Pelvic Organ Prolapse: Symptoms, Grading & Way Forward

What is Pelvic Organ Prolapse?

Pelvic organ prolapse (POP) occurs when one or more of the pelvic organs (such as the bladder, uterus, rectum, or small intestine) descend from their normal position and bulge into or out of the vagina. This happens due to weakened muscles or ligaments that support the pelvic floor. Factors like childbirth, ageing, menopause, chronic pressure (from obesity or constipation), or pelvic surgery can contribute to this weakening.

According to the National Health Service (NHS), pelvic organ prolapse is common in women over 50. POP can affect anyone with a vagina, and severity ranges from mild cases that often cause no symptoms to more advanced prolapse that leads to significant discomfort and functional problems.

Types of Pelvic Organ Prolapse

There are several types of pelvic organ prolapse, depending on which organ is affected:

• Cystocele (bladder prolapse): The bladder bulges into the front wall of the vagina. This can cause discomfort, urinary incontinence, or a feeling of pressure in the pelvic area. Women may notice difficulty emptying their bladder completely or frequent urinary tract infections.
• Uterine prolapse: The uterus descends into the vaginal canal. This may cause a sensation of heaviness or pulling in the pelvis and sometimes visible tissue protruding from the vaginal opening. Severe cases can interfere with sexual activity and cause urinary or bowel problems.
• Rectocele: The rectum bulges into the posterior vaginal wall, leading to difficulty with bowel movements such as constipation or the need for vaginal pressure support (splinting).
• Enterocoele (small bowel prolapse): A herniation of the small intestine into the upper posterior vaginal wall, often through a weakened vaginal apex. It often causes pelvic pressure or a pulling sensation, especially during activities like lifting or straining. Enteroceles can sometimes contribute to vaginal fullness or discomfort deep inside the pelvis.
• Vaginal vault prolapse: Descent of the upper portion of the vaginal canal, typically following hysterectomy, due to loss of apical support. This occurs because the support structures for the vaginal apex weaken or fail. It can cause a sensation of vaginal bulging, discomfort, and sometimes difficulty with intercourse.

Symptoms of Pelvic Organ Prolapse

• Feeling or seeing a bulge in or out of the vagina
• Sensation of heaviness, pressure, or fullness in the pelvis or vagina
• Low backache or pelvic pain
• Discomfort or pain during intercourse
• Urinary problems, such as leakage, slow stream, incomplete emptying, frequency, or urinary tract infections
• Bowel symptoms, like constipation, incomplete evacuation, or accidental leakage
• Difficulty inserting a tampon
• Spotting or vaginal bleeding
• Worsening of symptoms when standing, during physical activity, or at the end of the day

It's important to note that symptom severity doesn't always correlate with the degree of prolapse. Even mild cases can cause significant discomfort, while advanced prolapse may present with subtle symptoms.

Vaginal Bulge and Pressure

One of the most noticeable symptoms of pelvic organ prolapse is a sensation of pressure, fullness, or heaviness in the pelvis or vagina. Many women describe this feeling as a dragging or pulling sensation, as if something is "falling out" of their vagina. This sensation may be accompanied by a feeling of fullness, heaviness, or pressure in the pelvic region, which can worsen after standing for long periods, during physical activity, or as the day progresses.

In more advanced cases, the bulging tissue may be visible at or beyond the vaginal opening. Some women notice or feel the bulge during bathing or with a mirror. This symptom can be distressing and impact daily activities, self-image, and sexual function.

Urinary and Bowel Changes

Pelvic organ prolapse can lead to changes in urinary and bowel functions, which can be frustrating and embarrassing. Common urinary symptoms include:

• Leakage of urine (stress incontinence), especially when coughing, laughing, or exercising
• Difficulty starting urination or a slow urine stream
• Feeling of incomplete bladder emptying or needing to urinate more frequently
• Urgency: a sudden, strong need to urinate
• Increased risk of urinary tract infections

Prolapse can also affect bowel movements, causing:

• Difficulty with bowel movements, including constipation or needing to strain
• Sensation of incomplete evacuation
• Accidental bowel leakage or incontinence

These symptoms occur because the prolapsed organs can press against the bladder or rectum, disrupting their normal functions. In some cases, women may need to manually support the prolapsed tissue to initiate or complete urination or bowel movements.

Untreated severe POP can occasionally lead to complications such as recurrent urinary tract infections, pelvic discomfort, or hydronephrosis due to urinary obstruction.

Grading & Stages of Pelvic Organ Prolapse (Stage I–IV Classification)

The severity of pelvic organ prolapse is assessed using a grading system called the Pelvic Organ Prolapse Quantification (POP-Q) system. This system assigns a stage from 0 to IV based on precise measurements taken during a pelvic exam. The grading helps doctors objectively describe the extent of the prolapse and guide treatment decisions.

The stages of pelvic organ prolapse are classified as follows:

• Stage 0: No prolapse; organs are in their normal position.
• Stage I: The most descended portion of the prolapse is more than 1 cm above the hymen (the vaginal opening).
• Stage II: The most descended portion is within 1 cm above or below the hymen.
• Stage III: The most descended portion is more than 1 cm below the hymen but not completely outside the vagina.
• Stage IV: Complete eversion; the vaginal walls are fully everted and the uterus (if present) may protrude outside the vaginal opening (procidentia).

It's important to note that:

• Mild prolapse (Stages I–II) is often asymptomatic or associated with mild symptoms, as the organs are still within the vagina.
• Moderate prolapse (Stage III) involves organs descending beyond the hymen but not completely outside the vagina; symptoms are usually more pronounced at this stage.
• Severe prolapse (Stage IV) is rare but can cause significant discomfort and functional impairment, as the vagina is completely turned inside out.

If you suspect you have pelvic organ prolapse, it's essential to consult a doctor for a proper diagnosis and treatment plan. Your doctor may recommend conservative measures such as pelvic floor exercises, pessaries, or lifestyle changes for mild to moderate cases. More severe cases may require surgical intervention to restore the organs to their normal position and improve symptoms.

Causes of Pelvic Organ Prolapse

Pelvic organ prolapse results from a combination of factors that weaken or damage the pelvic floor support structures to compromise the structural integrity of the pelvic floor. Vaginal childbirth is the most significant risk factor, particularly when deliveries involve prolonged labour, multiple births, forceps or vacuum assistance, or large birth weight infants.

As women age, their pelvic tissues naturally weaken, and oestrogen deficiency after menopause further contributes to tissue atrophy and loss of collagen strength. Chronic conditions that increase intra-abdominal pressure, such as chronic cough from pulmonary disease, chronic constipation requiring repetitive straining, and obesity, place sustained stress on pelvic support structures.

Previous pelvic surgeries, particularly hysterectomy, can disrupt the normal support mechanisms of the vaginal apex. Genetic factors influencing connective tissue composition, like collagen disorders such as Ehlers-Danlos syndrome and Marfan syndrome, also predispose some women to developing prolapse. Heavy lifting, either occupational or recreational, and conditions causing chronic ascites further contribute to the progressive weakening of pelvic support over time.

Dietary & Lifestyle Modifications

Making specific dietary and lifestyle changes can significantly reduce symptoms and prevent the progression of pelvic organ prolapse. Maintaining a healthy body weight through balanced nutrition alleviates excessive pressure on the pelvic floor, as obesity substantially increases the risk of prolapse development and worsening.

Consuming a high-fibre diet prevents constipation and reduces the need for straining during bowel movements, which repeatedly stresses pelvic support structures. Adequate hydration, typically eight to ten glasses of water daily, supports regular bowel function and helps maintain tissue health.

Women should avoid heavy lifting whenever possible or learn proper lifting techniques that engage core muscles rather than bearing down with the pelvic floor. Treating chronic cough through smoking cessation and managing respiratory conditions prevents repetitive increases in intra-abdominal pressure.

For postmenopausal women, topical vaginal oestrogen therapy may help maintain local tissue elasticity and reduce vaginal atrophy. Regular pelvic floor exercises, commonly known as Kegel exercises, strengthen the muscles supporting the pelvic organs and can prevent mild prolapse from progressing.

These lifestyle modifications work synergistically to reduce mechanical stress on already compromised pelvic support structures.

Diagnosis and Assessment

Diagnosing pelvic organ prolapse involves a thorough evaluation of your medical history, focusing on symptoms like a feeling of vaginal fullness, urinary problems, and bowel changes. Your doctor will perform a pelvic exam, assessing the degree of prolapse and identifying the affected organs.

Standardised grading systems, such as the Pelvic Organ Prolapse Quantification (POP-Q) system or the Baden-Walker halfway system, are used to objectively stage the prolapse. These systems help your doctor determine the severity and guide treatment decisions.

Examinations and Tests to Diagnose Pelvic Organ Prolapse

• Pelvic examination using a speculum to visualise all vaginal compartments and identify prolapsing organs
• POP-Q staging assessment for objective, reproducible staging of prolapse severity
• Pelvic floor muscle strength assessment to guide individualised management planning
• Urinalysis, such as Urine Routine Test (Urine R/M Test), to check for infection, particularly when bladder symptoms are present
• Bladder scan and urodynamic studies to assess bladder function and capacity when urinary symptoms are reported
• Examination in multiple positions, such as lying on the side or standing upright, to fully appreciate prolapse extent
• Digital vaginal examination to palpate for lumps and rule out differential diagnoses

Treatment Options & Way Forward

Pelvic organ prolapse treatment must be individualised based on prolapse severity, symptom burden, patient age, general health status, sexual activity, and family planning desires. Pelvic organ prolapse should only be considered requiring intervention if it causes bothersome pressure symptoms, affects sexual function, or disrupts normal lower urinary tract or bowel function.

For women with Stage 1 prolapse who typically have mild or no symptoms, a "wait and see" approach with observation is appropriate, as prolapse is not life-threatening. Conservative management includes pelvic floor muscle training (Kegel exercises) performed regularly to strengthen supportive muscles, which can be enhanced through pelvic floor physical therapy with biofeedback techniques.

Vaginal pessaries—removable silicone or plastic devices inserted into the vagina—provide mechanical support for prolapsed organs and represent an excellent non-surgical option for women who prefer to avoid surgery, have medical contraindications to surgery, or wish to delay surgical intervention. For postmenopausal women, vaginal oestrogen therapy may improve tissue quality and reduce prolapse-related symptoms.

Surgical intervention becomes appropriate when conservative measures fail to adequately control symptoms or when prolapse significantly impairs quality of life. Surgical options include reconstructive procedures that repair and restore normal anatomy using the patient's own tissues or, in select cases, synthetic mesh materials, though mesh use has become more restricted due to potential complications.

Obliterative procedures, which close part or all of the vaginal canal, provide a definitive treatment option for women who are not sexually active and prefer a lower-risk surgical approach.

Preventive Strategies

• Perform regular pelvic floor exercises (Kegel exercises) to strengthen the muscles supporting pelvic organs and prevent mild prolapse from developing or progressing
• Maintain a healthy body weight to reduce chronic pressure on the pelvic floor and decrease prolapse risk
• Prevent and treat constipation by consuming a high-fiber diet with adequate hydration to avoid straining during bowel movements
• Avoid heavy lifting or use proper body mechanics, engaging core muscles and avoiding bearing down with the pelvic floor
• Treat chronic cough promptly to prevent repetitive increases in intra-abdominal pressure that weaken pelvic support structures
• Consider vaginal oestrogen therapy for postmenopausal women to maintain vaginal and pelvic tissue integrity
• Schedule regular gynaecological check-ups to monitor pelvic health and address any concerns promptly

At Metropolis Healthcare, we understand the importance of early detection and personalised care in managing pelvic floor disorders. Our team of skilled phlebotomists offers convenient at-home sample collection services, ensuring your comfort and privacy. With a comprehensive portfolio of over 4,000 tests and profiles, ranging from routine diagnostics to highly specialised tests for cancer, neurological disorders, infectious diseases, and genetic conditions, Metropolis is committed to providing accurate, reliable results to guide your healthcare journey.

FAQs

What are the first signs of pelvic organ prolapse?

Early symptoms of pelvic organ prolapse may include a feeling of heaviness or pressure in the vagina, a visible or palpable bulge, urinary leakage or difficulty emptying the bladder, constipation or incomplete bowel emptying, and discomfort during intercourse.

Can pelvic organ prolapse fix itself?

While mild cases of pelvic organ prolapse may improve with conservative measures like pelvic floor exercises and lifestyle changes, the condition usually does not resolve completely on its own. Seeking medical advice is important for proper diagnosis and treatment.

What is the best treatment for pelvic organ prolapse?

The best pelvic organ prolapse treatment varies depending on the severity of the prolapse and the individual's symptoms and preferences. Options range from lifestyle modifications and pessary devices to surgical repair. Personalised care is key for optimal results.

Is pelvic organ prolapse painful?

Some women with pelvic organ prolapse may experience discomfort, pelvic pressure, lower back pain, or pain during intercourse. However, others may have no pain and only notice a bulge or a feeling of fullness in the vagina.

Can pelvic organ prolapse come back after surgery?

While surgical repair can effectively treat pelvic organ prolapse, there is a risk of recurrence, especially if contributing factors like obesity or chronic straining persist. Regular follow-up care and preventive strategies can help reduce the likelihood of prolapse returning.

How can I prevent pelvic organ prolapse?

To lower your risk of developing pelvic organ prolapse, maintain a healthy weight, perform regular pelvic floor exercises, eat a fibre-rich diet to prevent constipation, avoid heavy lifting and high-impact activities, treat chronic cough promptly, and seek early medical care for urinary or bowel symptoms.

References
1.    https://my.clevelandclinic.org/health/diseases/24046-pelvic-organ-prolapse
2.    https://www.nhs.uk/conditions/pelvic-organ-prolapse/
3.    https://www.mayoclinic.org/diseases-conditions/pelvic-organ-prolapse/symptoms-causes/syc-20360557
4.    https://www.ncbi.nlm.nih.gov/books/NBK563229/
5.    https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/bladder-prolapse