Prolapse is a condition where the womb or vaginal walls drop down from their normal position. Women may feel that ‘something is coming down’ in the pelvis or have symptoms of a lump or bulge in the vagina. In advanced cases, the lump may protrude out of the vagina and cause discomfort. It is rarely a cause of pain.
Prolapse is very common and around half of women over 50 years old may experience some symptoms. It is also quite common in younger women. It is estimated that around one in ten women will have surgery for prolapse in their lifetime.
What causes prolapse?
Prolapse occurs because of a weakening in the support to the vagina. This weakening is a result of damage to the ligaments and muscles that normally help to keep the womb and the vaginal walls in place.
Pregnancy and childbirth are considered to be the biggest cause of prolapse, although these other factors are recognised:
- heavy lifting, straining, persistent coughing, or constipation
- ageing and the menopause can cause further weakness
- some genetic conditions may cause prolapse, such as those that affect the connective tissues.
What are the different types of prolapse?
Prolapse can affect the vaginal walls or the womb. The prolapse might affect the front wall (a 'cystocele') or the back wall (a 'rectocele') of the vagina, although it is common to have a combination of both problems.
Even if a woman has had a hysterectomy, they can still develop vaginal wall prolapse, again affecting the front or back walls of the vagina, or the very end of the vagina (the 'vaginal vault').
What about bowel and bladder symptoms?
Prolapse often results in displacement of the womb, bladder or bowel out of their normal anatomical position. Bowel and bladder problems may be commonly associated with prolapse, although it is important to realise that the prolapse does not necessarily cause the bladder or bowel problems.
Bowel and bladder function is a complicated process and often results from years of environmental, lifestyle, and structural changes, repair of the prolapse may not therefore mean that bladder or bowel symptoms will improve.
For many women they do after fixing the prolapse, but for a small number of women the symptoms may even worsen. Some women may require separate treatment for problems such as urinary incontinence.
What are the treatments?
The presence of prolapse on its own does not necessarily require treatment. It is important to remember that many women will have a degree of prolapse. This means that there will be some evidence of prolapse for most women, and the real issue is the degree of prolapse and most importantly of all, the degree of bothersome symptoms.
Some women will have quite marked prolapse and be barely aware of any problems; for others quite the opposite is true.
For many women who have symptoms, it may be useful that they get an accurate assessment of the problem and then have the option to decide between the various treatments.
Broadly there are three different options:
- pelvic floor muscle training often with a physiotherapist
- the use of a vaginal support pessary
- an operation to repair the prolapse
Physiotherapy treatment for vaginal prolapse
Physiotherapy is an effective treatment, especially if the prolapse is not too severe. Around half of women who engage in physiotherapy will find that their symptoms improve.
Vaginal pessaries are an alternative treatment. A pessary is a removable device that is placed in the vagina and they relieve prolapse symptoms by keeping the womb and vaginal walls in their normal position. A number of women might experience some bleeding or discharge when they use a pessary.
Surgery can be done vaginally or abdominally, and is usually carried out by keyhole surgery. There are various indications and benefits and risks of either approach. Depending on the extent of prolapse the surgeon may also discuss the need to treat prolapse of the womb.
Following surgery it is usually important that sufficient convalescence is taken and that no undue strain is put upon the sites of the repair for at least six weeks.
It is difficult to accurately predict the progression of prolapse, and major interventions (surgery) ought to be reserved for the time when symptoms are sufficiently intrusive and causing a significant adverse impact on a woman’s lifestyle. This is important as all surgical interventions, whilst improving quality of life for many women, do carry risks and may not last for ever.
It is generally recommended that surgery should be performed after a woman’s family is complete. The concern is that further pregnancy or vaginal delivery might reduce the long-term success of an operation.
If you are concerned about vaginal prolapse, and would like to see an expert to discuss your options, you can do so here.