Pelvic Organ Prolapse (POP) is a not-uncommon condition that involves a general weakening of the connective tissue, supportive ligaments, and muscles of the pelvic floor (levator ani) It most commonly occurs as a result of vaginal birth, even if vaginal birth is largely uncomplicated.
There is a component of heredity, with POP occurring in women and their mothers, aunts, and daughters. It can equally occur after hysterectomy, as a result of menopause, as well as repetitive straining forces on the pelvic floor over many years due to chronic constipation, chronic coughing from asthma, or smoking. Even high-impact exercises such as jumping and weight lifting can exert straining force on the pelvic floor.
A bladder prolapse, known as a cystocele, is when the bladder protrudes down into the vaginal canal and sometimes sits at or beyond the vaginal opening. It can cause the symptoms of a vaginal bulge, bladder/pelvic/vaginal pressure, or “a ball” or “a mass” presenting at the vaginal opening. It can mimic the sensation of sitting on a ball. It may recede or withdraw when laying down but then descends and protrudes after long periods of standing, walking, or straining. But typically, there is no pain with a cystocele.
At times it is discovered accidentally and is completely without symptoms. Common urinary symptoms that may indicate a cystocele is present include:
Other symptoms may include mild burning with voiding urine, frequent urination in the daytime or night to void, the very strong sense of urgency to void, or in the inability to hold urine and then leaking with urgency.
If retained urine collects in the bladder, a woman may sense bladder or lower pubic pressure, as well as present a risk for urinary tract infections. A bulging cystocele can also be uncomfortable during sex.
A prolapsing rectum through the vagina is known as a rectocele. At times it can co-exist with the weakening of the perineal skin/muscles that are in between the lower vaginal opening and the anus. This can commonly occur after vaginal childbirth especially if an episiotomy or vaginal tearing occurred during birth.
Often, rectoceles are without symptoms, but at times can cause a sense of vaginal bulging, “a mass” at the vaginal opening, a sense of not being able to empty a bowel movement, a sense of bowel movement frequency, or even constipation.
At times, women who have trouble emptying their bowels due to a rectocele will find it easier to stabilize the perineal skin/muscles and the lower vaginal opening during the bowel movement by holding pressure on this area to assist in passing stool.
An apical prolapse occurs when the small intestine pushes the upper portion of the vaginal canal down as a protrusion into the vagina. It most commonly occurs after a hysterectomy and can very often be found in conjunction with a cystocele or rectocele at the same time. Uncommonly it can present by itself.
A careful exam can help delineate the degree of the apical prolapse and determine if it co-exists with other prolapses. In addition, if the woman still has her uterus, it can descend and protrude down into the vaginal canal. This is known as a procidentia. If it is more severe, the cervix can be visible at or close to the opening of the vagina. A procidentia can also co-exist with other prolapses such as a cystocele or rectocele. All three can co-exist together, in addition to perineal muscle weakness.
Depending on the type of prolapse, its severity, and if it causes any pelvic symptoms as noted above, there are a variety of non-surgical and surgical ways to treat the prolapsing organs.
Assessment of lifestyle choices, activities, and smoking status can help reduce progression or worsening of the prolapses. At times, urinary leakage (urinary incontinence) and/or stool leakage from the anus (fecal incontinence) can exist in conjunction with the prolapses, and if they are present, can also be addressed when coming in for an exam and consultation to determine the best course of action.