Understanding vaginal prolapse: a guide for patients

Vaginal prolapse is a common but often under-discussed condition affecting many women, particularly those who have experienced childbirth or gone through menopause. Although it can cause a range of symptoms, effective treatment options are available. In this article, a consultant gynaecologist with a specialist interest in urogynaecology, Mr Jonathan Bradley, provides an overview of vaginal prolapse, including why it happens and what can be done to manage or treat it.

What is vaginal prolapse?

Vaginal prolapse occurs when the muscles and tissues supporting the pelvic organs —including the bladder, uterus, and bowel — become weakened or stretched. As a result, one or more of these organs can bulge into the vagina, leading to discomfort and a feeling of pressure.

There are different types of vaginal prolapse depending on the organ involved. These include:

Cystocele (bladder prolapse)
Rectocele (bowel prolapse)
Uterine prolapse
Vault prolapse (after hysterectomy)

In many cases, more than one type may occur at the same time. While prolapse is not life-threatening, it can have a significant impact on quality of life, causing discomfort and feelings of shame.

What causes vaginal prolapse?

Vaginal prolapse is primarily caused by weakening of the pelvic floor muscles and connective tissue. Several factors can contribute to this weakening, including:

Vaginal childbirth, particularly after difficult or instrumental deliveries
Ageing and the natural drop in oestrogen after menopause
Chronic coughing, constipation, or heavy lifting, all of which increase pressure in the abdomen
Obesity, which adds strain on the pelvic floor
Previous pelvic surgery, such as hysterectomy

Women who have had multiple pregnancies or large babies are more likely to develop vaginal prolapse.

The symptoms and complications of vaginal prolapse

Symptoms of vaginal prolapse vary depending on the type and severity of the prolapse. Some women may have no symptoms at all, while others may experience:

A feeling of heaviness or pressure in the pelvis
A bulge or lump in the vagina, which may be felt or seen
Discomfort during intercourse
Urinary symptoms, such as incontinence, urgency, or difficulty emptying the bladder
Bowel symptoms, including constipation or incomplete emptying

These symptoms often worsen with prolonged standing or physical activity and improve when lying down.

If left untreated, prolapse can lead to worsening symptoms and complications such as recurrent urinary tract infections or ulceration of the exposed vaginal tissue.

How is vaginal prolapse treated?

A diagnosis is usually made following a clinical examination by a GP or specialist. In many cases, further tests are not required, though urodynamic testing or imaging may be used in complex cases or when planning surgery. It's important to have a thorough discussion about symptoms, lifestyle, and treatment preferences, as these all guide the treatment approach.

Treatment depends on the severity of the prolapse and how much it affects a woman's daily life. Broadly, options fall into conservative and surgical categories.

Conservative treatments include:

Pelvic floor muscle exercises (physiotherapy), which can help strengthen support structures
Use of a vaginal pessary, a removable device inserted into the vagina to support the prolapsed organs
Lifestyle modifications, such as weight loss, treating chronic cough or constipation, and avoiding heavy lifting

These options are often effective for mild to moderate prolapse or in women who prefer to avoid surgery.

Surgical treatment may be considered for more severe cases or when conservative measures are not effective. Procedures vary depending on the type of prolapse but may involve repair of the vaginal walls, hysterectomy, or suspension of the vaginal vault. These operations are usually performed vaginally, though some may be done laparoscopically.

Recovery from surgery generally takes several weeks, and patients are advised to avoid heavy lifting or strenuous activity during this time.