Vaginal Prolapse

The network of muscles, ligaments, and skin in and around a woman's vagina acts as a complex support structure that holds pelvic organs, and tissues in place. This support network includes the skin and muscles of the vaginal walls (a network of tissues called the fascia). Various parts of this support system may eventually weaken or break, causing a common condition called vaginal prolapse.

Vaginal prolapse is a condition in which structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself may begin to prolapse, or fall out of their normal positions. Without medical treatment or surgery, these structures may eventually prolapse farther and farther into the vagina or even through the vaginal opening if their supports weaken enough.

The symptoms that result from vaginal prolapse commonly affect sexual function as well as bodily functions such as urination and defecation. Pelvic pressure and discomfort are also common symptoms.

The following are types of vaginal prolapse:

• Rectocele (prolapse of the rectum): This type of vaginal prolapse involves a prolapse of the back wall of the vagina (rectovaginal fascia). When this wall weakens, the rectal wall pushes against the vaginal wall, creating a bulge. This bulge may become especially noticeable during bowel movements.
• Cystocele (prolapse of the bladder, dropped bladder): This can occur when the front wall of the vagina (pubocervical fascia) prolapses. As a result, the bladder may prolapse into the vagina. When this condition occurs, the urethra usually prolapses as well. A urethral prolapse is also called a urethrocele. When both the bladder and urethra prolapse, this condition is known as a cystourethrocele. Urinary stress incontinence (urine leakage during coughing, sneezing, exercise, etc) is a common symptom of this condition.
• Enterocele (herniated small bowel): The weakening of the upper vaginal supports can cause this type of vaginal prolapse. This condition primarily occurs following a hysterectomy. An enterocele results when the front and back walls of the vagina separate, allowing the intestines to push against the vaginal skin.
• Prolapsed uterus (womb): This involves a weakening of a group of ligaments called the uterosacral ligaments at the top of the vagina. This causes the uterus to fall, which commonly causes both the front and back walls of the vagina to weaken as well. The following are stages of uterine prolapse:
  • First-degree prolapse: The uterus droops into the lower portion of the vagina.
  • Second-degree prolapse: The uterus falls to the level of the vaginal opening.
  • Third-degree prolapse: The cervix, which is located at the bottom of the uterus, sags to the vaginal opening and protrudes outside the body. This condition is also called procidentia, or complete prolapse.
  • Fourth-degree prolapse: The entire uterus protrudes entirely outside the vagina. This condition is also called procidentia, or complete prolapse.
• Vaginal vault prolapse: This type of prolapse may occur following a hysterectomy (surgical removal of the uterus). Because the ligaments surrounding the uterus provides support for the top of the vagina, this condition is common after a hysterectomy. In vaginal vault prolapse, the top of the vagina gradually falls toward the vaginal opening. This may cause the walls of the vagina to weaken as well. Eventually, the top of the vagina may protrude out of the body through the vaginal opening, ultimately turning the vagina inside out. A vaginal vault prolapse is often accompanied by an enterocele.

A large percentage of women develop some form of vaginal prolapse during their lifetime, most commonly following menopause, childbirth, or a hysterectomy. Most women who develop this condition are older than 40 years of age. Many women who develop the symptoms of a vaginal prolapse do not seek medical help because of embarrassment or other reasons. Some women who develop a vaginal prolapse do not experience symptoms.

A network of muscles provides the main support for the pelvic viscera (the vagina and the surrounding tissues and organs within the pelvis). The major part of this network of muscles, which is located below most of the pelvic organs and supports the organs' weight, is called the levator ani. Pelvic ligaments provide additional stabilizing support.

When parts of this support network are weakened or damaged, the vagina and surrounding structures may lose some or all of the support that holds them in place. Collectively, this condition is called pelvic relaxation. A vaginal prolapse occurs when the weight-bearing or stabilizing structures that keep the vagina in place weaken or deteriorate. This may cause the supports for the rectum, bladder, uterus, small bladder, urethra, or a combination of them to become less stable.

Common factors that may cause a vaginal prolapse include the following:

• Childbirth (especially large babies): Childbirth is damaging to the tissues, muscles, and ligaments in and around the vagina. Long, difficult labors and large babies are especially stressful to these structures. Childbirth is the risk factor most commonly associated with cystoceles, in which the bladder prolapses into the vagina. A cystocele is sometimes accompanied by a urethrocele, in which the urethra becomes displaced and prolapses. A cystocele and urethrocele together are called a cystourethrocele.
• Menopause: Estrogen is the hormone that helps to keep the muscles and tissues of the pelvic support structures strong. After menopause, the estrogen level declines; and the support structures may weaken.
• Hysterectomy: The uterus is an important part of the support structure at the top of the vagina. A hysterectomy involves removing the uterus. Without the uterus, the top of the vagina may gradually fall toward the vaginal opening. This condition is called a vaginal vault prolapse. As the top of the vagina falls, added stress is placed on other ligaments. Hysterectomy is also commonly associated with an enterocele, in which the small intestine herniates downward near the top of the vagina.

Other risk factors of vaginal prolapse include:

• Advanced age
• Obesity
• Dysfunction of the nerves and tissues
• Abnormalities of the connective tissue
• Strenuous physical activity
• Prior pelvic surgery

The symptoms most commonly associated with a vaginal prolapse depend on the type of vaginal prolapse present. The most common symptom of all types of vaginal prolapse is the sensation that tissues or structures in the vagina are out of place. Some women describe the feeling as "something coming down" or as a dragging sensation. This may involve a protrusion or pressure in the area of the sensation. Generally, the more advanced the prolapse, the more severe the symptoms.

The following are general symptoms that may be seen with of all types of vaginal prolapse:

• Pressure in the vagina or pelvis
• Painful intercourse (dyspareunia)
• A mass at the opening of the vagina
• A decrease in pain or pressure when the woman lies down
• Recurrent urinary tract infections

• Difficulty emptying bowel: This may be indicative of an enterocele, vaginal vault prolapse, or rectocele. A woman with difficulty emptying her bowel may find that she needs to place her fingers on the back wall of the vagina to help evacuate her bowel completely. This is referred to as splinting.
• Difficulty emptying bladder: This may be secondary to a cystocele, urethrocele, enterocele, vaginal vault prolapse, or prolapsed uterus.
• Constipation: This is the most common symptom of a rectocele.
• Urinary stress incontinence: This is a common symptom often seen in combination with a cystocele.
• Pain that increases during long periods of standing: This may be indicative of an enterocele, vaginal vault prolapse, or prolapsed uterus.
• Protrusion of tissue at the back wall of the vagina: This is a common symptom of a rectocele.
• Protrusion of tissue at the front wall of the vagina: This is a common symptom of a cystocele or urethrocele.
• Enlarged, wide, and gaping vaginal opening: This is a physical finding frequently seen in combination with a vaginal vault prolapse.

Some women who develop a vaginal prolapse do not experience symptoms.

Generally, the most reliable way that a doctor can make a definite diagnosis of any type of vaginal prolapse involves a medical history and a thorough physical examination. This involves the doctor examining each section of the vagina separately to determine the type and extent of the prolapse in order to decide which type of treatment is most appropriate.

During the physical examination, a woman may need to sit in an upright position and strain so that any prolapsed tissues are more likely to become apparent.

Some types of vaginal prolapse such as cystocele or rectocele are more easily identifiable during the physical examination than are types such as vaginal vault prolapse or enterocele.

The following are tests that the doctor may use to evaluate women with advanced vaginal prolapse. Since many of these women also have urinary incontinence, these tests can further evaluate the anatomy and function of the pelvic floor.

• Q-tip test: In this diagnostic test, the doctor inserts a small cotton-tipped applicator lubricated with an anesthetic gel into the woman's urethra. The doctor then asks the woman to strain down. If the applicator raises 30 degrees or more as a result, this means that the urethra descends while straining and is a predictive factor of success of anti-incontinence surgery.
• Bladder function test: This involves a diagnostic procedure called urodynamics. This tests the ability of the bladder to store and evacuate urine (i.e. urinate) and to dispose of it. The first part of this test is called uroflowmetry, which involves measuring the amount and force of the urine stream. The second step is called a cystometrogram. In this step, a catheter is inserted into the bladder. The bladder is then filled with sterile water. The volume at which the patient experiences urgency and fullness are recorded. The pressures of the bladder and urethra are measured and the patient is asked to cough or bear down to elicit leakage with the prolapse pushed up (reduced). This is important clinical information that may assist the surgeon in selecting the correct type of surgery.
• Pelvic floor strength: During the pelvic examination, the doctor tests the strength of the woman's pelvic floor and of her sphincter muscles. The doctor also assesses the strength of the muscles and ligaments that support the vaginal walls, uterus, rectum, urethra, and bladder. These findings help the doctor determine if the woman would benefit from exercises to restore the strength of the muscles of the pelvic floor (for example, Kegel exercises [see Self-Care at Home]).

The following are imaging test that the doctor may use for further diagnostic purposes, if indicated:

• Magnetic resonance imaging (MRI) scan: This imaging tool uses a powerful magnet to stimulate tissues within the pelvis. These tissues produce a signal, which is analyzed by a computer. A 3-dimensional image of the pelvis is then produced on the computer screen using these signals.
• Ultrasound: This diagnostic tool uses sound waves. Sound waves are reflected back when they contact relatively dense structures, such as fibrous tissue or blood vessel walls. These reflected sound waves are then converted into pictures of the internal structures being studied. With an ultrasound, the doctor may visualize the kidneys or bladder in women with urinary incontinence or the muscles around the anus in women with anal incontinence.
• Cystourethroscopy: A cystoscope, which is a small, tubelike instrument, is lubricated with an anesthetic gel and inserted into the urethra. The cystoscope has a light and camera, which allow visualization of the interior of the bladder and urethra on a television screen. With this procedure, the doctor can view inside the urethra and bladder. Cystourethroscopy is especially valuable for women who have symptoms of urinary urgency, frequency, bladder pain, or blood in the urine. It can be performed in the office using local anesthesia.

Any woman who experiences symptoms that may indicate a vaginal prolapse should contact her doctor. A vaginal prolapse is rarely a life-threatening condition. However, most prolapses gradually worsen and can only be corrected with intravaginal pessaries or surgery. Thus, timely medical care is recommended to evaluate for and to prevent problematic symptoms and complications caused by weakening tissue and muscles surrounding the vagina.

• How will the vaginal prolapse affect sexual relations?
• Will the condition affect the ability to have children?
• Are any nonsurgical treatments options appropriate?
• When is surgical repair necessary?

Most vaginal prolapses will gradually worsen over time and can only be fully corrected with surgery. However, the type of treatment that is appropriate to treat a vaginal prolapse depends on factors such as the cause and severity of the prolapse, whether the woman is sexually active, her age and overall medical status, her desire for future childbearing, and her personal preference.

• Nonsurgical options may be most appropriate for women who are not sexually active, cannot undergo surgery because of medical reasons, or experience few or no symptoms associated with the condition.
• Surgical repair is the treatment option that most sexually active women who develop a vaginal prolapse choose because the procedure is usually effective and durable.

Treatments at home for vaginal prolapse include one or a combination of the following:

• Activity modification: For a vaginal prolapse that causes minor or no symptoms, the doctor may recommend activity modification such as avoiding heavy lifting or straining.
• Pessary: A pessary is a small device, usually made of soft plastic or rubber, that is placed within the vagina for support. Pessaries come in many different varieties. This nonsurgical treatment option may be the most appropriate for women who are not sexually active, cannot have surgery for medical reasons or because of advanced age, or plan to have surgery but need a temporary nonsurgical option until surgery can be performed (for example, women who are pregnant or in poor health). Pessaries must be removed and cleaned at regular intervals to prevent infection or erosion into the vaginal walls. Some pessaries are designed to allow the woman to do this herself. A doctor must remove and clean other types. Estrogen cream is commonly used along with a pessary to help prevent infection and vaginal wall erosion. Some women find that pessaries are uncomfortable or that they easily fall out or that they cannot be retained (i.e., they fall out).
• Kegel exercises: These are exercises used to tighten the muscles of the pelvic floor. Kegel exercises can be tried to treat mild-to-moderate cases of vaginal prolapse or to supplement other treatments for prolapses that are more serious.

Many women with a vaginal prolapse may benefit from estrogen replacement therapy. Estrogen helps strengthen and maintain muscles in the vagina. As with hormone therapy for other indications, the benefits and risks of estrogen therapy must be weighed for each individual patient.

Estrogen replacement therapy may be used to help the body strengthen the muscles in and around the vagina. Estrogen replacement therapy may be contraindicated (such as in a people with certain types of cancer) and has been associated with certain health risks including increased risk of blood clots and stroke, particularly in older postmenopausal women. Women's bodies cease producing estrogen naturally after menopause, and the muscles of the vagina may weaken as a result.

In mild cases of vaginal prolapse, estrogen may be prescribed in an attempt to reverse vaginal prolapse symptoms, such as vaginal weakening and incontinence.

For more severe prolapses, estrogen replacement therapy may be used along with other types of treatment.

A generalized weakness of the vaginal muscles and ligaments is much more likely to develop than are isolated defects. If a woman develops symptoms of one type of vaginal prolapse, she is likely to have or develop other types as well. Therefore, a thorough physical examination is necessary for the surgeon to detail what surgical steps are necessary to correct the vaginal prolapse completely. The typical surgical strategy is to correct all vaginal weaknesses at one time.

Surgery is usually performed while the woman is under general anesthesia. Some women receive a spinal or epidural. The type of anesthesia given usually depends on the anticipated length of the surgical procedure.

Laparoscopic surgery is a minimally invasive surgical procedure that involves slender instruments and advanced camera systems. This surgical technique is becoming more common for securing the vaginal vault after a hysterectomy and correcting some types of vaginal prolapse such as enteroceles or uterine prolapses.

• Vaginal vault prolapse: This is a defect that occurs high in the vagina, so it may be approached surgically through the vagina or abdomen. Generally, the abdomen is the entry of choice for a severe vaginal vault prolapse. This corrective surgical procedure usually involves a technique called a vaginal vault suspension, in which the surgeon attaches the vagina to strong tissue in the pelvis or to a bone called the sacrum, which is located at the base of the spine.
• Prolapsed uterus: For women who are postmenopausal or do not want to have more children, a prolapsed uterus is usually corrected with a hysterectomy. The common approach for this procedure is through the vagina.
• Cystocele and rectocele: These are usually corrected through the vagina. Typically, the surgeon makes an incision in the vaginal wall and pushes up the organ. The surgeon then reinforces the tissues beneath the vaginal wall to restore the organ to its normal position. Any excess tissue is then removed, and the vaginal wall is closed. On occasion, the surgeon may elect to use a surgical procedure called a laparoscopic bladder suspension, or modified Burch procedure, to correct a cystocele. If urinary incontinence is present, the surgeon may need to support the urethra (bladder neck suspension).

Women who undergo surgery for vaginal prolapse repair should normally expect to spend 2-4 days in the hospital depending on the type and extent of the surgical. After surgery, women are usually advised to avoid heavy lifting for approximately 6-9 weeks.

Physical therapy such as electrical stimulation and biofeedback may be used to help strengthen the muscles in the pelvis.

• Electrical stimulation: A doctor can apply a probe to targeted muscles within the vagina or on the pelvic floor. The probe is hooked up to a device that measures and delivers small electrical currents that contract the muscles. These contractions help strengthen the muscles. A less intrusive type of electrical stimulation is available that magnetically stimulates the nerve that supplies the pelvic floor muscles from outside the body. This activates these and may help treat incontinence.
• Biofeedback: A sensor is used to monitor muscle activity in the vagina and on the pelvic floor. The doctor can recommend exercises that the woman can use to strengthen these muscles. In some cases, these exercises may help strengthen the muscles enough to reverse or relieve some symptoms related to vaginal prolapse. The sensor can monitor the muscular contractions during the exercises, and the doctor may be able to determine if the targeted muscles would benefit from the exercises.

After surgery, most women can expect to return to a normal level of activity after 3 months.

A woman undergoing treatment should schedule follow-up visits with her doctor to evaluate progress. Pessaries need to be removed and cleaned at regular intervals to prevent infection.

Women at risk for vaginal prolapse (including those who have had corrective surgery) should, if possible, avoid heavy lifting or any activity that increases pressure within the abdominal cavity.

Obesity puts extra stress on the muscles and ligaments within the pelvis and vagina. Weight reduction can help prevent this condition from developing or recurring.

Vaginal prolapse is rarely a life-threatening condition. Some mild cases can be treated without surgery. More severe cases of vaginal prolapse will likely require surgery for correction.

Vaginal prolapse surgery is generally susccessful, but recurrence remains an issue.