Pelvic Organ Prolapse: a guide for women

Glossary

pelvic organ prolapse - The downward movement of one or more walls of the vagina. This may be the front (anterior) or back (posterior) wall of the vagina; the uterus (womb) or top of the vagina (if after a previous hysterectomy).
vagina - a muscular tube leading from the external genitalia (labia and vulva) to the end of the uterus (cervix)
uterus - the hollow organ in which a foetus / baby develops in pregnancy (sometimes called the womb)
rectum/back passage - where stool / faeces / poo is stored just before a bowel movement
anus - the opening at the end of the rectum where the stool comes out
bladder - where urine is stored until you go to the toilet to pass water/ have a pee
pelvic floor muscles - the group of muscles supporting the pelvic organs. They span the base of your bony pelvis and are held in place by ligaments which support the pelvic organs. Pelvic floor muscle exercises / Kegels will help keep these muscles strong
vaginal pessary - a plastic or silicone device fitted into the vagina to support the walls or the uterus that have moved downwards
symptoms - a feeling of a physical change caused by the prolapse
hysterectomy - an operation to remove the uterus.
incontinence - loss of urine or stool when it was not intended
episiotomy - a cut made to the perineum at the time of delivery of a baby
menopause - when a woman stops having periods due to hormonal changes.
Average age for the menopause is 51 years
intra-abdominal pressure - an increase in the pressure in the tummy which causes strain downwards

Useful Websites

https://www.rcog.org.uk/en/patients/patient-leaflets/pelvic-organ-prolapse/ www.nhs.uk/livewell/loseweight

www.nhs.uk/smokefree/help-and-advice/support https://www.nice.org.uk/guidance/ng123/informationforpublic

Introduction

This booklet is for women who know they have or feel they might have symptoms associated with a pelvic organ prolapse.

The information will help you understand what a prolapse is. It will also explain possible causes and what you might be able to do to improve the symptoms you are experiencing.

Prolapse is very common affecting about 1 in 3 women who have had children. It can also affect women who have not been pregnant or given birth. Many women do not seek help until their symptoms become very bothersome.

What is a pelvic organ prolapse and what are the symptoms?

Pelvic organ prolapse, often referred to as ‘prolapse’, is described as a vaginal change where a pelvic organ which may be the bladder, bowel, rectum or uterus moves downwards in the vagina causing the symptom of ‘something coming down’ or a feeling of vaginal heaviness. The bulge may be felt inside or outside the vagina. Prolapse may also cause bladder, bowel or sexual symptoms.

The pelvic organs - the bladder, the vagina, the uterus and the rectum - are held and supported inside the bony pelvis by ligaments and muscles; commonly called the ‘pelvic floor’.

The pelvic floor muscles help to support the pelvic organs and control the bladder and bowel to prevent incontinence. If either the pelvic floor muscles or the supporting

structures weaken, the pelvic organs can bulge into the vagina causing the vaginal walls to move downwards resulting in a prolapse.

A prolapse can be mild, causing little or no bother, or it may be severe causing many problems and badly affecting your quality of life. How much the prolapse interferes with your life may relate to whether the downward bulge is felt within the vagina or can be felt or seen beyond the entrance to the vagina. It is common for a prolapse to vary from day to day and within a single day. On some days you may not be aware of it at all and on other days you may be very aware of your symptoms; it may be fine in the morning and very uncomfortable later in the same day. You may already know what activities will make the symptoms worse e.g. after a long day of standing or after opening your bowels.

The most common symptom is the feeling of ‘something coming down’ or a feeling of vaginal heaviness/bulge. Other common symptoms of the bladder and bowel can be caused by a prolapse but may also be unrelated to the prolapse.

There are different types of pelvic organ prolapse and it is quite common to have more than one type of prolapse at the same time.

Front vaginal wall prolapse (previously called a cystocele)

This is the most common prolapse. The wall supporting the bladder bulges down into the vagina. This may contribute to bladder symptoms such as:

problems with emptying which may mean frequent urinary tract infections
urgency - a strong need to empty the bladder
frequency - needing to go to the toilet more often including at night (nocturia)
incontinence - leakage of urine which may be related to coughing/activity or may be associated with urgency
difficulty in starting to pass urine or a slow flow when emptying the bladder. You may find that you have to change position on the toilet to empty your bladder properly

Back vaginal wall prolapse (previously called a rectocele)

The wall supporting the rectum/back passage bulges down into the vagina. This may contribute to bowel symptoms such as:

difficulty emptying your bowels or incomplete emptying which leads to straining more than normal
bowel or wind leakage and smearing/ staining at the anus
bowel urgency - a sudden need to open your bowels
needing to use your fingers to press around the vagina or anus to help empty your bowel

Uterine prolapse (previously known as the womb coming down)

The uterus moves downwards into the vagina due to the lack of support. The cervix will then sit lower in the vagina which might be mentioned when you have a smear test even if you have not been aware of any symptoms.

Vaginal vault prolapse

After a hysterectomy, when the uterus has been removed, the top of the vagina (known as the vault) can bulge downwards.

Vaginal symptoms may include:

a feeling of something coming down
a feeling of bulge felt within or outside the vagina. The bulge can sometimes be seen with a mirror, or felt at the vaginal entrance
laxity - a feeling that the vagina is wider, looser or more open than normal
difficulty inserting or keeping tampons in. They may also shift position and be uncomfortable

Sexual symptoms:

obstructed intercourse - a feeling that vaginal intercourse is not possible because something is in the way
discomfort or pain during sexual intercourse
anxiety about whether sex with a prolapse is safe or may cause damage

Pain symptoms:

backache, abdominal discomfort and vaginal pain can be associated with prolapse but are not usually the main symptom

All of these symptoms can also occur in the absence of a prolapse.

Prolapse symptoms are often worse at the end of a day, with prolonged standing or at times of increased intra-abdominal pressure e.g. heavy lifting, coughing or straining to go to the toilet. Symptoms may ease with rest and may come and go according to daily activities.

What causes pelvic organ prolapse?

Prolapse is caused by a number of factors which affect the support system of the vagina.

The factors known to be related to pelvic organ prolapse are listed below with a short explanation why.

Pregnancy and childbirth:

This is the most common factor particularly where there has been a vaginal delivery. The weight of the growing baby puts strain on the pelvic organs and pelvic floor muscles and the hormone changes during pregnancy cause relaxation of the supporting ligaments in preparation for delivery.

An episiotomy, vaginal tear or a delivery requiring forceps can also weaken the supporting structures contributing to problems at the time or in later life.

Pelvic floor muscle exercises while you are pregnant will help maintain the strength of your pelvic floor muscles.

Obesity and being overweight:

The more weight your body has to manage, the more pressure there is through the pelvis and onto the pelvic organs. A big increase in weight can put extra strain on the supporting structures and increase the likelihood of prolapse.

Heavy lifting:

If your job or daily life includes heavy lifting or repeated bending, the increased abdominal pressure pushing downwards may make a prolapse more likely, particularly if the pelvic floor supports are not strong enough.

Family history:

A strong family history such as your mother or sister having pelvic organ prolapse, may increase your chances of developing a prolapse. This is thought to be due to an inherited weaker collagen type. Collagen helps provide strength to the ligaments and vaginal supports.

Age:

The older you are the more likely you are to have a prolapse. Along with other changes due to ageing, muscle strength and the vaginal supports may weaken.

Menopausal changes:

Some of the hormonal changes that come with the menopause, when your levels of vaginal oestrogen fall, can make prolapse symptoms more bothersome. After the menopause the lower levels of vaginal oestrogen may affect the symptoms of prolapse.

Constipation:

Chronic constipation and straining to empty your bowels may make prolapse more likely or make an existing prolapse worse. This is due to increased intra-abdominal pressure directed down onto the pelvic floor which causes strain and stretch.

Chronic cough:

If you have asthma or other conditions that cause you to have a persistent cough, this may make a prolapse more likely. Again this is due to repeated increases of intra-abdominal pressure causing strain on the pelvic floor.

Previous pelvic surgery:

If you have already had an operation to repair a prolapse, or a hysterectomy, your risk of developing a subsequent prolapse is increased.

What can you do to help a pelvic organ prolapse?

Pelvic organ prolapse is not a life threatening condition, and not all prolapses get worse; some may improve. If you have been told that you have a pelvic organ prolapse you may have the following choices:

do nothing and wait and see how your symptoms change
adopt good bladder and bowel habits
make lifestyle changes to reduce the downward pressures through your pelvis, particularly if some of your existing activities make your symptoms worse e.g. weight loss, trying to avoid or reduce the amount of lifting you do
improve the strength of your pelvic floor muscles to increase the vaginal support
try a vaginal pessary which will support the vaginal walls (see glossary)
speak to a gynaecologist about the possibility (or option) of surgery

You may choose to do nothing if your prolapse is not bothersome. However research suggests you can prevent your prolapse getting worse by doing your pelvic floor muscle exercises and following the advice below.

Bowels

It is important to avoid constipation as this puts extra strain on the pelvic floor muscles and can worsen prolapse symptoms. Eating plenty of fruit, vegetables and fibre can help. Make sure you are also drinking enough (between 1.5 to 2 litres of fluid per day).

Try to develop good toilet habits when you go for a poo:

do not strain
sit fully on the toilet, do not hover; it will help you to relax the right muscles
have your feet apart and raised up on a stool/ support, with your arms resting comfortably on your legs
keep your tummy relaxed; don’t tighten your abdominals
avoid breath holding; try to have a relaxed breathing pattern
sit fully on the toilet, do not hover; it will help you to relax the right muscles

Some women may find it helpful to support the perineum (the area between the back passage and the vagina) when emptying their bowels. Applying some pressure vaginally on the bulging wall towards the back passage may help to empty the bowels more fully and effectively.

Bladder

try to avoid going to the loo ‘just in case’, instead, go when your bladder needs emptying
sit fully on the toilet, do not hover; it will help you to relax the right muscles
after passing urine, you may find it helpful to lean forward and back several times to help make sure that all the urine comes out
do not push or strain to empty your bladder; you might increase the prolapse
try not to reduce your daily fluids (1.5 - 2 litres per day is recommended); drinking less may not always reduce the number of times you need to empty your bladder

Sex

Having sex with a prolapse is safe and will not damage or make the bulge worse. It may help to try different positions for sexual intercourse, and use a suitable lubricant to help with vaginal dryness or discomfort with penetration

Weight

Being overweight puts extra strain on the pelvic floor muscles. Your symptoms may improve if you lose weight. Contact your GP for help and try some of the many websites available e.g. www.nhs.uk/livewell/loseweight

Reducing your intra-abdominal pressure Reduce your cough:

• if you have a persistent cough make sure you take any medication as prescribed, and follow any other medical advice

• if you are a smoker, try to stop. Ask your GP for advice about what is available locally to help you stop such as cessation groups or patches. There are several helpful websites such as www.nhs.uk/smokefree/help-and-advice/support

Lifting:

it is not only the weight of the object you lift that can make symptoms worse. Frequent or repetitive bending and lifting can also be a problem
try to get into a good lifting habit for all tasks, even the light ones (see picture). Tighten your pelvic floor muscles before each lift
try to split loads for carrying, making more frequent trips, and lift correctly when picking up from low down

Exercise and activities:

Avoid activities that make the symptoms worse such as standing for long periods. Try to break up your day wherever possible into shorter periods of standing with sitting in between.

High impact exercise such as jumping, running or aerobics (e.g. any activity when both feet are off the ground at the same time) may worsen your symptoms especially if your pelvic floor muscles are not strong. Activities using weights may also cause too much downward pressure. Try low impact exercise instead such as modified aerobics, cycling, a cross trainer, fast walking, Pilates or swimming. If your normal exercise routine makes your prolapse symptoms worse, seek advice about how it can be modified or try different activities.

Improving your pelvic floor muscles

The pelvic floor muscles act like a hammock to support the pelvic organs. Pelvic floor muscle exercises will strengthen the muscles and retrain them to be more effective in supporting the pelvic organs making the symptoms of prolapse less bothersome.

Pelvic floor muscle exercises (sometimes called Kegels) should include long, held squeezes as well as short quick squeezes, ensuring that you fully relax the muscles after each squeeze. You should work the muscles until they tire and do the exercises regularly to help the muscles become stronger and more effective. You may be able to do these exercises in any position, but if your prolapse is bulging beyond the vaginal entrance, you may find it better to do them lying down. If your prolapse is less severe you may find it easier to do these exercises in sitting.

Imagine that you are trying to stop yourself from passing wind at the same time as trying to stop passing urine. You should feel a squeeze and a lift inside. Try not to hold your breath or squeeze other muscles, such as your legs or buttock muscles.

Long squeezes

• tighten your pelvic floor muscles, hold them tight, then release and let them fully relax. How long can you hold the squeeze?

• repeat the squeeze and hold until the pelvic floor muscles tire. How many times can you repeat the squeezes?

Short squeezes

• quickly tighten your pelvic floor muscles, then immediately let them go again. How many times can you do this quick squeeze before the muscles get tired?

• always let the muscles fully relax after each squeeze

Pelvic Floor Muscle Exercises

• Aim to be able to do 10 long squeezes, holding each squeeze for 10 seconds, followed by 10 short squeezes

• You may need to start with ‘little and often’ if you find that you can only hold the squeeze for a short time, or only do a few before the muscles tire

• You should do your pelvic floor muscle exercises at least 3 times each day. You may find it easier to start your programme when you are sitting or lying down

• Build up your exercise routine gradually over the weeks and months. You should notice an improvement in 3 - 5 months and then keep practising your pelvic floor muscle exercises once a day to maintain the improvement

• As your muscles improve, aim to do your exercises in other positions such as standing up. Eventually you can practise using these muscles whilst doing activities such as walking and bending

It is important that you do your pelvic floor muscles exercises correctly. If you are having difficulty or not improving ask to be referred to a specialist physiotherapist (see inside back cover). A pelvic health physiotherapist will be able to assess your prolapse and pelvic floor muscles and give you further advice. This may include supervised pelvic floor muscle

training for at least 16 weeks, as recommended by the NICE guideline, with advice that you continue the exercises in the long-term.

Draw up and tighten your pelvic floor muscles before any activity which increases the intra-abdominal pressure. This helps the pelvic floor to resist the downward movement of pelvic organs that happens with prolapse.

There are many devices available to help with pelvic floor muscle training although there is no evidence yet, that using a device is better than just doing the exercises. There is no reason why women with prolapse should not use these as long as the device stays in and doesn’t cause discomfort.

It is important that you do your pelvic floor muscles exercises correctly. If you are having difficulty ask to be referred to a specialist physiotherapist for proper assessment, and further advice (see inside back cover).

Vaginal Pessaries

A vaginal pessary is a device that sits inside the vagina to support the vaginal walls and uterus. It is made of plastic or silicone and once fitted will need to be checked regularly and replaced as required. There are several types of pessary, and it may take several attempts

to find the right one for you. Some healthcare professionals can fit you with a pessary and teach you to manage it yourself. If you do self-manage with a pessary, some women find they only wish to wear the pessary during activities that make their prolapse symptoms worse. Once correctly fitted, many women say that they are unaware of the pessary.

Pessaries can be used for all types of prolapse but do not work for everyone and may not improve your symptoms or level of prolapse.

Commonly women notice an increase in vaginal discharge when using a pessary, which may be bothersome.

If you wish to try a pessary, speak to your GP or gynaecologist.

Oestrogen

A course of vaginal oestrogen medication may help with some of the symptoms particularly vaginal dryness and milder bladder symptoms such as urgency. The vaginal tissues can benefit from an oestrogen supplement. Oestrogen may be prescribed at the same time as a vaginal pessary is fitted.

Surgery

An operation may be appropriate for some women with prolapse. The main aim of surgery is to correct the vaginal bulge and improve the symptoms from the prolapse.

The choice of operation depends on a number of factors including type and severity of prolapse, general health including previous pelvic floor operations and other symptoms particularly relating to bladder, bowel and sexual function.

The most common procedures are vaginal operations where the front (anterior colporrhaphy) or back (posterior colporrhaphy) walls of the vagina are repaired. Abdominal surgery for prolapse includes hysterectomy which can also be performed vaginally.

You will find more detailed information on surgery for pelvic organ prolapse in the Patient Information section on the following websites:

www.rcog.org.uk www.bsug.org.uk

Pelvic Organ Prolapse Symptom Score

This symptom score can be used from time to time to help you check how your prolapse symptoms are changing.

Answer the following questions, thinking about how you have been, on average, over the PAST FOUR WEEKS. (Please cross one box in each row).

Getting help

If you have any difficulty following the advice or exercises in this booklet,

or find that your symptoms are not improving, ask to be referred to a specialist physiotherapist who has experience in treating women with pelvic floor muscle problems. A specialist physiotherapist will be able to assess you and offer specific treatments/alternatives, suitable for your needs. Some specialist physiotherapists are able to accept self-referrals.

To find your nearest specialist physiotherapist visit https://pogp.csp.org.uk

Further advice and information booklets are also available from https://pogp.csp.org.uk

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Physiotherapy (Pelvic, Obstetric and Gynaecological)