Pelvic Organ
Prolapse

What do the pelvic organs consist of?

In a woman, the pelvic organs consist of the bladder, uterus and rectum. They are, in turn, supported by a strong pelvic floor.

What are the Different Types of Pelvic Organ Prolapse?

1. Cystocele (Bladder Prolapse)

Bladder prolapse occurs when the fascia (supportive layer) between the bladder and vagina stretches and weakens. This issue causes the bladder to sag and bulge into the anterior (front) vaginal wall. Due to bladder involvement, ladies with a cystocele may experience urinary symptoms such as urinary frequency/urgency, slow urinary stream, and/or sensation of incomplete emptying.

2. Uterine/ vaginal vault prolapse

In this situation, the supportive ligaments holding the uterus become weak, resulting in the uterus slipping down from its usual position and dropping into or out of the vagina. In cases where the woman has had a previous hysterectomy (i.e. removal of the uterus), the top of the vaginal vault can also sag and prolapse into or out of the vaginal opening.

3. Rectocele (Rectal Prolapse)

Rectal prolapse occurs when the fascia weakens, creating a bulge in the back (posterior) vaginal wall. Due to bowel involvement, ladies with a rectocele may experience difficulty in passing motion, feeling of incomplete stool passage and may (in severe cases) even need to press on the back of their vaginal wall to defecate smoothly.

What are the Common Causes of Pelvic Organ Prolapse?

Damage, trauma and progressive weakening of the pelvic floor muscles, ligaments and nerves results in pelvic organ prolapse. Common risk factors include pregnancy and childbirth, particularly prolonged labour/pushing, and assisted vaginal births are important contributing factors.

The pelvic floor weakens further as ladies age and enter menopause, with associated age-related degeneration exacerbated by declining estrogen-related tissue changes. Additionally, factors that chronically increase intra-abdominal pressures, e.g. being involved in strenuous physical work or suffering from chronic cough and constipation/straining, will increase the overall strain on the pelvic floor and up the tendency to develop pelvic organ prolapse in future.

Other (less common) causes include being born with natural/congenital weakness of the pelvic floor muscles, ligaments and fascia – for example, ladies suffering from collagen deficiency diseases are also at risk of developing pelvic organ prolapse.

Do I Have Pelvic Organ Prolapse?

Not all women with pelvic organ prolapse have symptoms. Some get diagnosed only when they go for their routine gynaecological checks. 

Depending on the severity, pelvic organ prolapse symptoms include:

• Dragging sensation in the lower abdomen and pelvis
• An uncomfortable sensation in the vagina, which may include feeling a lump inside or out of the vagina
• Constant pulling backache 
• Abnormal vaginal bleeding and discharge
• Difficulty in walking and sitting
• Difficulty in passing urine and motion
• Difficulty or inability to have sex

You should seek professional help if you feel small bulges in your vagina, even if there are no signs of symptoms or pain before the bump becomes more prominent and uncomfortable.

How is Pelvic Organ Prolapse Diagnosed?

The evaluation of pelvic organ prolapse begins with a thorough medical history and a pelvic examination. This is best done by a urogynaecologist, who will be able to determine the presence, type and severity of prolapse (i.e. bladder, rectum or uterine). Many women may present with multi-compartmental prolapse, which means that they have prolapse involving more than 1 pelvic organ. 

After that, your doctor might do one or more of the following tests to delineate further information:

• Pelvic floor strength test – to ascertain the strength and tone of the pelvic floor muscles. 
• Pelvic ultrasound – to check the uterus and ovaries to make sure there are no abnormal growths and also to check your post-void residual urine (to ensure proper bladder emptying, particularly in cases of cystocele) 
• Urine tests – to rule out other coexisting conditions such as urinary tract infections 
• Urodynamic studies – to check for bladder stability, maximum bladder capacity, presence and severity of urinary incontinence (if any), voiding function

How is Pelvic Organ Prolapse Treated?

Treatment of pelvic organ prolapse depends heavily on the extent of the patient’s symptoms, the presence of complications and how bothered they are by the prolapse. For less severe cases, conservative, non-surgical treatments might be sufficient. However, you may need surgery if your symptoms significantly affect your quality of life.

Treatment options include:

Non-Surgical Treatments

1. Pelvic Floor Exercises (Kegels)
   For mild cases of pelvic organ prolapse, your doctor might recommend pelvic floor exercises to help strengthen the weakened pelvic floor muscle tone and improve the symptoms of your prolapse. Kegel exercises require consistent daily efforts for at least 3 to 6 months for significant improvement to be seen. Working with a trained women’s health physiotherapist can help grasp the proper techniques for maximal effectiveness.
2. Vaginal Pessaries
   Vaginal pessaries are soft, silicone, removable devices inserted in the vagina to support the prolapsed pelvic organs and relieve the symptoms. This method is a temporary treatment as the prolapse will recur once you remove the pessary. Vaginal pessaries come in various shapes and sizes. The most commonly used one in Singapore is the ring pessary, which typically requires removal, wash and replacement by a gynaecologist every 4 months or so; alternatively, if you are comfortable with self-management of the vaginal pessary, you can be taught on how to remove, wash and replace the pessary yourself at home.The advantage of the vaginal pessary is that it can be sized and fitted in the outpatient clinic setting, without the need for an operation or anaesthesia risks. Suppose the correct shape and size is settled upon. In that case, you can generally go about your daily activities with ease and comfort as vaginal pessaries effectively relieve the symptoms of pelvic organ prolapse. However, there are small risks of complications, including discomfort, vaginal erosions, bleeding and infection, particularly in women with post-menopausal tissue changes.
3. Medications
   If you are peri- or postmenopausal, topical vaginal estrogens in the form of creams and tablets may be recommended as menopausal tissue changes may worsen pelvic organ prolapse and its symptoms. These can help alleviate vaginal dryness and thinness and also reduces the risk of vaginal pessary complications.
4. Lifestyle Changes
   This is important to prevent worsening prolapse or recurrent prolapse after treatment and includes modifications such as:
   • Quit smoking
   • Get treatment for underlying medical conditions that increase your intra-abdominal pressure (e.g. constipation, chronic cough etc.)
   • Avoid lifting heavy weights
   • Do regular exercises that strengthen your core and pelvic muscles
   • Eating a healthy diet to maintain a healthy weight

Surgical Treatments

Surgery is usually performed by a trained urogynaecologist and needs to be individually tailored according to the type and severity of prolapse, age and general health.

1. Vaginal Pelvic Reconstructive Surgery
   Surgery for prolapse in the pelvic floor involves making a cut in the vagina and separating the prolapsed organ from the vaginal wall. Your doctor will use stitches or mesh to strengthen the defect in the supporting tissue (fascia), and the vagina skin is then closed to reduce the bulge. In cases where there is a uterine prolapse and no future desire for fertility, a vaginal hysterectomy (surgical removal of the uterus) can also be performed. Via this vaginal approach, there are typically no cuts or scars on the abdomen, and recovery is usually faster.
2. Abdominal Approach (Sacrocolpopexy)
   In certain cases, an abdominal approach may be chosen, particularly if you have had a hysterectomy before or require other procedures to be done abdominally simultaneously and require the vaginal vault to be lifted and supported. This procedure can be done either open (laparotomy) or laparoscopically (keyhole) and involves the use of a Y-shaped permanent synthetic mesh to hitch the front and back walls of the vagina as well as the apex of the vaginal vault up to the sacrum, which is a bony structure that sits at the base of the lumbar spine.
3. Vaginal Closure Surgery
   In rare (and selected) instances, your doctor may recommend vaginal closure surgery (otherwise known as colpocleisis) if you have severe pelvic organ prolapse, which may have failed conservative, non-surgical treatment options and are medically unfit for vaginal pelvic reconstructive surgery. This surgery involves pushing the prolapsed organs back into the vagina and stitching the vaginal walls together. Although this surgery involves shorter anaesthesia time and has a high patient satisfaction rate, it usually requires thorough pre-operative investigations to ensure that it is safe to perform this procedure; it is also important to note that you will permanently not be able to have sexual intercourse following vaginal closure surgery.