Pelvic Prime's Anatomy Academy Series
Understanding Prolapse & vaginal Support
Pelvic organ prolapse involves the descent of female pelvic organs such as the vagina, uterus, bladder, and/or rectum into or through the vagina. Vaginal or uterine prolapse is common, affecting 43% to 92% of women during their routine gynecological exams. Among postmenopausal women, these rates are higher, ranging from 86% to 98%.
Prevalence and Impact
Pelvic organ prolapse affects between 3% and 28% of women. The most common symptoms are vaginal bulging and pelvic heaviness, which can greatly impact a woman's quality of life by limiting activities like exercise. About 50% of women experience some loss of pelvic floor support due to childbirth, leading to varying levels of prolapse.
In the UK, prolapse accounts for 20% of the women waiting for major gynecological surgery. In Australia, up to 19% of women undergo surgery for prolapse, while in the Netherlands, the number is 20%. However, up to 70% of prolapses return after surgery, and about one-third of these women need more surgery.
Pelvic organ prolapse is often not noticed until it becomes more severe because it might not show symptoms until the organ descends to the vaginal opening. While it was once thought to be non-reversible, many minor cases of prolapse can regress on their own. A 5-year study showed that 47% of women with symptomatic prolapse had no change in their condition, 40% improved, and only 13% got worse.
Risk Factors
Several well-known factors contribute to pelvic organ prolapse:
Age. As women get older, the chance of having prolapse increases by 40% each decade.
Pregnancy. A study from the UK found that the more children a woman has, the higher her risk of prolapse.
Childbirth. The way a woman gives birth also matters; a study of over 3,000 women showed that vaginal delivery causes 46% of the cases of symptomatic prolapse.
Obesity. Overweight and obese women are more than three times as likely to have a prolapse compared to women of normal weight.
Additional risk factors: Constipation, pelvic surgery, genetic factors, being Caucasian, connective tissue disorders, chronic anemia, chronic lung diseases, low education or income, and heavy physical work.
Cystocele: The Most Common Form of Prolapse
The most common form of prolapse is a cystocele, also known as the prolapse of the front wall of the vagina. It is found twice as often as rectocele and three times more often than apical prolapse. Even though a cystocele is the most common type, it is rare to have problems only in the front, top, or back parts of the vagina. A study using special MRI scans found a strong link between the sagging of the front and top parts of the vagina, no matter how bad the prolapse was or what symptoms the women had. This study estimated that losing support at the top of the vagina caused 53% of bladder sagging, 67% of urethra sagging, and 71% of the side walls of the vagina to sag.
Cystocele Common Symptoms
73% experiencing urinary incontinence
86% having a frequent or urgent need to urinate
34% -62% having trouble peeing
31% have fecal incontinence.
The levator ani muscle group is very important in the development and worsening of prolapse. Computer models suggest that these muscles get stretched during vaginal childbirth, especially the pubococcygeus muscle, stretching more than typical muscle forces.
Prolapse can greatly affect a woman's daily life and quality of life. Understanding the symptoms, their severity, and how they impact a woman's life is key to deciding the right treatment.
Common Symptoms in Women with Prolapse
Feeling or seeing a bulge in the vagina
Pressure or heaviness in the pelvic area
Leaking urine (stress, urge, or mixed incontinence)
Frequent or urgent need to urinate
Weak or slow urinary stream
Hesitation or feeling like the bladder isn't empty
Needing to push the prolapse back to start or finish peeing
Changing position to start or finish peeing
Bowel incontinence (gas or liquid/solid stool)
Feeling like the bowel isn't empty
Straining to have a bowel movement
Urgent need to have a bowel movement
Needing to use fingers to help with bowel movements
Feeling blocked or obstructed during bowel movements
Pain during sex
Physical Examination for Prolapse
A full assessment for women with prolapse includes taking a detailed history and doing a pelvic exam. During a pelvic exam, the doctor should check the woman both while she is resting and straining, in both lying down and standing positions, to understand the prolapse better.
If a woman sees or feels a bulge in her vagina, it strongly indicates advanced prolapse. Other symptoms like pressure, heaviness, and fullness are less specific and not strongly linked to prolapse. Symptoms often get worse after standing for a long time or exercising and get better when lying down. Vaginal bleeding, discharge, or infections might happen due to sores in the vagina. Problems with the lower urinary tract often occur with prolapse symptoms, and losing vaginal support can affect how the bladder or urethra work.
Treatment options include doing nothing, using a pessary (a device inserted into the vagina to support organs), pelvic floor muscle exercises, and surgery.
Pessaries
A pessary is a device placed inside the vagina to support the vaginal walls in women who have pelvic organ prolapse. According to the International Consultation on Incontinence, pessaries should be the first choice for managing prolapse without surgery. These modern pessaries are made from soft, hypoallergenic medical-grade silicone and come in different shapes and sizes.
In the UK, a clinical practice survey showed that pessaries are mainly given to older women who can't or don't want surgery. They are also used for pregnant and postpartum women, but there isn't much evidence on their effectiveness during childbearing years or if they can prevent or slow down prolapse. Although not well-known or widely promoted by doctors, pessaries can greatly improve the lives of women with prolapse. They help women get back to daily activities, exercise, and sports, providing both mental and physical benefits.
Pessaries are considered a cost-effective way to manage prolapse. However, there is not much data comparing the cost benefits of pessaries to surgery. There is also limited evidence that pessaries might be cheaper than pelvic floor muscle training. More research is needed to understand the economic advantages of using pessaries.
Comparing Pessaries with Surgery
Comparing pessaries with surgery is tricky for ethical reasons. Studies that followed patients for at least a year showed that surgery had higher and more severe complication rates, while patients were generally happy with pessaries. Since having had pelvic surgery before can make pessary fitting harder, trying a pessary first is recommended before considering surgery. Pessary use has been reported to improve quality of life, body perception, and sexual function, but more research is needed to confirm these benefits.
Complications with Pessaries
A systematic review found that all types of pessaries can have complications, including severe ones. There were even three deaths from poorly managed pessaries. Recent studies have reported problems like the pessary coming out, inflammation, changes in vaginal bacteria, and serious issues like vaginal evisceration and fistula development. More research is needed to find ways to prevent these complications. Teaching patients how to manage their pessaries themselves has been linked to fewer complications, and some think leaving pessaries in place for longer periods might reduce tissue trauma.
Choosing Pessary Types, Sizes, and Fitting Expectations
Choosing the right pessary involves clinical judgment since there isn’t much evidence-based guidance. Clinical practice guidelines recommend starting with a ring pessary because it’s the easiest to use. Success rates for fitting pessaries range from 58% to 97%, with many patients needing to try up to three different sizes or types.
A properly fitting pessary should not cause discomfort or pain during urination, and it should stay in place during activities. Factors that can make fitting harder include a higher BMI, advanced prolapse, and previous surgery.
People often stop using pessaries because they prefer surgery or find the pessary uncomfortable, especially during the first month of trying different sizes or types.
Pelvic Floor Muscle Training
There are two main ideas for how PFMT can prevent and treat stress urinary incontinence and prolapse:
1. Conscious Contraction: Women learn to contract their pelvic floor muscles before and during activities that increase abdominal pressure to prevent pelvic floor descent.
2. Strength Training: Regular strength training builds structural support and stiffness in the pelvic floor, lifting it over time.
Both ideas are supported by our understanding of how the body works. Voluntary pelvic floor muscle contractions can tighten the levator hiatus and elevate the pelvic floor.
Randomized controlled trials favor pelvic floor muscle training for treating prolapse, showing significant improvements in symptoms and the anatomical stages of prolapse.
Training periods in studies ranged from 12 weeks to 2 years, with physical therapy visits ranging from 4 to 18 times. Pelvic floor muscle training was usually taught individually and combined with home training programs. Better results and higher adherence were seen with more frequent physical therapy visits.
Pelvic Floor Muscle Training Vs Hypopressive Exercises
Pelvic floor muscle training was found to be more effective than the hypopressive technique for prolapse treatment. While hypopressive techniques activated the transverse abdominal muscle, they did not provide additional benefits when combined with pelvic floor muscle training.
Clinical Recommendations
Watchful Waiting: Recommended for prolapse stage 3 if symptoms are absent or low, as both the stage and symptoms can regress.
First-Line Treatment: Pelvic floor muscle training should be the first-line treatment for symptomatic prolapse, requiring proper teaching, assessment, and feedback
Supervised PFMT: Must be supervised and combined with home training programs.
Adjunct to Surgery: Current evidence is inconclusive on the benefits of adding pelvic floor muscle training to prolapse surgery. Further long-term studies are needed.
References: Bo, K., Berghmans, B., Mørkved, S., & Van Kampen, M. (Eds.). (2023). Evidence-Based Physical Therapy for the Pelvic Floor (3rd ed.). Elsevier.