Genital prolapse, also known as pelvic organ prolapse (POP), is a common condition affecting a significant number of women, particularly as they age. It occurs when one or more of the pelvic organs (such as the bladder, uterus, or rectum) descend from their normal position and bulge into the vagina. This condition can range in severity from mild to extremely bothersome, impacting a woman’s quality of life.
Recognizing Genital Prolapse: Signs and Symptoms
The symptoms of genital prolapse can vary greatly depending on which organ is prolapsing, the severity of the descent, and individual factors. Some women may experience no symptoms at all, especially with mild prolapse, while others describe significant discomfort and interference with daily activities. It is important to note that symptoms often worsen with prolonged standing, physical activity, or towards the end of the day.
Common signs and symptoms include:
- Pelvic Pressure or Heaviness: This is one of the most frequently reported symptoms, often described as a feeling of “something falling out” or a “dragging” sensation in the vagina or pelvis. This pressure can be constant or intermittent.
- Visible or Palpable Bulge: A noticeable lump or bulge may be felt or seen emerging from the vaginal opening, particularly when coughing, straining, or standing. This is a direct indication of organ descent.
- Urinary Symptoms:
- Urinary Incontinence: Involuntary leakage of urine, especially with coughing, sneezing, laughing, or exercising (stress urinary incontinence).
- Urinary Urgency and Frequency: A sudden, strong urge to urinate and needing to urinate more often than usual.
- Difficulty Emptying the Bladder: A sensation of incomplete bladder emptying, sometimes requiring manual pressure on the perineum or vagina (splinting) to void fully.
- Recurrent Urinary Tract Infections (UTIs): Prolapse can sometimes impede complete bladder emptying, leading to stagnant urine and increased risk of infection.
- Bowel Symptoms:
- Difficulty with Bowel Movements: Constipation or a feeling of incomplete bowel emptying, often requiring digital support (splinting) on the perineum or within the vagina to facilitate defecation.
- Faecal Incontinence: Less common, but can occur if the rectum and anal sphincter are significantly affected.
- Sexual Dysfunction:
- Dyspareunia (Painful Intercourse): Discomfort or pain during sexual activity.
- Reduced Sensation: A feeling of looseness or lack of sensation during intercourse.
- Difficulty with Penetration: Due to the visible bulge.
- Low Backache or Pelvic Pain: While not always solely attributable to prolapse, persistent low backache or a dull ache in the pelvis can sometimes be a symptom, particularly with more severe prolapse or concurrent musculoskeletal issues.
If any of these symptoms are present and are bothersome, it is highly recommended to consult a healthcare professional for an accurate diagnosis and personalized advice.
Factors Influencing Genital Prolapse Risk
Genital prolapse is a multifactorial condition, meaning it arises from a combination of factors that weaken the pelvic floor muscles, fascia, and ligaments that support the pelvic organs. While some factors are beyond an individual’s control, others can be modified to reduce risk.
Key factors contributing to genital prolapse include:
- Childbirth-Related Factors: This is the most significant risk factor.
- Vaginal Delivery: The mechanical stress and stretching of pelvic floor muscles and connective tissues during a vaginal birth significantly increase the risk.
- Multiple Pregnancies/Deliveries: Each subsequent vaginal delivery further increases the cumulative risk.
- Difficult or Instrumental Deliveries: Prolonged labor, large babies, or the use of forceps or vacuum assistance can cause more extensive damage to pelvic support structures.
- Perineal Tears and Episiotomy: Severe tears or surgical cuts during delivery can directly damage support tissues.
- Aging and Menopause:
- Estrogen Deficiency: Estrogen plays a crucial role in maintaining the strength and elasticity of connective tissues. After menopause, declining estrogen levels can lead to thinning and weakening of vaginal and pelvic floor tissues, making them more susceptible to prolapse.
- Increased Intra-Abdominal Pressure: Chronic or repetitive increases in pressure within the abdominal cavity exert downward force on the pelvic floor.
- Chronic Cough: Conditions like chronic bronchitis, asthma, or smoking-related cough can repeatedly strain the pelvic floor.
- Chronic Constipation and Straining: Frequent and forceful straining during bowel movements puts immense pressure on pelvic support structures.
- Heavy Lifting: Occupations or activities involving regular heavy lifting contribute to increased intra-abdominal pressure.
- Obesity: Excess abdominal weight increases the overall pressure on the pelvic floor.
- Genetic Predisposition and Connective Tissue Disorders:
- Family History: Women with a mother or sister who experienced prolapse are at a higher risk, suggesting a genetic component.
- Inherited Connective Tissue Disorders: Rare conditions like Ehlers-Danlos syndrome or Marfan syndrome, which affect collagen synthesis, can lead to weakened connective tissues throughout the body, including the pelvis.
- Prior Pelvic Surgery:
- Hysterectomy: While often performed for prolapse, in some cases, the removal of the uterus can alter pelvic anatomy and potentially lead to new or worsening prolapse, particularly of the vaginal vault.
- Lifestyle Factors:
- Smoking: Nicotine and other chemicals in smoke can impair collagen synthesis and breakdown, weakening connective tissues.
- Nutritional Deficiencies: While less direct, overall poor nutrition can affect tissue health.
Understanding these factors can help individuals and healthcare providers assess risk and implement preventative strategies where possible.
The Stages of Genital Prolapse
Genital prolapse is typically classified into stages based on the degree of descent of the pelvic organs. The most widely accepted system for classification is the Pelvic Organ Prolapse Quantification (POP-Q) system, which provides a standardized, objective method for describing the extent of prolapse. This system uses fixed anatomical points relative to the hymenal ring (the opening of the vagina) to measure the position of the most descended part of the prolapse.
The POP-Q system defines four stages:
- Stage 0: No Prolapse.
- The most dependent portion of any prolapsed organ is at least 3 cm above the hymenal ring. This indicates normal support with no measurable descent.
- Stage I: Mild Prolapse.
- The most dependent portion of the prolapse is still more than 1 cm above the hymenal ring, but has descended from its Stage 0 position. Some initial weakening and descent are present, but the prolapse is not at, or close to, the vaginal opening. Symptoms are often absent or very mild.
- Stage II: Moderate Prolapse.
- The most dependent portion of the prolapse is between 1 cm above and 1 cm below the hymenal ring. This means the prolapse is close to or reaching the vaginal opening. Women in this stage commonly begin to experience symptomatic pelvic pressure or a visible bulge, especially with straining.
- Stage III: Advanced Prolapse.
- The most dependent portion of the prolapse is more than 1 cm below the hymenal ring, but the vagina is not completely everted. A significant portion of the prolapsed organ is outside the vaginal opening. Symptoms are typically more pronounced, including a constant feeling of a bulge or a mass protruding from the vagina.
- Stage IV: Complete Prolapse (Procidentia or Eversion).
- This is the most severe stage, where the entire length of the vagina has everted, and the most dependent portion of the prolapse protrudes at least 2 cm outside the vaginal opening. In essence, the pelvic organs are fully prolapsed outside the body. This stage is usually associated with severe symptoms and significant impact on daily life.
Staging is crucial for diagnosis and for guiding treatment decisions. While higher stages generally correlate with more severe symptoms and a greater likelihood of needing surgical intervention, treatment is always individualized based on symptoms, patient preferences, and overall health.
Managing Genital Prolapse: Advice and Treatment Options
Treatment for genital prolapse is highly individualized, depending on the type and stage of prolapse, the severity of symptoms, the woman’s age, overall health, desire for future pregnancies, and personal preferences. The approach can range from conservative management for mild cases to surgical intervention for more severe or bothersome symptoms.
A. Conservative Management (Advice & Non-Surgical Treatments):
Conservative management is often the first line of treatment, especially for mild to moderate prolapse or for women who wish to avoid surgery.
- Lifestyle Modifications:
- Weight Management: Losing excess weight significantly reduces the intra-abdominal pressure on the pelvic floor.
- Dietary Changes: Increasing fiber intake and ensuring adequate fluid consumption can prevent constipation and reduce straining during bowel movements.
- Smoking Cessation: Quitting smoking improves overall tissue health and reduces chronic cough.
- Managing Chronic Cough: Treating underlying respiratory conditions can alleviate persistent pelvic floor strain.
- Avoiding Heavy Lifting and Straining: Modifying daily activities and adopting proper lifting techniques can prevent further descent.
- Pelvic Floor Muscle Training (PFMT):
- Often referred to as Kegel exercises, PFMT involves strengthening the muscles that support the bladder, uterus, and bowel.
- Role of a Pelvic Floor Physiotherapist: A specialized physiotherapist can accurately assess pelvic floor muscle function and provide personalized guidance on proper technique, exercise regimens, and progression. This is crucial as many women perform Kegels incorrectly.
- Benefits: PFMT can improve symptoms of mild prolapse, prevent progression, and enhance bladder and bowel control. It is also often recommended before and after surgical repair.
- Vaginal Pessaries:
- Description: Pessaries are removable devices, usually made of medical-grade silicone, that are inserted into the vagina to provide mechanical support to the prolapsed organs. They come in various shapes and sizes (e.g., ring, cube, donut).
- Purpose: They physically hold the prolapsed organs in a more anatomical position, thereby relieving symptoms such as pressure, bulge sensation, and sometimes improving bladder and bowel function.
- Management: Pessaries require proper fitting by a healthcare provider and regular removal, cleaning, and re-insertion (either by the woman or a professional) to prevent complications like vaginal irritation, discharge, or infection.
- Advantages: Non-surgical, reversible, and effective for many women.
- Disadvantages: Requires maintenance, can cause discomfort or discharge, may interfere with intercourse (though some types allow for it).
- Topical Estrogen Therapy:
- For post-menopausal women, topical estrogen creams, rings, or tablets applied vaginally can improve the health, thickness, and elasticity of the vaginal and pelvic floor tissues.
- This therapy doesn’t cure prolapse but can alleviate local symptoms like dryness, irritation, and potentially improve the success of PFMT or surgical outcomes by improving tissue quality.
B. Surgical Management:
Surgery is considered when conservative measures fail to adequately relieve symptoms, when the prolapse significantly impacts quality of life, or in cases of advanced prolapse. The goal of surgery is to restore the pelvic organs to their normal anatomical position, alleviate symptoms, and preserve sexual and urinary/bowel function.
There are various surgical approaches, tailored to the type of prolapse and individual patient factors:
- Native Tissue Repair: These procedures use the woman’s own tissues (ligaments and fascia) to reconstruct the pelvic floor support.
- Anterior Colporrhaphy: Repairs a cystocele (bladder prolapse) by reinforcing the front vaginal wall.
- Posterior Colporrhaphy: Repairs a rectocele (rectum prolapse) by reinforcing the back vaginal wall.
- Uterosacral Ligament Suspension/Sacrospinous Fixation: These procedures address apical (top of the vagina/uteri) prolapse by reattaching the vaginal apex (or cervix/uterus if still present) to stronger ligaments within the pelvis.
- Periurethral Bulking Agents: For some cases of stress urinary incontinence associated with prolapse, injections near the urethra can improve bladder control.
- Mesh Repair (Synthetic or Biological):
- While native tissue repair is preferred for most types of prolapse, synthetic mesh may be considered in specific complex cases, especially for recurrent prolapse or severe apical prolapse.
- Sacrocolpopexy: This is considered the “gold standard” for apical prolapse, involving the attachment of a mesh to the top of the vagina and the sacrum (tailbone) to suspend the vagina. It can be performed abdominally (open, laparoscopic, or robotic-assisted). It generally has high success rates with good long-term durability.
- Note on Vaginal Mesh: It is important to distinguish between abdominal sacrocolpopexy and transvaginal mesh procedures. Due to historical complications, the use of transvaginal mesh for prolapse repair has significantly declined and is largely reserved for very specific, complex cases after extensive discussion with the patient.
- Obliterative Procedures (Colpocleisis):
- This surgical option involves closing the vaginal canal, essentially eliminating the space for organs to prolapse into.
- Considerations: It is typically reserved for women who have completed childbearing, do not desire future vaginal intercourse, and may be poor candidates for reconstructive surgery due to other health conditions.
- Advantages: High success rates and shorter recovery times compared to reconstructive surgery.
- Disadvantages: Eliminates the possibility of vaginal intercourse.
Key Considerations for Surgery:
- Type and Severity of Prolapse: Dictates the specific procedure.
- Symptoms: Surgery is primarily for symptomatic relief.
- Patient’s Health: Co-morbidities can influence surgical choice.
- Sexual Activity: Procedures are chosen to preserve or restore sexual function.
- Future Pregnancy: Vaginal delivery after some prolapse surgeries is generally not recommended, which needs to be discussed.
- Risks and Benefits: All surgeries carry risks (infection, bleeding, pain, nerve damage, recurrence of prolapse, new onset of symptoms like incontinence). These must be thoroughly discussed with the surgeon.
Conclusion
Genital prolapse is a prevalent condition that, while often not life-threatening, can significantly impact a woman’s comfort and quality of life. Understanding the signs and symptoms, identifying the contributing factors, and recognizing the stages of prolapse are essential steps towards effective management.
Fortunately, a range of advice and treatment options are available, from lifestyle modifications and pelvic floor therapy to pessaries and surgical interventions. The most appropriate approach is always a personalized one, determined in consultation with a healthcare professional who can accurately diagnose the condition, discuss all available options, and help you make an informed decision that aligns with your health goals and lifestyle. Early intervention and proactive management can greatly improve outcomes and enable women to live fuller, more comfortable lives.
