FAQs Prolapse

Genitourinary prolapse occurs when the normal support structures for the organs inside a women’s pelvis (uterus, bladder and lower bowel/rectum) are weakened and no longer effective. The result is that one or more of the organs can drop down into the vagina. When this happens it is known as prolapse. This may lead to no symptoms at all but more usually causes discomfort in the vagina as well as other symptoms, including urinary and bowel problems.

Depending on which part of the pelvis is affected, genitourinary prolapse is divided into the following (different parts of the pelvis can be affected at the same time):

Front of the pelvis (anterior)

• Cystocele – prolapse of the bladder into the vagina.
• Urethrocele – prolapse of the urethra into the vagina.
• Cystourethrocele – prolapse of both the urethra and the bladder into the vagina at the same time. Cystourethrocele is the most common form of genitourinary prolapse.

Rear of the pelvis (posterior)

• Rectocele – prolapse of the rectum into the vagina. This is also a common form of genitourinary prolapse.

Middle of the pelvis

• Uterine prolapse – prolapse of the uterus (womb) into the vagina is the second most common form of genitourinary prolapse.
• Vault prolapse – during a hysterectomy (removal of the uterus), the end of the vagina that would normally attach to the cervix is closed up. This now blind-end of the vagina is referred to as the vaginal vault, and can prolapse into the vagina.
• Enterocle – prolapse of the pouch of Douglas (the space between the rectum and the uterus) into the vagina.

It is difficult to estimate how many women are affected by genitourinary prolapse because many women do not visit their doctor for help. It is thought that up to 50% of women who have had children have some degree of prolapse but that only 10% of those with prolapse seek medical advice.

The following may increase the risk of genitourinary prolapse:

• Childbirth – genitourinary prolapse is more likely after a difficult, prolonged labour, a forceps delivery, or if a woman gives birth to a large baby. It also becomes more likely the more times a woman has given birth.
• Gynaecological surgery – a hysterectomy, or other gynaecological surgery may have weakened the ligaments, pelvic floor muscles and other support structures for the pelvic organs.
• Increased pressure inside the abdomen – increase in pressure can occur in women who are overweight, who have persistent lung problems such as a chronic cough, who regularly lift heavy objects, or who frequently strain due to constipation.
• Increasing age – as a woman gets older, her chance of genitourinary prolapse increase. This is due to the lack of oestrogen hormone that occurs after the menopause, which affects the pelvic floor muscles and structures around the vagina, making them less springy and supportive.
• Congenital problem – rarely genitourinary prolapse could be due to a collagen deficiency. Collagen is needed to help form the ligaments that normally support the pelvic organs.

There are a number of things that may help to prevent genitourinary prolapse, such as:

• Regular pelvic floor exercises (especially if you are planning to get pregnant, are pregnant, or have given birth).
• Eat a high-fibre diet (plenty of fruit and vegetables and wholegrain bread and cereal) and drink plenty of water to avoid constipation.
• Stoping smoking.
• Losing weight, if you are overweight.
• Avoid occupations that involve heavy lifting.

Watchful waiting

If you have little in the way of symptoms, you may choose to wait and see if they become worse. It is a good idea to visit your doctor for regular check-ups in case you develop any new symptoms.

There are a number of things that you may be able to do to help prevent the prolapse from getting any worse:

• If you are overweight, it may help to lose weight.
• If you smoke, try to give up. Coughing can make prolapse worse.
• Eat a high-fibre diet and drink plenty of water to help avoid or relieve constipation.
• Try to avoid heavy lifting.
• Try to take a frequent breaks during the day, where you can put your feet up and rest.

Pelvic floor exercises
Pelvic floor exercises are recommended for all women with GU prolapse, however they are not likely to improve prolapse that is already present. The exercises help to stop mild degrees of prolapse from getting any worse and to relieve symptoms such as abdominal discomfort and backache.

Vaginal oestrogen creams
For mild prolapse, oestrogen cream applied to the vagina may help ease feelings of discomfort. Symptoms may return once the cream is stopped.

Vaginal pessary
A vaginal pessary is recommended for women who do not wish to have surgery, are waiting for surgery, or  who have other illnesses that make surgery risky.

The pessaries are usually in the shape of a ring and made of silicone or plastic. They are inserted into the vagina and left in place to help lift up the walls of your vagina and any prolapse of your womb. They should be changed every 6 to 12 months.

Vaginal pessaries rarely cause any problems but have been known to affect the skin inside the vagina, which can become ulcerated. Some women experience some discomfort during sexual intercourse.

The aim of surgery is to provide a permanent cure for genitourinary prolapse and there are various operations available, depending on the type of prolapse. Your Consultant can advise which operation is best for you.

• Vaginal repair operation – the walls of the vagina are reinforced and tightened up, by making a tuck in the wall of your vagina. Stitches are then used to hold the tuck in place. Surgery is usually performed through the vagina, avoiding cuts to the abdomen.There are different types of vaginal repair operation and in some cases, a mesh or special tape may be sewn into the vaginal walls. 
  
• Hysterectomy – removal of the uterus. Genitourinary prolapse is the most common reason why women over the age of 50 have a hysterectomy.
• Sacrospinous fixation – during this operation, the vagina is hitched up and stitched to a ligament inside the pelvis (the sacrospinous ligament). It is usually carried out through your vagina rather than the abdomen.
• Sacrohysteropexy – a special mesh is used that acts like a kind of sling to help to support the uterus and hold it in place. One end of the mesh is attached to the cervix and the other to the bone at the back of the pelvis (the sacrum). This operation is usually done through a cut in the abdomen.
• Sacrocolpopexy – during this operation, the vagina is hitched up and held in place by fixing it to the sacrum. A mesh or another material is usually used to hold the vagina in place. This operation is also done through a cut in the abdomen.
• Infracoccygeal hysteropexy or colpopexy – newer techniques where the mesh is inserted through the vagina rather than making a cut in the abdomen.

You are likely to need to stay in hospital for a few days after your operation. Full recovery may take up to six to eight weeks. You should avoid heavy lifting and sexual intercourse during this time. There is a small chance that a prolapse can return after surgery.

Left untreated, GU prolapse will usually gradually get worse. The outlook is best for younger women who are of a normal weight and are in good health. The outlook is worst for older women, those in poor physical health and those who are overweight. GU prolapse can return after surgery in about 16% of women.