Vaginal Prolapse Overview

The network of muscles, ligaments, and skin in and around a woman's vagina acts as a complex support structure that holds pelvic organs, tissues, and structures in place. This support network includes the skin and muscles of the vagina walls (a network of tissues called the fascia). Various parts of this support system may eventually weaken or break, causing a common condition called vaginal prolapse.

A vaginal prolapse is a condition in which structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself may begin to prolapse, or fall, out of their normal positions. Without medical treatment or surgery, these structures may eventually prolapse farther and farther into the vagina or even through the vaginal opening if their supports weaken enough.

The symptoms that result from vaginal prolapse commonly affect sexual functions and bodily functions such as urination and defecation. Pelvic pressure and discomfort are also common symptoms.

The following are types of vaginal prolapse:

• Rectocele (prolapse of the rectum) - This type of vaginal prolapse involves a prolapse of the back wall of the vagina (rectovaginal fascia). When this wall weakens, the rectal wall pushes against the vaginal wall, creating a bulge. This bulge may become especially noticeable during bowel movements.
  
  
• Cystocele (prolapse of the bladder, bladder drop) - This can occur when the front wall of the vagina (pubocervical fascia) prolapses. As a result, the bladder may prolapse into the vagina. When this condition occurs, the urethra usually prolapses as well. A urethral prolapse is also called a urethrocele. When both the bladder and urethra prolapse, this condition is known as a cystourethrocele. Urinary stress incontinence (urine leakage during coughing, sneezing, exercise, etc) is a common symptom of this condition.
  
  
• Enterocele (herniated small bowel) - The weakening of the upper vaginal supports can cause this type of vaginal prolapse. This condition primarily occurs following a hysterectomy. An enterocele results when the front and back walls of the vagina separate, allowing the intestines to push against the vaginal skin.
  
  
• Prolapsed uterus (womb) - This involves a weakening of a group of ligaments called the uterosacral ligaments at the top of the vagina. This causes the uterus to fall, which commonly causes both the front and back walls of the vagina to weaken as well. The following are stages of uterine prolapse:
  
  
  • First-degree prolapse: The uterus droops into the upper portion of the vagina.
    
    
  • Second-degree prolapse: The uterus falls into the lower part of the vagina.
    
    
  • Third-degree prolapse: The cervix, which is located at the bottom of the uterus, sags to the vaginal opening and may protrude outside the body. This condition is also called procidentia, or complete prolapse.
    
    
  • Fourth-degree prolapse: The entire uterus protrudes entirely outside the vagina. This condition is also called procidentia, or complete prolapse.
    
    
• Vaginal vault prolapse - This type of prolapse may occur following a hysterectomy, which involves the removal of the uterus. Because the uterus provides support for the top of the vagina, this condition is common after a hysterectomy, with upwards of 10% of women developing a vaginal vault prolapse after undergoing a hysterectomy. In vaginal vault prolapse, the top of the vagina gradually falls toward the vaginal opening. This may cause the walls of the vagina to weaken as well. Eventually, the top of the vagina may protrude out of the body through the vaginal opening, effectively turning the vagina inside out. A vaginal vault prolapse often accompanies an enterocele.

Approximately 30-40% of women develop some presentation of vaginal prolapse in their lifetime, usually following menopause, childbirth, or a hysterectomy. Most women who develop this condition are older than 40 years. Many women who develop symptoms of a vaginal prolapse do not seek medical help because of embarrassment or other reasons. Some women who develop a vaginal prolapse do not experience symptoms.

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Vaginal Prolapse Causes

A network of muscles provides the main support for the pelvic viscera (the vagina and the surrounding tissues and organs within the pelvis). This network, which is located below most of the pelvic viscera and supports the viscera's weight, is called the levator ani. Pelvic ligaments provide additional stabilizing support.

When parts of this support network are weakened or damaged, the vagina and surrounding structures may lose some or all of the support that holds them in place. Collectively, this condition is called pelvic floor relaxation. A vaginal prolapse occurs when the weight-bearing or stabilizing structures that keep the vagina in place weaken or deteriorate. This may cause the supports for the rectum, bladder, uterus, small bladder, urethra, or a combination of them to become less stable.

Common factors that may cause a vaginal prolapse include the following:

• Childbirth (especially multiple births): Childbirth is stressful to the tissues, muscles, and ligaments in and around the vagina. Long, difficult labors and large babies are especially stressful to these structures. Childbirth is the risk factor most commonly associated with cystoceles. A cystocele is a condition in which the rectum prolapses into the vagina. A cystocele is usually accompanied by a urethrocele, in which the urethra becomes displaced and prolapses. A cystocele and urethrocele together are called a cystourethrocele.
  
  
• Menopause: Estrogen is a hormone that helps to keep the muscles and tissues of the pelvic support structure strong. After menopause, the estrogen level decreases; this means that the support structures may weaken.
  
  
• Hysterectomy: The uterus is an important part of the support structure at the top of the vagina. A hysterectomy involves removing the uterus. Without the uterus, the top of the vagina may gradually fall toward the vaginal opening. This condition is called a vaginal vault prolapse. As the top of the vagina droops, added stress is placed on other ligaments. Hysterectomy is also commonly associated with a condition called an enterocele, in which the small bladder herniates near the top of the vagina.

Other risk factors of a vaginal prolapse include the following:

• Advanced age
  
  
• Obesity
  
  
• Dysfunction of the nerves and tissues
  
  
• Abnormalities of the connective tissue
  
  
• Strenuous physical activity
  
  
• Prior pelvic surgery

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Vaginal Prolapse Symptoms

The symptoms associated with a vaginal prolapse depend on the type of vaginal prolapse present. The most common symptom of all types of vaginal prolapse is the sensation that tissues or structures in the vagina are out of place. Some women describe the feeling as "something coming down" or as a dragging sensation. This may involve a protrusion or pressure in the area of the sensation. Generally, the more advanced the prolapse, the more severe the symptoms.

The following are general symptoms of all types of vaginal prolapse:

• Pressure in the vagina or pelvis
  
  
• Painful intercourse (dyspareunia)
  
  
• A lump at the opening of the vagina
  
  
• A decrease in pain or pressure when the woman lies down
  
  
• Recurrent urinary tract infections

• Difficulty emptying bowel - This may be indicative of an enterocele, vaginal vault prolapse, or prolapsed uterus. A woman with difficulty emptying her bowel may find that she needs to place her fingers on the back wall of the vagina to help evacuate her bowel completely. This is referred to as splinting.
  
  
• Difficulty emptying bladder -This may be indicative of a cystocele, urethrocele, enterocele, vaginal vault prolapse, or prolapsed uterus.
  
  
• Constipation - This is the most common symptom of a rectocele.
  
  
• Urinary stress incontinence - This is a common symptom of a cystocele.
  
  
• Pain that increases during long periods of standing - This may be indicative of an enterocele, vaginal vault prolapse, or prolapsed uterus.
  
  
• Protrusion of tissue at the back wall of the vagina - This is a common symptom of a rectocele.
  
  
• Protrusion of tissue at the front wall of the vagina - This is a common symptom of a cystocele or urethrocele.
  
  
• Enlarged, wide, and gaping vaginal opening - This is a common symptom of a vaginal vault prolapse.

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Vaginal Prolapse Treatment

Most vaginal prolapses gradually worsen and can only be fully corrected with surgery. However, the type of treatment that is appropriate to treat a vaginal prolapse depends on factors such as the cause and severity of the prolapse, whether the woman is sexually active, and the woman's treatment preference.

• Nonsurgical options may be most appropriate for women who are not sexually active, cannot undergo surgery because of medical reasons, or experience few or no symptoms associated with the condition.
  
  
• Surgery is the treatment option that most sexually active women who develop a vaginal prolapse choose because the procedure is usually effective.

Medical Treatment

Many women with a vaginal prolapse may benefit from estrogen replacement therapy. Estrogen helps strengthen and maintain muscles in the vagina.

Medications

Estrogen replacement therapy may be used to help the body strengthen the muscles in and around the vagina. Estrogen replacement therapy may be contraindicated (such as in a people with certain types of cancer). Women's bodies stop creating estrogen naturally after menopause, and the muscles of the vagina may weaken as a result. In mild cases of vaginal prolapse, estrogen may be prescribed in an attempt to reverse vaginal prolapse symptoms, such as vaginal weakening and incontinence. For more severe prolapses, estrogen replacement therapy may be used along with other types of treatment.

Surgery

A generalized weakness of the vaginal muscles and ligaments is much more likely to develop than are isolated defects. If a woman develops symptoms of one type of vaginal prolapse, she is likely to have or develop other types as well. Therefore, a thorough physical examination is necessary for the surgeon to detail what surgical steps are necessary to correct the vaginal prolapse completely. The typical surgical strategy is to correct all vaginal weaknesses at once.

Surgery is usually performed while the woman is under general anesthesia. Some women receive a spinal epidural. The type of anesthesia given usually depends on how invasive and lengthy the surgery is expected to be.

Laparoscopic surgery is a minimally invasive surgical procedure that involves slender instruments and advanced camera systems. This surgical technique is becoming more common for securing the vaginal vault after a hysterectomy and correcting some types of vaginal prolapse such as enteroceles or uterine prolapses.

• Vaginal vault prolapse: This is a defect that occurs high in the vagina, so it may entail a surgical approach through the vagina or abdomen. Generally, the abdomen is the entry of choice for a severe vaginal vault prolapse. The surgical correction of this condition usually involves a technique called a vaginal vault suspension, in which the surgeon attaches the vagina to strong tissue in the pelvis or to a bone called the sacrum, which is located at the base of the spine.
  
  
• Prolapsed uterus: For women who are postmenopausal or do not want to have more children, a prolapsed uterus is usually corrected with a hysterectomy. The common approach for this procedure is through the vagina.
  
  
• Cystocele and rectocele: These are corrected through the vagina. Typically, the surgeon makes an incision in the vaginal wall and pushes up the organ. The surgeon then secures the vaginal wall to secure the organ in its normal position. Any excess tissue is then removed, and the vaginal wall is closed. The surgeon may use a surgical procedure called a laparoscopic bladder suspension, or modified Burch procedure, to correct a cystocele. If urinary incontinence is present, the surgeon may need to support the urethra. This usually involves a procedure called a bladder neck suspension.

Women who undergo surgery for vaginal prolapse repair should normally expect to spend 2-4 days in the hospital depending on the type and extent of surgery involved. After surgery, women are usually advised to avoid heavy lifting for approximately 6-9 weeks.

Other Therapy

Physical therapy such as electrical stimulation and biofeedback may be used to help strengthen the muscles in the pelvis.

• Electrical stimulation: A doctor can apply a probe to targeted muscles within the vagina or on the pelvic floor. The probe is hooked up to a device that measures and delivers small electrical currents that contract the muscles. These contractions help strengthen the muscles. A less intrusive type of electrical stimulation is available that magnetically stimulates the pudendal nerve from outside the body. This activates the muscles of the pelvic floor and may help treat incontinence.
  
  
• Biofeedback: A sensor is used to monitor muscle activity in the vagina and on the pelvic floor. The doctor can recommend exercises that the woman can use to strengthen these muscles. In some cases, these exercises may help strengthen the muscles enough to reverse or relieve some symptoms related to vaginal prolapse. The sensor can monitor the muscular contractions during the exercises, and the doctor may be able to determine if the targeted muscles would benefit from the exercises.

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Follow-up

A woman undergoing treatment should schedule follow-up visits with her doctor to evaluate progress. Pessaries need to be removed and cleaned at regular intervals to prevent infection.

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Prevention

Women at risk for vaginal prolapse should avoid heavy lifting, if possible.

Obesity puts extra stress on the muscles and ligaments within the pelvis and vagina. Weight control may help prevent this condition from developing.

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Complications

In severe cases of uterine prolapse, you may develop sores (ulcers) in your vagina where the fallen uterus rubs against your skin and the thin skin lining your vaginal walls is exposed outside of your body. In rare cases, infection is a possibility.

Also associated with uterine prolapse is prolapse of other pelvic organs, including your bladder and rectum. A prolapsed bladder bulges into the front part of your vagina, causing a cystocele that can lead to difficulty in urinating and increased risk of urinary tract infections. A prolapsed rectum causes a rectocele, which often leads to uncomfortable constipation and possibly hemorrhoids.

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