Figuring out the cause of pelvic pain can be challenging. With muscles, organs, and nerves so close together, finding the root cause can be difficult and takes some investigative work. One condition that should be considered is pelvic organ prolapse, a condition commonly found in women who have had children and/or who are going through menopause.

I understand this firsthand. After the birth of my daughter in 2009, I was diagnosed with pelvic organ prolapse. I tried a few treatments and worked closely with my ob/gyn before getting pregnant again to ensure I would even be able to carry another baby. During the third trimester of my second pregnancy, my prolapsed uterus put even more pressure on my bladder and caused extra pain. After my second child was born in 2013, my prolapse symptoms continued to worsen until I turned to surgery. I had a hysterectomy and rectal prolapse repairs. Three years later, I needed a vaginal vault repair for vaginal prolapse.

Since then, I’ve not had additional pelvic organ prolapse symptoms, but the struggle is definitely real. And finding the right doctor to see for treatment is also a challenge. For my second prolapse surgery, I drove four hours from home to see a urogynecologist who was highly trained in such repairs. That was after having seen a urogynecologist closer to home who insisted my prolapse couldn’t be causing me any symptoms and told me to go to a pain clinic. I’m glad I didn’t stop there, because the right doctor helped me so much.

As with so many things that are health-related, the more we understand about them, the better we can advocate for ourselves and our treatment. Knowing about pelvic organ prolapse, its risk factors, symptoms and treatments is important for all IC patients.

What is Pelvic Organ Prolapse?

Simply put, pelvic organ prolapse occurs when the vagina, uterus, bladder and/or rectum descend downward into the vagina. This doesn’t mean your organs are literally going to fall out of your body — the odds of that happening are extremely low. But, it does mean your organs can shift and move lower than they should be.

Pelvic organ prolapse becomes an issue when it causes symptoms. For example, while 40 to 50% of women have some degree of prolapse upon examination, many don’t have symptoms. In that case, there is no need for any further treatment or concern.(1) Not all pelvic organ prolapse is created equal. Doctors use measurements to assign degrees to prolapse form 0 to 4, with 0 being no prolapse and 4 being the most severe.(2)

There are five types of prolapse that can occur together or independently.(3)

  1. Cystocele or urethrocele (anterior vaginal wall prolapse): This happens when the bladder drops from its normal position because the front wall of the vagina sags downward or outward.
  2. Enterocele: This term refers to when the top of the vagina weakens and allows the small intestine to bulge into the vagina.
  3. Rectocele (posterior vaginal wall prolapse): This describes what happens when the rectum bulges upward into the vagina due to a weakened perineum or vaginal wall.
  4. Uterine prolapse: This occurs when the uterus slides down into the vaginal canal or beyond the vaginal opening due to weakening of the supports to the uterus and vagina.
  5. Vaginal vault prolapse: For women who have had a hysterectomy, this can happen when the upper support of the vagina weakens and the vaginal walls sag or fall into the vaginal canal or beyond the vaginal opening.

Risk Factors

Though doctors cannot predict who will experience prolapse, certain risk factors increase your likelihood of doing so:

  • Pregnancy and childbirth: Both being pregnant and having a vaginal delivery can damage muscles and nerves in the pelvis. In fact, 30% of women who have given birth have prolapse to some degree. The risk increases further for women who had a large baby, needed forceps during delivery or had many babies.
  • Menopause and aging: Estrogen helps strengthen the pelvic floor. Loss of estrogen during menopause as women age can weaken the pelvic floor and increase chances for prolapse. Ages 70 to 79 is the peak incidence of prolapse diagnosis.(4)
  • Being overweight: Extra weight increases the pressure on tissues in the pelvis and can make them more likely to descend.
  • Chronic constipation: Straining to have a bowel movement weakens the tissues in the pelvis, increasing the chance for them to move.
  • Chronic coughing: Coughing causes the pelvic floor to move downwards. Repeated coughing can lead to weakened tissues in the pelvis and, in turn, to prolapse.(5)
  • Heavy lifting: Extreme weight lifting or repeatedly picking up heavy items can cause pressure and stress on the pelvis.
  • Genetics: Your genes factor into the strength of your connective tissue. The weaker that tissue is, the higher your risk for prolapse.
  • Smoking: Smoking weakens all tissues in the body, including those holding up your pelvic organs.

Symptoms of Pelvic Organ Prolapse

Symptoms vary in severity and in type from one patient to the next. The most common bothersome symptom of pelvic organ prolapse is referred to as the “vaginal bulge.” This means a bulge of vaginal tissue is felt during daily activities like wiping or sitting.

Pressure is another symptom. This can include discomfort, aching or fullness in the pelvis that gets worse when standing, coughing or as the day goes on.(6) Pelvic floor muscle spasms can also cause symptoms similar to these, so having a pelvic floor assessment is recommended before attributing these symptoms to pelvic organ prolapse.

Using a tampon can be challenging. It may not stay in place or be very uncomfortable.

Some less common symptoms include interference with intercourse due to the bulge getting in the way, obstruction of the urine flow and trouble with having bowel movements without moving the vagina.

Symptoms not usually caused by pelvic organ prolapse are pelvic pain, back pain or painful sex. If your doctor attributes those symptoms to prolapse, consider getting a second opinion.

Treatments

Pelvic organ prolapse has a few treatment options that range from self-help to surgery. Typically, doctors and patients start with moderate interventions and work from there. (That’s what my doctor and I did.)

Self-help

Some lifestyle and behavior changes can help keep prolapse from worsening or prevent it from occurring (especially if you have numerous risk factors). These include the following:

  • managing constipation
  • avoiding lifting heavy items
  • keeping your weight in a normal range
  • stopping smoking (if you are a smoker)

Physical therapy

Pelvic floor physical therapy isn’t just for helping a tight pelvic floor, which is what we usually talk about in the IC community. It can also help with preventing prolapse from worsening. A trained pelvic floor physical therapist can help you strengthen your pelvic floor muscles to aid in holding your organs in place without increasing tightness.

Vaginal device

A pessary is a silicone device that comes in different shapes and sizes and is inserted into the vagina to help lift the bladder or vaginal walls. Pessaries are inserted by patients themselves, a lot like a diaphragm is. Pessaries can usually stay in for a month or more between cleanings. They do need to be removed for intercourse but can then be re-inserted.

Pessaries have a high success rate. Approximately 90% of women who have bothersome symptoms from mild to moderate prolapse find relief with pessaries. For women with moderate to severe prolapse, the pessary success rate is 64 to 70%, which is still a pretty high success rate. If you are trying a pessary, work with your doctor to ensure you have the right fit. It may take trying different sizes and styles to find what works for you.

Surgery

Multiple surgical options are available for treating pelvic organ prolapse. The type of surgery depends on what organ(s) is prolapsed, the severity of the prolapse, symptoms and more. Doctors recommend not having any surgical repair for prolapse until you are finished having babies since pregnancy and childbirth can undo repairs that have been made.

When it comes to surgical repairs, the biggest decision is what to use for the repair: the patient’s own tissues or synthetic mesh. Generally, synthetic mesh is only recommended when the risk of surgery failing without it is high, because mesh has a history of severe complications, including infection, recurring UTI, bleeding and mesh erosion.(7) Mesh has been known to travel through other tissue, such as the wall of the vagina, urethra or bladder requiring surgical repair and/or removal.  If your doctor has recommended mesh, seek a second opinion, preferably from an ob/gyn or urologist who has done a fellowship in pelvic reconstructive surgery, to be sure mesh is the best choice for you.

References:

  1. Glass D. Demystifying Pelvic Organ Prolapse. At the Forefront: U Chicago Medicine. Jan. 30, 2019.
  2. Gunter J. The Vagina Bible. Piatkus. 2019.
  3. American Urogynecologic Society. Pelvic Organ Prolapse. 2016.
  4. American Urogynecologic Society. AUGS Guidelines: Pelvic Organ Prolapse. Female Pelvic Medicine & Reconstructive Surgery. Nov.-Dec. 2019 Volume 25, No. 6.
  5. Kenway M. Prolapse and Coughing — How to Cough and Avoid Prolapse Worsening. Pelvic Exercises Physiotherapy.
  6. Office on Women’s Health. Pelvic Organ Prolapse. U.S. Department of Health and Human Services. Feb. 22, 2021.
  7. Cleveland Clinic.  Surgical Mesh: Use and Complications in Women.  09/30/2020. Accessed 02/03/23