Pelvic Organ Prolapse

Overview

Pelvic organ prolapse (POP) occurs when the muscles and connective tissues supporting the pelvic organs weaken, allowing the bladder, uterus, rectum, or small bowel to descend and press against the vaginal walls. This condition affects up to half of women who have given birth vaginally, though many experience no symptoms or only mild ones.

The pelvic floor functions as a hammock of muscles, ligaments, and fascia that holds the pelvic organs in place. When these supports stretch or tear—most commonly during childbirth—organs gradually shift downward over subsequent years. While prolapse is not dangerous, it can substantially impact quality of life, affecting urinary and bowel function, sexual activity, and daily comfort.

Prolapse is classified by which organ has descended. Anterior prolapse (cystocele) involves the bladder dropping into the front vaginal wall and is the most common type. Posterior prolapse (rectocele) occurs when the rectum bulges into the back vaginal wall. Uterine prolapse involves the uterus descending into the vaginal canal, ranging from mild to complete eversion. Vaginal vault prolapse affects women who have had a hysterectomy, with the top of the vagina collapsing inward. Enterocele involves the small bowel pushing into the upper vaginal wall and often accompanies other prolapse types.

Prolapse severity is graded using the POP-Q staging system. Stage 1 indicates descent halfway to the hymen. Stage 2 means the prolapse reaches the level of the hymen. Stage 3 describes descent beyond the hymen but not complete. Stage 4 represents complete eversion with maximum possible descent. Treatment recommendations depend on both stage and symptoms, as mild prolapse without bothersome symptoms may require only monitoring.

Symptoms

The hallmark symptom of pelvic organ prolapse is a sensation of vaginal bulging or heaviness—many women describe feeling as though something is falling out of the vagina. A visible or palpable bulge at the vaginal opening may be present, particularly with more advanced prolapse. Pelvic pressure typically worsens with prolonged standing, physical activity, or straining and often improves when lying down. Some women need to manually push the bulge back to urinate or have a bowel movement.

Urinary symptoms commonly accompany prolapse, especially cystocele. Women may experience stress urinary incontinence—leakage with coughing, sneezing, or exercise—or conversely, difficulty starting urination and incomplete bladder emptying. A slow or intermittent urine stream, needing to shift position to void, and recurrent urinary tract infections from retained urine are also common. Some women develop overactive bladder symptoms with urinary frequency and urgency.

Bowel symptoms occur particularly with rectocele. Difficulty evacuating stool, needing to press on the vagina or perineum to complete bowel movements (splinting), and chronic constipation are characteristic. Some women feel they cannot fully empty their bowels despite multiple attempts.

Sexual function is frequently affected. Discomfort during intercourse, reduced sensation, and embarrassment about the prolapse may lead to avoidance of intimacy. Dull lower back pain that worsens throughout the day is another common complaint.

Causes

Pregnancy and vaginal delivery are the primary causes of pelvic organ prolapse. The weight of pregnancy stretches pelvic floor muscles, and vaginal delivery can tear muscle fibers and damage the connective tissue attachments between organs and the pelvic sidewall. Risk increases with multiple pregnancies, prolonged pushing during labor, large babies, forceps or vacuum-assisted delivery, and perineal tears. The damage often manifests years or decades later, typically around menopause.

Menopause and estrogen deficiency accelerate prolapse progression. Estrogen maintains the strength and elasticity of pelvic tissues, and its decline after menopause causes these tissues to thin and weaken. Collagen content decreases with age, further reducing structural support.

Chronic increases in abdominal pressure contribute significantly to prolapse development and worsening. Chronic constipation with straining, persistent cough from smoking or lung disease, heavy lifting occupations or exercise, and obesity all place sustained downward force on the pelvic floor. Women who strain repeatedly at stool are at particular risk.

Previous pelvic surgery, including hysterectomy, can disrupt the normal support structures. Genetic factors influence connective tissue quality—women with hypermobile joints or hernias elsewhere may have inherently weaker collagen. Neurological conditions affecting pelvic nerve function and connective tissue disorders like Ehlers-Danlos syndrome also increase susceptibility.

Diagnosis

Diagnosis begins with a detailed symptom history, including the nature and severity of vaginal bulge, urinary and bowel function changes, impact on daily activities and sexual function, and previous pregnancies, deliveries, and pelvic surgeries. A voiding diary documenting urinary frequency and incontinence episodes provides valuable information.

Physical examination is the cornerstone of prolapse diagnosis. The clinician performs a pelvic examination with the woman in various positions—lying down, sitting, and standing—since prolapse severity often differs with position. The woman is asked to strain (Valsalva maneuver) to demonstrate maximum prolapse extent. Each vaginal compartment is assessed separately using a speculum to determine which organs are involved and to what degree. The POP-Q system provides standardized measurements for documentation and treatment planning.

Additional testing depends on symptoms. Post-void residual measurement determines whether the bladder empties completely. Urodynamic studies may be ordered if significant urinary symptoms are present or if surgery is planned, particularly to identify hidden stress incontinence that may emerge after prolapse repair. Imaging is rarely necessary but may be used for complex cases or recurrence after surgery.

Treatment

Pelvic floor muscle training is the first-line treatment for mild to moderate prolapse. Properly performed exercises strengthen the muscles supporting the pelvic organs, potentially improving symptoms by one to two stages. A pelvic floor physiotherapist can ensure correct technique, as many women contract the wrong muscles when attempting these exercises independently. Consistency over months is essential for benefit.

Pessaries are removable silicone devices inserted into the vagina to mechanically support prolapsed organs. Ring pessaries are most commonly used and can often be self-managed with insertion and removal for cleaning. Gellhorn, cube, and donut pessaries provide greater support for more advanced prolapse. Pessaries are an excellent option for women who prefer to avoid surgery, have medical conditions making surgery risky, wish to complete childbearing, or want to trial symptom improvement before deciding on surgery. Regular follow-up is needed to check for erosion or discharge, and vaginal estrogen cream is often prescribed alongside to maintain tissue health.

Vaginal estrogen therapy restores tissue thickness and elasticity, improving pessary tolerance and potentially slowing prolapse progression. It is available as cream, tablets, or rings and is safe for most women even with contraindications to systemic hormone therapy due to minimal absorption.

Lifestyle modifications address modifiable risk factors. Weight loss reduces pressure on the pelvic floor. Treating chronic cough, managing constipation with fiber and fluids, avoiding heavy lifting, and stopping smoking all help prevent worsening. These measures are important before surgery to reduce recurrence risk.

Surgical repair is considered when conservative measures fail or symptoms significantly impair quality of life. Native tissue repair uses the woman’s own tissues to restore support: anterior repair (anterior colporrhaphy) for cystocele, posterior repair for rectocele, and various procedures to support the vaginal apex. Sacrocolpopexy, performed abdominally or laparoscopically, attaches the top of the vagina to the sacrum using mesh and is considered the gold standard for vault prolapse with excellent durability. Transvaginal mesh for prolapse has been largely discontinued due to complication concerns, though abdominal mesh remains well-established. For women who do not wish to preserve vaginal function, obliterative procedures such as colpocleisis close the vaginal canal and have low recurrence rates.

When to See a Doctor

Seek evaluation if you feel a bulge at the vaginal opening, experience a sensation of something falling out, have difficulty emptying your bladder or bowels, or develop urinary incontinence or recurrent bladder infections. Even mild prolapse warrants discussion so you understand your options and can implement preventive strategies.

See your doctor promptly if you cannot urinate, develop new urinary retention, or notice blood in the urine. Worsening prolapse despite conservative measures, pessary problems such as discomfort or persistent discharge, and symptoms that interfere with work, exercise, or intimacy all warrant specialist referral.

After prolapse surgery, follow lifting restrictions carefully—typically avoiding more than 10 pounds for three months. Continue pelvic floor exercises lifelong and maintain healthy weight and bowel habits to minimize recurrence risk. Report any new bulge, urinary symptoms, or pain to your surgeon promptly. Prolapse can recur, with lifetime reoperation rates of 10 to 30 percent, but with appropriate management most women achieve excellent quality of life.