How We Treat Pelvic Organ Prolapse

Incontinence. Constipation. Painful sex.

Not necessarily topics you want to discuss with your friends, let alone your doctor. But if you suffer from such symptoms, it’s ok to speak up. At MedStar Washington Hospital Center, we understand and we can help!

For some of our female patients, these symptoms, and other discomforts in the pelvic area, may actually be caused by pelvic organ prolapse—a quite common condition that up to half of all women will experience to some degree over time.

In most cases, pelvic organ prolapse has few or no symptoms. But for some women, symptoms can begin to impair normal bodily functions and require treatment. It’s never too soon to start making things better.

What Causes Prolapse?

Within a woman’s pelvic floor, a group of muscles supports the pelvic organs—bladder, uterus, vagina, and rectum. Pelvic floor disorders begin when those muscles weaken and fail to give the organs the necessary support, causing organs to sag and bulge into the vagina.

Several factors may lead to this weakening of pelvic floor muscles:

• The hormone estrogen keeps pelvic floor muscles strong and elastic. As women age—and particularly at, and post-, menopause—estrogen levels drop, muscles weaken, and the lining of the vagina becomes dry and tender.
• Childbirth may damage pelvic muscles and nerves during delivery, as the baby passes through the birth canal. This is especially true if the baby is large, if the mom has experienced multiple deliveries, or if a delivery requires forceps.
• Any extra strain on pelvic floor muscles can weaken them over time. Obesity, chronic cough, straining to have a bowel movement, or lifting heavy weights can contribute.
• Genetics may play a part as well: the strength of a woman’s connective tissue may be determined from birth. If you ask other females in your family, you may find you’re not the only one with this condition.

Pelvic Organ Prolapse Symptoms

A woman with pelvic organ prolapse may experience a particular pelvic sensation alerting her that something is not quite right. This sensation can vary from woman to woman, depending on the organs involved and the severity of the prolapse.

Some women may feel, or even see, a bulge in the vagina. There could be a feeling of heaviness in the pelvis—some report that it feels as if they’re always wearing a tampon. These various sensations may also make urination, bowel movements, or sexual activity difficult or painful. And symptoms may worsen by day’s end or after a long period of standing.

The female bladder is certainly prone to the effects of prolapse. Urine is stored in the bladder and leaves the body via the urethra. A prolapsed or “fallen” bladder is known as a cystocele; if either the bladder or the urethra begins to bulge into the vagina, it can become difficult for a woman to empty her bladder. Or she may feel she has to urinate frequently or that her bladder is never completely emptied. If the bladder cannot empty, this can cause urinary tract infections or, in rare cases, kidney disease. The same damage to muscles and nerves that causes prolapse can also cause leakage of urine with laughing, sneezing, or coughing, known as stress incontinence.

The rectum can also bulge into the vagina; this bulging is known as a rectocele. The rectocele can make it difficult for a woman to pass stool. By applying perianal pressure (also known as splinting), some women find that they can direct the bulging organ back to its normal position and allow stool to pass unobstructed.

Prolapse may also present as pain with intercourse. If a prolapsed organ causes protrusion of the vaginal walls outside of the body, the delicate tissue of the vagina may become irritated from rubbing against one’s underwear and there may even be some spotting or bleeding. In addition, some women may become self-conscious during sex because of the vaginal protrusion.

Pelvic Organ Prolapse: Stages

At the time that we diagnose a patient with pelvic organ prolapse, we assign a stage—or grade of severity—to her condition, based on the extent to which the affected organ has dropped:

• In Grade 1, prolapse is mild—the organ drops a short distance into the space of the vagina.
• In Grade 2, the organ has a moderate drop to the opening of the vagina. This is when symptoms typically become evident.
• Grade 3 is a severe condition in which the organ drops slightly through the vaginal opening.
• Grade 4 is total prolapse, in which the organ has completely descended.

It is helpful for women to be aware of the possibility of prolapse, to recognize when it may be happening, and to know that they’re not alone in this scenario. If you’re unable to empty your bladder, feel that your bowel movements are being blocked, have painful intercourse, or feel an uncomfortable bulge in the vagina, it’s time to seek medical attention.

We can often recommend specific exercises that will actually help improve the situation. And if the problem is severe, reaching out for treatment can be life-changing.

Pelvic Organ Prolapse Treatment

Degree of patient bother and severity determine the course of treatment.

Mild cases may be monitored for worsening. We teach our patients how to correctly perform Kegel exercises, which can go a long way toward improving strength in the pelvic muscles. To do these exercises you squeeze the same muscles you would to stop the flow of urine, but don’t practice regularly while you are urinating!

I tell my patients to perform Kegels three times a day when the pelvic muscles are at rest: while brushing your teeth or sitting at a red light—really, whenever you think of it. Simply squeeze the pelvic floor muscles for 10 seconds, then relax for 10 seconds. Repeat 10 times, three times a day. Your doctor may ask you to demonstrate your Kegel during an exam to ensure that you are doing it correctly. A good indicator: If you can halt the flow of urine midstream, you’ve mastered the technique.

Some physical therapists are trained to address pelvic floor issues. We may refer you to one of these specialists for training on when and how to contract and relax pelvic muscles, in order to minimize pain and improve muscle tone.

Post-menopausal women with symptoms of pelvic organ prolapse may be prescribed estrogen applied as a cream, suppository, or ring. Use of the hormone can help strengthen vaginal tissue and make it less dry and painful.

As part of treatment, we sometimes recommend that the patient use a pessary—a silicone disc placed into the vagina like a diaphragm. The pessary, which may be inserted for up to three months, provides structural support for the vagina, lifting the walls and preventing adjacent organs from bulging inward. The doctor can remove and replace the device as appropriate. The patient can learn to remove it temporarily as well; it should always be removed prior to sex.

Pelvic Organ Prolapse Surgery

In situations when surgery is required, we can often correct prolapse with vaginal native tissue repair, requiring no abdominal incisions. We correct weak areas and anchor the vagina to stronger structures, pulling organs back to their proper position. This procedure may or may not be done in conjunction with a hysterectomy, which eliminates the weight of the uterus and reduces risk of future prolapse.

For younger women, we may recommend an abdominal surgery known as sacrocolpopexy, which can be done with minimally invasive techniques, using tiny abdominal incisions. This type of repair is generally longer lasting.

Prevention and Action

Of course, it’s always better to prevent a problem than to treat it. Women can take some very basic measures to preserve pelvic muscle tone:

• Maintaining healthy weight helps prevent a multitude of health issues, including pelvic organ prolapse. Excess weight can place more pressure on the muscles and organs of the pelvis, causing strain, wear, and tear.
• Practicing Kegels is advisable for all women, particularly after childbirth and when approaching menopause. Ten repetitions, three times a day may be all it takes to keep pelvic muscles strong and functioning well.
• Adding fiber to your diet increases the bulk of the stool, preventing both constipation and diarrhea. If a rectocele is present, this additional bulk may prevent stool from becoming stuck. This regimen requires some patience—a minimum two to four weeks is a fair trial period to see if the additional fiber is helpful.

Pelvic floor problems can worsen over time, making activities of daily living more and more difficult. Untreated, this condition can also set the stage for recurrent urinary tract infections, kidney disease, and other long-term problems.

If you find you are having pelvic problems, don’t wait to address them. Here at MedStar Washington Hospital Center, we take every precaution to ensure that your visit to the doctor’s office or hospital is safe, with COVID-19 protocols in place.

We have a full range of professionals to meet the unique needs of every patient—from gynecologists and urologists to surgeons and specially trained physical therapists. To examine you for pelvic organ prolapse, we do need to see you in person. But telehealth checkups from the comfort of your home are often useful for follow-up visits, as needed.

Our capable and caring team will tailor a care plan that works for you.