Pelvic organ prolapse (vaginal prolapse)

The female pelvis is home to several organs including the uterus (womb), the bladder and the rectum. The pelvic floor is a structure of muscles and ligaments that supports and holds all these organs in place.      
 
If the pelvic floor becomes weak or unable to do its job effectively, one or more of these organs can drop from their normal position and bulge into the vagina. This is known as a prolapse – or, to give it its correct medical name, a pelvic organ prolapse (sometimes also called a genitourinary prolapse, pelvic floor prolapse, or a vaginal prolapse).

A vaginal prolapse may not be serious or life threatening. But if you have more than a mild case it can be painful quite uncomfortable.    
 

 How common are vaginal prolapses?

Pelvic organ prolapse is very common in the UK, with up to 40 - 60 per cent of women who have given birth to a child and one in 12 women in the community affected (though experts admit it’s difficult to put a more precise figure on the number of those who experience a prolapse, since some may not see a doctor for help) (i).      
 

Types of pelvic organ prolapse

There are four main types of pelvic organ prolapse, though it’s common to have more than one type at the same time:
 

Anterior (bladder) prolapse   

An anterior prolapse is when either the bladder or the urethra - the tube that carries urine from the bladder and empties it out of the body – bulges into the front of the vagina.
 

• When the urethra prolapses into the vagina it’s called a urethrocele. This is often associated with urinary stress incontinence 

• A prolapse of the bladder into the vagina is called a cystocele

• A prolapse of both the urethra and the bladder into the vagina is called a cystourethrocele (this is the most common type of prolapse)

 

Posterior (rectal) prolapse  

 
Also called a rectocele, this is caused by the rectum – the lower part of the large bowel – bulging into the back wall of the vagina. Another type of posterior prolapse is called an enterocele, which is when the small bowel bulges into the back wall of the vagina.
 

Uterine prolapse   

 
The second most common type of pelvic organ prolapse, this is when the uterus drops down into the vagina. In some cases the uterus can drop right down and protrude outside of the vagina – if it’s completely outside the vagina it’s called a procidentia.
 

Vault prolapse  

 
Some women who’ve had surgery to remove their uterus (hysterectomy) can find the top of their vagina that used to be attached to their cervix (neck of the uterus) sags down. This is called a vault prolapse because the end of the vagina that used to be attached to the cervix is called the vaginal vault.
 

Vaginal prolapse diagnosis

 
Pelvic organ prolapses are diagnosed at various grades or stages, depending on how far down the prolapse has descended into the vagina. Diagnosed by internal examination, one of the grading systems called the Pelvic Organ Prolapse Quantification (POP-Q) system was developed by the International Continence Society. It has five stages, ranging from stage 1 (no prolapse) to stage 4 (complete eversion of the vagina – that is, the vagina has been completely turned inside out). 
 

Vaginal prolapse symptoms

Some women with a pelvic organ prolapse don’t realise they have a problem because they don’t have any symptoms. In such cases, prolapses are only diagnosed after an internal examination for another reason – a cervical smear test, for example. It is, however, common to have some symptoms, with general symptoms including:
 

• A sensation of a lump or a ‘dragging’, or ‘coming down’ sensation in your vagina (you may even be able to feel a bulge or lump with your fingers)

• A sensation of heaviness around the lower part of your abdomen and your genitals

• Pain in your vagina, back or abdomen

• An unpleasant smelling or blood-stained vaginal discharge 

• Discomfort, pain or numbness during sex

 
Any of the above symptoms can often become worse when you stand for long periods and improve when you lie down. Other symptoms, meanwhile, are often specific to the type of prolapse you have. For instance, if you have an anterior prolapse you can have urinary symptoms such as:
 

• Frequent need for urination

• Sudden urges to urinate

• Interrupted urine flow (stopping and starting) 

• Needing to urinate again soon after you’ve urinated because you feel your bladder hasn’t emptied properly 

• Leaking urine when you cough, sneeze, laugh or lift something heavy

 
Urinary complications can happen too – these can include urine infections, urinary incontinence and not being able to urinate at all (if this happens you may need to have your bladder drained by using a tube called a catheter),
 
On the other hand if you have a posterior prolapse you may experience bowel-related symptoms such as constipation, excess wind, feeling a sudden urge to pass stools, feeling your bowels haven’t emptied fully, bowel incontinence (being unable to control your bowels) and the sensation of a blockage when you’re passing stools.
 

What causes a prolapse?

We know that pelvic organ prolapses are caused by one or more of the pelvic organs dropping down into the vagina, but why this happens to some women and not others isn’t completely clear. Some things, however, may make you more susceptible to developing a pelvic organ prolapse, including:
 

Age

As women age, risk of prolapse increases due to weaker and less elastic pelvic floor structures. Especially after menopause, when oestrogen levels plummet.    
 

Childbirth  

Not all women who give birth develop a prolapse, but those who had a difficult or long labour,  had a forceps or suction delivery or  gave birth to a large baby may have a higher-than-normal risk. Having a vaginal delivery rather than a caesarean section is also thought to increase your risk of having a prolapse, as is giving birth when you’re aged 30 or older.
 

Increased abdominal pressure  

Things that increase the pressure inside the abdomen and pelvis can also increase the risk for a prolapse because of the strain they put on the pelvic floor. Pregnancy and childbirth are two examples, but other things include being overweight or obese, constipation, frequently lifting heavy weights and having a chronic lung problem such as a persistent cough.
 

Hysterectomy  

Having your uterus surgically removed – as well as having other types of gynaecological surgery – can make you more likely to develop a prolapse because these operations may weaken the pelvic floor. If you have keyhole surgery however, your risk may be lower.
 

Family history  

If someone in your close family has incontinence (urinary or bowel) or an overactive bladder, you may also have a higher-than-average risk of developing a prolapse. Experts also think that having a mother or sister who has a pelvic organ prolapse might increase your risk too (ii). 
 

Other conditions that can increase your risk of vaginal prolapse

 
Other medical conditions that have been identified as possible risk factors for pelvic organ prolapse include diabetes, and gynaecological cancers (and their treatments). Your lifestyle may also be to blame – for instance, smoking and being inactive have both been linked with an increased risk of developing a prolapse (i). 
 

Vaginal prolapse treatment

Pelvic organ prolapse isn’t usually treated in women who have no or very mild symptoms. Those who have more troublesome symptoms may be treated with hormones, with a device called a vaginal pessary or by having surgery. With or without symptoms, however, you will usually be advised to do pelvic floor exercises to help make your pelvic floor muscles stronger (read on to find out more about pelvic floor exercises).       

Mild pelvic organ prolapse

 
If your prolapse is mild and you’ve been through the menopause, your doctor may recommend hormone replacement treatment (HRT). The hormone in this case is oestrogen, which you may be prescribed in a cream format, vaginal tablets or a vaginal ring that releases oestrogen into your body.
 
The other main non-surgical treatment is a device called a vaginal pessary. Pessaries are often prescribed for moderate or severe prolapses and are plastic or silicone devices that fit in the vagina where they help support the pelvic organs. Available in different types and sizes – the most common type looks like a ring – pessaries are often an option for women who want to have children in the future, for those who would prefer to avoid having surgery and for women with medical conditions that make surgery more risky (they’re also often used in women who are waiting to have prolapse surgery).
 
According to the Royal College of Gynaecologists, vaginal pessaries don’t usually cause any problems but they can sometimes cause infection, discharge, bleeding or ulceration (iii). They also have to be changed or removed, cleaned and reinserted regularly (usually between every four to 12 months). Sometimes you may need to try more than one type and size of pessary before you find one that works best for you.
 

Vaginal prolapse surgery

 
If you have a severe prolapse or if other treatments haven’t worked for you, your GP may recommend that you have a surgical procedure. Some of the main types of surgery for pelvic organ prolapse include the following:
 

• Hysterectomy (removal of the uterus): this is often used to treat a uterine prolapse (it’s the most common reason why women aged 50 or older have a hysterectomy (ii)). A hysterectomy is only suitable for women who have been through the menopause and for those who don’t want to have any more children.

• Vaginal repair surgery: during these procedures the walls of the vagina are reinforced and tightened by making a tuck in the vagina wall and stitching it in place. There are several different types of vaginal repair surgery.

• Obliterative surgery involves closing off the vagina completely, and is only used in cases of advanced prolapse when other treatments haven’t worked and for those who no longer want to have sex.

 
Meanwhile vaginal mesh surgery – which places a piece of synthetic mesh inside the vagina to hold the pelvic organs in place – is no longer routinely offered for pelvic organ prolapse on the NHS because it has caused significant complications in some women who have had the operation. Nowadays it’s only an option if there’s no alternative treatment available.
 

Exercises for your pelvic floor

 
Pelvic floor muscle training is widely recommended for most women with mild pelvic organ prolapse, or even those who aren’t experiencing any symptoms. Also known as Kegel exercises, they are also help with      stress incontinence, as they help keep the pelvic floor muscles strong.
 
These exercises teach you how to actively tense or squeeze your pelvic floor muscles and can be done easily at any time of day (in fact you can practice them in almost any situation and nobody will realise what you’re doing).
 
The pelvic floor muscles are the muscles you use to stop urinating. If you’ve been diagnosed with a pelvic organic prolapse your doctor or specialist will help you get started and may recommend a number of different exercises – the following may be among them:
 

• Slowly tighten and pull up your pelvic floor muscles as hard as you can and for as long as you can, then rest for four seconds and repeat. Build up gradually until you can do 10 slow contractions at a time, holding them for 10 seconds each with rests of four seconds in between.

• When you get more experienced, practice drawing in the muscles quickly, holding them for just a second before relaxing. Build up to 10 quick contractions in succession.

 
Work towards doing eight repetitions of each exercise three times a day.
 

How to treat a prolapse without surgery      

 
Alongside vaginal pessaries and HRT for menopausal women, making a few changes to your lifestyle may help if you have a mild prolapse, and may even stop the prolapse from getting worse.
 
If you’re heavier than you should be, losing weight can help reduce the pressure the extra weight puts on your pelvic floor considerably. Read more about the benefits of losing weight in our weight-loss guide.
 
It’s also a good idea to avoid lifting anything heavy if that’s possible (if you have to lift something heavy, try squeezing your pelvic floor muscles while you do it, and lift by bending your knees and keeping the weight as close to your body as possible).
 
Constipation can put a lot of pressure on your pelvic floor too, so try avoiding it by making sure your diet contains enough fibre. Your fibre intake should be between 18 - 21g per day, with roughly three fifths coming from fruit, pulses and vegetables (soluble fibre) and two fifths from wholemeal bread, brown rice, wholemeal pasta and nuts (insoluble fibre) (iv). Drinking plenty of fluid can also help prevent constipation – aim for 1.5 - 2 litres, 3 - 4 pints or 6 - 8 glasses a day.      
 
Some of the other things you could do, if they apply to you, include giving up smoking, getting treatment for a persistent cough (quitting smoking will help with that too) and avoiding exercises that put pressure on your pelvic floor such as running, jumping or trampolining. Staying active, however, is still important as it can help you control your weight.
 

Watch your posture

 
Even the way you stand or walk can help prevent an existing prolapse from becoming worse. For instance, when you stand, try to stretch the space between the bottom of your ribs and the top of your pelvic bones on both sides – this may help reduce the pressure in your abdomen. Keep that waist lengthening feeling when you walk too, and imagine there’s a string attached to the top of your head that’s pulling you upwards. Also as you walk try to get into the habit of tightening your pelvic floor muscles – not all the way, but about half of your normal squeeze.
 
Most importantly, if your symptoms get worse the longer you stand or walk, take regular breaks and only walk as far as you feel comfortable at any one time.
 

Can supplements help vaginal prolapse symptoms?

 
Another lifestyle change you could make is to start taking a nutritional supplement that may help relieve pain and discomfort or one that supports your pelvic ligaments. Some of the supplements you may want to consider trying include the following:
 

PEA (palmitoylethanolamid)  

PEA is a fatty acid made naturally by the body and found in all cells, tissues and fluids (it’s also found in foods such as soya beans, peanuts, eggs, flaxseed and milk). PEA is an alternative to CBD, since both substances are thought to have similar properties including the ability to reduce pain and inflammation. Studies have suggested PEA may be a safer option than CBD, given its more extensive research and more robust safety profile (vi) with no known side effects (v).
 

Bioflavonoids  

These plant compounds found in a variety of fruits, vegetables and teas – including green tea, pomegranates and turmeric – are believed to help keep body tissues including ligaments healthy. Certain bioflavonoids – including anthocyanidins – are thought to stimulate collagen production (collagen being a protein that’s essential for strong, elastic connective tissues). Anthocyanidins are available in nutritional supplements or in foods such as dark-skinned fruits such as blueberries, cranberries, raspberries, blackberries and red grapes, as well as vegetables including red cabbage, red onions and aubergine.
 

Vitamin C  

Vitamin C contributes to normal collagen formation. As well as in supplements you can find it in a range of fruits and vegetables including chilli peppers, Brussel sprouts, broccoli, blackcurrants, kale, kiwi fruit, papayas and cantaloupe melon, to name just a few of the richest sources. Some vitamin C supplements also contain bioflavonoids.
 

Zinc  

This important mineral is found in all of the body’s tissues, including ligaments. It’s also a component of many enzymes and proteins that help with tissue repair (vii). Zinc is available in supplements as well as in foods such as fish, shellfish, meat, nuts, seeds, pulses and whole grains.
 

High-strength fish oils 

Often recommended for their anti-inflammatory properties, the omega-3 fatty acids found in oily fish such as salmon, sardines, mackerel and herring may help with recovery of the pelvic floor, including after childbirth (viii).      

Multivitamin and mineral  

A good-quality multivitamin and mineral supplements may be more convenient if you decide to take more than one of the recommended nutrients     .
 

Can pelvic organ prolapse be prevented?

 
There may not always be anything you can do to prevent having a pelvic organ prolapse – after all you can’t do anything about getting older or having a family member who has experienced it. However, some of the things you can do to stop a prolapse getting worse may also help prevent one, such as giving up smoking, treating a chronic cough or chronic constipation, losing weight and avoiding activities that put too much pressure on your pelvic floor.      
 
It’s also a really good idea to practice pelvic floor exercises throughout your life, even if you don’t have a prolapse or a problem with bladder weakness. There’s more information if you need it in this NHS guide to pelvic floor exercises for women. 
 

Need more information?

 
Pelvic floor prolapse is just one of many health conditions that affect women. To find out more about a wide range of women’s health issues, take a look around the women’s health section of our pharmacy health library. 

References:

1. Available online: https://patient.info/womens-health/genitourinary-prolapse-leaflet

2. Available online: https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/pelvic-organ-prolapse-patient-information-leaflet/

3. Available online: https://www.uhd.nhs.uk/uploads/about/docs/our_publications/patient_information_leaflets/physiotherapy/011-22_prolapse_-_lifestyle_advice.pdf

4. Clayton P. et al., Palmitoylethanolamide: A Natural Compound for Health Management. Int J Mol Sci. 2021 May;22(10): 5305. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8157570/

5. Clayton P. et al., Palmitoylethanolamide: A Potential Alternative to Cannabidiol. J Diet Suppl. 2021 Nov;28;1-26. Available online: https://www.tandfonline.com/doi/full/10.1080/19390211.2021.2005733

6. Chasapis CT. et al., Recent aspects of the effects of zinc on human health. Arch Toxicol. 2020 May;94(5):1443-1460. Available online: https://link.springer.com/article/10.1007/s00204-020-02702-9

7. Tackacs P. et al., Randomized controlled trial for improved recovery of the pelvic floor after vaginal delivery with a specially formulated postpartum supplement. Obstet Gynecol Sci. 2020 May;63(3): 305-314. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7231945/

Disclaimer: The information presented by Nature's Best is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. Self-treatment is not recommended for life-threatening conditions that require medical treatment under a doctor's care. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or pharmacist for any health problem and before using any supplements or before making any changes in prescribed medications.

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