but it can affect comfort, bladder and bowel function, sexual health, and quality of life. In many hospitals, including the Gynecology & Obstetrics department at Acibadem, the condition is managed by gynecologists, sometimes together with specialists in urogynecology (a field that focuses on pelvic floor disorders) and pelvic floor physical therapy.

Pelvic organ prolapse symptoms

Pelvic organ prolapse symptoms vary widely. Some women with a noticeable prolapse on examination feel nothing at all, while others with a milder prolapse are quite troubled by it. Symptoms are often worse at the end of the day, after standing for long periods, or after heavy lifting, and they may ease when lying down.

Common symptoms include:

• A feeling of heaviness, pressure, or dragging in the pelvis or vagina
• A sensation that something is coming down or falling out of the vagina
• A bulge or lump that can be seen or felt at the vaginal opening
• Difficulty emptying the bladder completely, a slow or interrupted urine stream, or needing to change position to pass urine
• Leaking urine, especially when coughing, sneezing, or exercising (stress urinary incontinence)
• Frequent urinary tract infections
• Constipation, straining, or a feeling that the bowel has not emptied fully; some women need to press on the vagina or perineum (the area between the vagina and anus) to pass stool
• Discomfort or reduced sensation during sex
• Low back ache or pelvic aching that improves when lying down
• Vaginal spotting or irritation if tissue protrudes and rubs against clothing

The pattern of symptoms often reflects the type of prolapse. Bladder-related problems such as incomplete emptying or leakage are more typical of anterior (bladder) prolapse. Bowel-related symptoms such as straining are more typical of posterior (rectal) prolapse. Uterine or vaginal vault prolapse tends to cause the strongest sensation of heaviness or a bulge. In advanced prolapse, where tissue sits outside the vaginal opening most of the time, the exposed skin can become dry, sore, or ulcerated (an open, raw area), and it may bleed.

Doctors often describe the extent of prolapse in stages. In early stages the organ has moved only slightly and stays inside the vagina. In later stages the organ reaches or passes the vaginal opening. Symptoms do not always match the stage exactly, which is one reason a clinical examination is important.

Causes and risk factors

Pelvic organ prolapse causes come down to one underlying problem: the pelvic floor muscles and connective tissues have been stretched, weakened, or torn, so they can no longer hold the organs firmly in place. Several factors can contribute to this, and most women who develop prolapse have more than one.

• Pregnancy and childbirth: carrying a baby and, in particular, giving birth vaginally place significant strain on the pelvic floor. A long labor, a large baby, several vaginal births, or a delivery that required forceps may increase the risk.
• Aging and menopause: after menopause the body produces less estrogen (a hormone that helps keep pelvic tissues thick and elastic), and the tissues gradually weaken.
• Long-term pressure on the pelvic floor: chronic constipation and straining, a persistent cough (for example from smoking or lung disease), and repeated heavy lifting can slowly stretch the supporting tissues.
• Excess body weight: being overweight adds ongoing downward pressure on the pelvic organs.
• Previous pelvic surgery: hysterectomy removes the uterus and can alter the support at the top of the vagina, which may contribute to vaginal vault prolapse in some women.
• Inherited connective tissue differences: some women appear to be born with weaker connective tissue, and prolapse can run in families. Certain connective tissue disorders also raise the risk.

Having risk factors does not mean prolapse will develop, and some women develop prolapse without any obvious risk factor. Your doctor may ask about these factors because addressing some of them, such as constipation or a chronic cough, can form part of treatment.

Pelvic organ prolapse diagnosis

Pelvic organ prolapse diagnosis is based mainly on your description of symptoms and a physical examination. In most cases no complex testing is required to confirm the condition itself, although tests may be used to understand how it is affecting the bladder or bowel.

• Medical history: your doctor will ask about your symptoms, when they occur, your pregnancies and births, previous surgery, bladder and bowel habits, and how the problem affects your daily life.
• Pelvic examination: this is the key step. The doctor examines the vagina, usually with you lying down and sometimes also standing, and may ask you to cough or bear down (push as if having a bowel movement) so that any prolapse becomes visible. A speculum (a smooth instrument used to gently hold the vaginal walls apart) helps the doctor see which wall or organ is involved.
• Staging: many clinicians use a standardized system called the Pelvic Organ Prolapse Quantification (POP-Q) system, which measures how far each part of the vagina has descended relative to the vaginal opening. This gives a stage from 0 (no prolapse) to 4 (complete prolapse) and allows changes to be tracked over time.
• Pelvic floor muscle assessment: the doctor may check how well you can squeeze the pelvic floor muscles, which helps in planning physical therapy.
• Urine tests: a urine sample may be checked for infection, and the amount of urine left in the bladder after passing urine may be measured using a small ultrasound device or a catheter (a thin tube).
• Urodynamic testing: if there are significant bladder symptoms or surgery is being considered, tests that measure bladder pressure and function may be recommended.
• Imaging: ultrasound or, less commonly, MRI (magnetic resonance imaging, a scan that uses magnets to create detailed pictures) may be used in complex cases, for example when several compartments are involved or when the examination findings do not explain the symptoms. A specialized X-ray or MRI of bowel emptying (defecography) is occasionally used for bowel-related symptoms.

Because prolapse can coexist with other conditions, such as urinary incontinence or other gynecologic problems, the examination often looks for these as well.

Pelvic organ prolapse treatment options

Pelvic organ prolapse treatment options range from simple lifestyle changes to surgery. The right approach depends on the type and stage of prolapse, how much the symptoms bother you, your age and general health, whether you plan to have more children, and your personal preferences. Prolapse that causes no symptoms often does not need any active treatment.

Watchful waiting and lifestyle measures

If symptoms are mild, your doctor may suggest monitoring the prolapse and making changes that reduce strain on the pelvic floor. These commonly include treating constipation with adequate fluid and fiber intake, avoiding heavy lifting where possible, managing a chronic cough, stopping smoking, and losing weight if you are overweight. These steps do not reverse a prolapse, but they may ease symptoms and help slow progression.

Pelvic floor muscle training

Pelvic floor exercises, sometimes called Kegel exercises, strengthen the muscles that support the pelvic organs. They are most effective when taught by a pelvic floor physical therapist who can check that you are contracting the correct muscles. Supervised training over several months can reduce symptoms in many women with early-stage prolapse and is often recommended alongside other treatments, including before and after surgery.

Vaginal estrogen

For women after menopause, a low-dose estrogen cream, tablet, or ring placed in the vagina may be prescribed to improve the thickness and health of the vaginal tissue. This does not correct the prolapse itself, but it can reduce dryness and irritation and may make a pessary more comfortable to use. Your doctor will discuss whether it is suitable for you.

Vaginal pessary

A pessary is a removable device, usually made of silicone, that is placed inside the vagina to hold the prolapsed organs in position. Pessaries come in many shapes and sizes, and a fitting appointment is needed to find one that stays in place comfortably. Some women learn to remove and clean the pessary themselves; others return to the clinic every few months for this. Pessaries are a widely used non-surgical option for women of any age, including those who wish to avoid or delay surgery or who are not well enough for an operation. Possible side effects include vaginal discharge, irritation, or, rarely, small sores on the vaginal wall, so regular checks are important.

Surgery

Surgery may be considered when symptoms significantly affect quality of life and non-surgical measures have not helped enough. Several approaches exist, and the choice depends on which organs are involved and other individual factors:

• Native tissue repair: the surgeon uses stitches to tighten and reinforce the woman’s own supporting tissue, usually through the vagina. Anterior and posterior repairs are examples.
• Suspension procedures: the top of the vagina or the cervix is attached to strong ligaments in the pelvis to lift and hold it in place. This can be done through the vagina or through the abdomen, often with keyhole (laparoscopic or robotic) techniques.
• Hysterectomy: removing the uterus is sometimes performed as part of a repair for uterine prolapse, although uterus-preserving options are also available and are discussed with each patient.
• Mesh procedures: synthetic mesh is sometimes used in abdominal suspension procedures. The use of mesh placed through the vagina has been restricted or withdrawn in many countries because of complications, and any proposal to use mesh should be discussed in detail with your surgeon.
• Obliterative surgery (colpocleisis): for women who no longer wish to be sexually active, the vaginal canal can be narrowed or closed to support the organs. This is a shorter operation that may suit older women with other health problems.

All surgery carries risks, including infection, bleeding, injury to nearby organs, pain during sex, new or persisting bladder symptoms, and the possibility that the prolapse returns over time. Your surgeon should explain the expected benefits and risks of each option so that you can make an informed decision.

Living with pelvic organ prolapse and outlook

Pelvic organ prolapse is a chronic condition, meaning it tends to persist or progress slowly over years rather than resolve on its own. However, it is not life-threatening, and for many women the symptoms can be controlled well with conservative measures alone. Progression is unpredictable: some prolapses stay stable for a long time, while others gradually worsen, particularly if the pelvic floor continues to be strained.

Day to day, many women find it helps to plan activity so that periods of standing or lifting are broken up with rest, to keep bowel movements soft and regular, and to continue pelvic floor exercises as a long-term habit. Prolapse can affect body image, confidence, and intimacy, and it is reasonable to raise these concerns with your doctor; support from a pelvic health physical therapist or counselor may be useful.

After surgery, most women experience an improvement in their symptoms, but no operation can guarantee a permanent result. Recurrence is possible, especially in women with weak connective tissue or ongoing strain on the pelvic floor, and some women eventually need a second procedure. Recovery from surgery usually involves several weeks of avoiding heavy lifting and strenuous exercise, and your care team will give specific guidance. Long-term follow-up is common whether you choose a pessary, physical therapy, or surgery, so that any change can be addressed early.

Frequently asked questions

What does pelvic organ prolapse feel like?

Many women describe a feeling of heaviness, fullness, or pressure in the vagina or pelvis, as though something is coming down. Some can feel or see a soft bulge at the vaginal opening, especially at the end of the day. Others notice only bladder or bowel changes, such as difficulty emptying, and have no sensation of a bulge at all.

Can pelvic organ prolapse go away on its own?

An established prolapse generally does not reverse by itself, because the supporting tissue has already been stretched. Mild prolapse noticed shortly after childbirth may improve as the body recovers over the following months. For other women, symptoms can often be reduced with pelvic floor training and lifestyle changes, even though the anatomy does not fully return to normal.

Is pelvic organ prolapse dangerous?

In most cases pelvic organ prolapse is not dangerous, and it is not a form of cancer. Rarely, a severe prolapse can make it difficult to empty the bladder, which may lead to repeated infections or, very rarely, kidney problems, and exposed tissue can become sore or ulcerated. These situations are uncommon and are usually detected and managed during routine follow-up.

How is pelvic organ prolapse diagnosed?

Diagnosis is made mainly through a pelvic examination, during which your doctor looks for the prolapse while you cough or bear down and may grade it using a standardized staging system. Urine tests, bladder function tests, or imaging such as ultrasound or MRI are sometimes added when bladder or bowel symptoms are significant or when surgery is being planned.

Do I need surgery for pelvic organ prolapse?

Not necessarily. Many women manage their symptoms with pelvic floor exercises, a vaginal pessary, and measures that reduce strain on the pelvic floor. Surgery is usually considered only when symptoms are bothersome enough to affect daily life and non-surgical options have not helped sufficiently. The decision is individual and is made together with your doctor.

Can I exercise with pelvic organ prolapse?

Staying active is generally encouraged, as it supports overall health and weight management. Low-impact activities such as walking, swimming, and cycling are often well tolerated. High-impact exercise and heavy lifting may worsen symptoms in some women, so your doctor or a pelvic floor physical therapist can help you adapt your routine.

Will pelvic organ prolapse come back after treatment?

Recurrence is possible after surgery, and it is more likely in women with weaker connective tissue, ongoing constipation or coughing, or heavy physical work. Continuing pelvic floor exercises and reducing strain on the pelvic floor may lower the chance of recurrence, but no treatment can offer a guarantee. Regular follow-up allows any return of symptoms to be addressed early.

When to see a doctor

It is a good idea to see a doctor if you notice a bulge in or outside the vagina, a persistent feeling of heaviness or pressure in the pelvis, or new difficulties with emptying your bladder or bowel. These symptoms are common and treatable, and an early assessment can help you understand your options. If you already use a pessary, keep your scheduled review appointments even if you feel well.

Seek prompt or urgent medical attention if you experience any of the following:

• You are unable to pass urine, or you can pass only very small amounts with pain or a feeling of a very full bladder
• Fever, chills, or pain in the lower back or side together with urinary symptoms, which may indicate a kidney infection
• Heavy or persistent vaginal bleeding, or bleeding after menopause
• Prolapsed tissue that has become dark, very painful, or cannot be pushed back inside
• Severe pelvic or abdominal pain
• A pessary that has caused bleeding, significant pain, or a foul-smelling discharge
• Signs of infection or worsening pain after prolapse surgery

These signs do not necessarily mean something serious is happening, but they should be assessed by a healthcare professional without delay.