Pelvic Organ Prolapse

Understanding Pelvic Organ Prolapse

Pelvic organ prolapse (POP) occurs when the pelvic organs drop or prolapse from their normal position due to the weakening of the pelvic floor. In women, a POP is a hernia of the vaginal canal. It’s when a pelvic organ (e.g., bladder, uterus, vaginal wall, small bowel) bulges into the vagina due to a weakened pelvic floor. Usually the pelvic floor—which is made up of muscles, connective tissues, and nerves—works to support the structure and function of the pelvic organs. But when the pelvic floor is weakened or damaged and can no longer provide proper support, a prolapse can occur. Although it’s rare, POP can occur in men.

There are different types of POP depending upon which pelvic organ is involved. Below are the common types and their related pelvic organs. To get a better picture of these, you can take a look at the animations created by the American College of Obstetricians and Gynecologists.

1. • Uterine prolapse: Uterus moves down into the vagina.

2. • Cystocele (anterior vaginal wall prolapse): Bladder bulges into the vagina.

3. • Rectocele (posterior vaginal wall prolapse): Rectum bulges into the vagina.

4. • Vaginal vault prolapse: Vaginal wall moves down into the vaginal canal and the top of the vagina loses support and drops into itself.

5. • Enterocele: Small intestine bulges into the vagina.

POP occurs in stages. Early stages are when pelvic organs have descended a short distance. More-severe stages are when they have moved farther down. Each stage is measured and categorized based on how far a pelvic organ has descended into the vaginal canal, using the opening of the vagina as a point of reference. Stages range from 0 to 4. Zero represents the absence of a prolapse and 4 represents the greatest descent of the prolapse.

1. • Stage 0: No prolapse.

2. • Stage 1: Prolapse is descended halfway to the opening of the vagina.

3. • Stage 2: Prolapse is descended to the opening of the vagina.

4. • Stage 3: Prolapse is descended beyond the opening of the vagina.

5. • Stage 4: Prolapse has descended the maximum possible.

(ACOG, 2019, 2019; DeLancey, 2016; Hans Peter Dietz, 2015; Iglesia & Smithling, 2017; Tso et al., 2018; Vergeldt et al., 2015; Weintraub et al., 2020)

Primary Symptoms

In early stages of POP, most people do not experience symptoms or are asymptomatic. If or when POP reaches later stages, symptoms are more likely to occur. Many prolapses are not detected until later stages, when people have symptoms of a visible bulge protruding from the vagina, which occurs in stage 3 or 4. Urinary and bowel symptoms, like urinary incontinence, incomplete emptying of the bladder, constipation, or fecal incontinence may also be experienced during stages 3 and 4. These symptoms can dramatically interfere with daily activities, like routine tasks, chores, and physical and recreational activities. They can make it difficult to walk or stand for long periods of time, so many people report decreased productivity with POP. Whether you have symptoms or not, speaking with your gynecologist about pelvic health and POP can be beneficial. (Anyone who has given birth should ask their doctor about it.) For inspiration on how to start the conversation, you can watch these videos from the National Association for Continence and Voices for PFD (Pelvic Floor Disorders) (Iglesia & Smithling, 2017; Ouchi et al., 2017; Tso et al., 2018; Vergeldt et al., 2015).

Potential Causes of Pelvic Organ Prolapse and Related Health Concerns

POP is caused by the weakening of the pelvic floor, which is made up of muscles, connective tissues, and nerves. They all work together to support the pelvic organs and allow them to function properly. One muscle group is particularly important in forming the pelvic floor—the levator ani muscle. It is a thin, broad muscle group that forms a large portion of the pelvic floor (shown here). It interacts with pelvic connective tissues to support the pelvic organs, similar to a hammock holding your body. It allows the uterus and vagina to attach to the side walls of the pelvis, which is important for keeping them in their proper place and maintaining their function. If the levator ani muscle is weakened or damaged, pelvic organs can move from their normal location and descend or protrude into the vagina, causing a prolapse.

The weakening of or injury to the levator ani muscle is likely due to a combination of things—anatomy, physiology, genes, lifestyle, and reproductive factors—that change throughout a women’s life. The most prominent contributors are childbirth, menopause, advanced age, and elevated body mass index (BMI). Other risk factors include family history of prolapse; chronically increased intra-abdominal pressure from chronic cough, constipation, or repeated heavy lifting; and potentially ethnicity and race (more on that below).

Stress urinary incontinence (leakage due to laughing, coughing, sneezing, jumping, etc.), overactive bladder, and fecal incontinence (uncontrolled bowel movements) are health concerns that may be linked to the dysfunction of pelvic floor muscles and can be experienced with POP. But having these conditions does not necessarily mean you have developed POP (Iglesia & Smithling, 2017; Tso et al., 2018; Vergeldt et al., 2015; Weintraub et al., 2020).

Childbirth

Childbirth is the primary contributing factor for developing POP. It’s possible for people who have not given birth to develop POP, but it’s very rare. Women who have given birth to one child are four times more likely to experience POP than women who have not given birth. And those who have given birth to two children are eight times more likely to develop POP. And the effects can be long delayed. A study showed that women can experience POP sixteen to twenty-four years after their first delivery. We don’t know for sure why childbirth increases the risk of POP, but it’s likely related to trauma to the pelvic floor during vaginal delivery. About 85 percent of vaginal deliveries result in some type of pelvic floor trauma. An injury to the levator ani muscle increases the risk of a prolapse sevenfold, and this injury occurs in about 10 to 30 percent of vaginal deliveries. The increased risk of an injury to the pelvic floor is not seen with Cesarean births. Some studies show a decreased risk of experiencing POP with a Cesarean delivery, yet more research is needed to determine if this is generally true.

Menopause and Age

Women are more likely to develop prolapse later in life. The data is not complete, but estimates show that of all the cases of POP, women eighty years of age and older make up almost 50 percent of the cases, women fifty to fifty-nine years of age make up 31 percent, and women twenty to twenty-nine make up 6 percent. Considering the increase in the aging population in the US, it’s expected that the prevalence of POP will increase from the current 25 percent of women to about 50 percent by 2050.

There is a direct link between menopause and POP that is independent of age, even though they are inherently connected. The increased risk of developing POP that comes with menopause and advanced age is likely due to a combination of factors, predominantly lower levels of estrogen during menopause, which leads to changes in collagen production. Since collagen is a structural protein that makes up muscles, bones, and connective tissues, when less collagen is present, the pelvic muscles and connective tissues can weaken, contributing to the development of POP (ACOG, 2019; Weintraub et al., 2020).

Other Potential Causes

Research is still emerging on the factors that contribute to developing POP, but data show that elevated BMI, smoking, chronic coughing, repeated heavy lifting, constipation, and family history all play a role. Researchers hypothesize that the increased risk of developing POP from elevated BMI, chronic coughing, smoking, repeated heavy lifting, and constipation may be connected to a chronic increase in internal abdominal pressure, which means pressure inside of the abdomen. Over time, increased pressure inside the abdomen weakens the pelvic floor, which can lead to POP. And since these factors can all chronically increase internal abdominal pressure, they can subsequently increase the chances of developing POP.

Women who have a family history of POP are more than twice as likely to develop it. This could be in part due to a genetic factor that prevents some women from making strong collagen, affecting the strength of the pelvic floor. Research is emerging on the specific genes this could be due to, and one strong contender is the collagen type 3 alpha 1 (COL3A1) rs1800255 genotype AA. A study showed that this genotype was significantly associated with POP in an Asian and Dutch population of women. However, studies examining other populations of women have not found genetic variations linked to POP.

It’s thought that race plays a role in the risk of developing POP, but the evidence is conflicting. Some studies have reported that race is not a factor in women developing POP, and other studies have reported that it is a factor. In one study looking at a diverse population of over 1,000 women (44 percent White, 20 percent Black, 18 percent Asian American, 18 percent Latina or other race), researchers found that White and Latina women were more likely to develop POP than Asian and Black women. Latina and White women had a four to five times higher risk of developing symptomatic prolapse compared to Black women. And White women had a 40 percent higher risk of developing a stage 3 to 4 prolapse than Black women (Giri et al., 2015; Graham & Mallett, 2001; Kudish et al., 2011; Nygaard, 2008; Vergeldt et al., 2015; Weintraub et al., 2020; Whitcomb et al., 2009).

Related Health Concerns

POP often coexists with other pelvic floor disorders. Many people with POP have stress urinary incontinence (leakage due to laughing, coughing, sneezing, jumping, etc.), overactive bladder, and fecal incontinence (uncontrolled bowel movements). Treating POP can relieve the severity of these symptoms (Iglesia & Smithling, 2017).

How Pelvic Organ Prolapse Disease Is Diagnosed

A pelvic examination is needed to diagnose POP. The type and stage of prolapse can be determined through this examination. A primary care physician can typically conduct a screening and a basic evaluation, but for advanced assessment and treatment, a gynecologic specialist with board certification in female pelvic medicine and reconstructive surgery is recommended. Depending upon the stage of POP, some people may not be aware that they have a prolapse, so asking your gynecologist if they see early signs of a prolapse at your next visit may be beneficial (Iglesia & Smithling, 2017).

Pelvic Examination

If POP is detected during a pelvic examination, its stage is measured using a quantification system called POP-Q (Pelvic Organ Prolapse Quantification). POP-Q measures how far an organ has prolapsed into the vaginal canal by using the hymen, a thin membrane surrounding the opening of the vagina, as a point of reference. Based on these measurements, POP is classified into stages 0 to 4. POP-Q was created by the International Continence Society as a system to uniformly measure the stages of POP and to better communicate diagnoses, preventive measures, treatments, etc. (Bump et al., 1996; H.P. Dietz & Wilson, 2005; Persu et al., 2011).

Dietary Changes for Pelvic Organ Prolapse

There are no known dietary changes that can help reduce the risk of POP. But theoretically, since weakened collagen may be linked to developing POP, increasing foods high in collagen or collagen supplementation may be worth considering. Vitamin C is involved in collagen production, so supplementing with vitamin C may be helpful, too. However, there is no research to support the idea that doing so would be beneficial (Arnouk et al., 2017).

Lifestyle Support for Pelvic Organ Prolapse

Anything that chronically increases intra-abdominal pressure or involves excessive straining can increase the chances of a prolapse. Over time, the pressure can damage muscles, nerves, and connective tissues that make up the pelvic floor, increasing the chances of developing POP. To reduce your risk, it’s suggested that you avoid activities that put extra strain on the pelvic floor, like smoking (which can lead to chronic coughing), repeated heavy lifting, constipation, and excessive weight gain. Pelvic floor exercises may also help prevent POP (discussed in the Conventional Treatment Options section) (Arnouk et al., 2017; Iglesia & Smithling, 2017).

Conventional Treatment Options for Pelvic Organ Prolapse

The primary goal of treating POP is to decrease symptoms and minimize the prolapse’s progress. Treatment options vary depending on the individual and the stage of prolapse. Some people choose not to have any treatment, but if the prolapse is impeding their daily activities or is beyond the opening of the vagina, then most choose to have some intervention.

The conventional options to treat POP include Kegels (pelvic floor muscle training), pessaries (ring-shaped medical-grade silicone devices placed in the vagina), and surgery. More research is needed to determine just how effective Kegels and pessary use are, but it’s clear they are beneficial. For most people with prolapse, pessary use is a viable nonsurgical option, together with Kegels. More than two thirds of women choose pessaries as their treatment, and 77 percent of those who use pessaries continue to do so for longer than a year. Kegels and pessary use may be more effective in early stages of POP, but that is yet to be confirmed.

Surgery may be required for those who have more severe symptoms of POP, like obstruction of urine flow, swelling of the kidneys, recurrent urinary tract infections, or infections of the vaginal canal or cervix. But it’s generally recommended that conservative options (like Kegels, pessaries, and lifestyle changes) be the first line of treatment for POP, especially in early stages (Iglesia & Smithling, 2017; C. Li et al., 2016; Tso et al., 2018; Vergeldt et al., 2015).

Kegels

Pelvic floor muscle training, commonly known as Kegels, is the intentional contraction and relaxation of the pelvic floor muscles. Kegels are so effective for strengthening the pelvic floor that the International Continence Society recommends them as the first line of treatment for POP. Kegels can increase the strength and thickness of the pelvic floor muscles, including the levator ani muscle (a muscle group associated with developing POP when it’s damaged or weakened). And they can improve POP and the symptoms of vaginal irregularities (vaginal bulging or heaviness), stress urinary incontinence, and fecal incontinence.

Kegel treatment is most effective when performed consistently and with the guidance of a physical therapist. A study showed that women who performed three sets of eight to twelve Kegels per day for six months, with weekly supervision by a physical therapist, improved their prolapse by one stage (e.g., going from a stage 2 to stage 1 prolapse). In another study, significant improvement in the quality of life, physical abilities, emotional health, and overall well-being—all things that are typically disrupted by POP—was seen after eight to twelve weeks of Kegel exercises (forty-five to sixty Kegels per day, split into two or three sets). Other studies show that twelve to sixteen weeks of Kegels can increase pelvic muscle strength. And there is emerging research suggesting that consistently performing Kegels within the six- to twelve-week postpartum period may contribute to preventing a prolapse later in life.

Biofeedback

Properly performing Kegels is important for strengthening the pelvic floor muscles and improving POP. Yet these exercises are not always intuitive, leaving many women performing them incorrectly and not seeing improvement. Biofeedback is a complementary treatment process that uses physiological feedback to guide women to correctly contract and relax the pelvic floor muscles. It does so by monitoring the activity of the pelvic floor in real time while Kegels exercises are being performed. Generally, sensors are placed in the vagina and/or around the pelvic region during Kegel exercises. The sensors detect which pelvic muscles are contracting, how tightly they are contracting, and for how long. A biofeedback therapist can help interpret this immediate feedback and guide you into doing the Kegels the correct way. And newer digital biofeedback devices allow people to monitor and get immediate feedback, without assistance, in the comfort of their homes (Ahadi et al., 2017; Bø, 2012; NAFC, 2018a).

Electrical Stimulation

As the name implies, electrical stimulation delivers electrical impulses to the pelvic floor muscles to help them contract. This technique allows people to familiarize themselves with the location of their pelvic floor muscles and what it feels like for them to contract. Typically, a device is placed in the vagina that stimulates the nerves and muscles of the pelvic floor. A tightening or lifting of the pelvic floor muscles is usually felt. When used with pelvic floor muscle training, research shows that electrical stimulation can help to strengthen pelvic floor muscles, improve POP, and improve symptoms of stress urinary incontinence (Allon, 2019; Arnouk et al., 2017; W. Li et al., 2020; NAFC, 2018b; Q. J. Wang et al., 2019).

Pessary Use

Pessaries are commonly used to help people manage POP and its symptoms. They are devices, usually ring-shaped and made from medical-grade silicone, that are placed in the vagina to provide pelvic support. Pessaries are an option for any stage of prolapse. They can prevent a prolapse from progressing or decrease its symptoms and may prevent or delay the need for surgery. For many people, they can be life-changing by improving productivity and allowing increased physical activity and social engagement. The evaluation of long-term use of pessaries is ongoing. In a twelve-year study looking at 310 women sixty-five to seventy-four years of age, 41 percent of women continued to use a pessary after twelve years, and most used it for almost eight years.

But even though pessaries are a great option for many, people with a hysterectomy, pelvic reconstructive surgery, or vaginal wall prolapse may be less likely to experience success with pessary use. More pelvic support may be needed. People who are unlikely to follow instructions for the care and maintenance of the pessary may want to avoid using them, because serious complications can occur if a pessary is not cared for properly. And people with dementia may also want to avoid using a pessary, because remembering instructional care is critical, as may those with pelvic pain, as a pessary may cause additional pain.

Even though pessaries are generally safe and effective, they may have side effects. Vaginal discharge, irritation, ulceration, bleeding, pain, and odor are the most common complications. Bacterial vaginosis (a vaginal infection caused by bacteria overgrowth) can occur in up to 30 percent of pessary users, but it is more common in those who remove them less frequently. It’s important to clean the pessary regularly and check in with your doctor. Together, you and your doctor can determine if pessary treatment is best you (Iglesia & Smithling, 2017; Ramsay et al., 2016; Tso et al., 2018).

Surgery

Surgery is also an option for treating POP, usually for women with stage 3 or 4 prolapse. Surgery can correct the anatomy of the pelvic floor and organs and help with symptoms—improving vaginal, bladder, and bowel function. In the US, the average age at the time of surgery for POP is sixty to sixty-five years old. Yet surgery does not guarantee that the prolapse will not return—6 to 30 percent of women require a second surgery for a recurring prolapse, which is more likely in women sixty years of age or younger, with stage 3 or 4 prolapse, and with a less experienced surgeon. Common surgical options for treating POP are:

1. • Cystocele repair: repairs prolapsed bladder or urethra

2. • Hysterectomy: removes the uterus

3. • Rectocele: repairs fallen rectum and small bowel

4. • Vaginal vault suspension: repairs the vaginal wall

5. • Colpocleisis (vaginal obliteration or vaginal closure): closes the vagina

New and Promising Research on Pelvic Organ Prolapse

New research on treatments for POP show continued potential for effective less-invasive treatments with limited side effects. Studies are scarce, but the results are promising.

Laser Therapy

Laser therapy is a treatment that uses focused light to stimulate tissue repair. The research on laser therapy and POP is slim, yet extraordinarily promising. One study showed that with three to four laser treatments, 95 percent of women improved their POP by at least one stage. Results showed that 50 percent of women with stage 2 prolapse improved to stage 0 and 43 percent to stage 1. Twenty percent of women with stage 3 prolapse improved to stage 0 and 40 percent to stage 2. And 83 percent of women with the most severe prolapse, stage 4, improved to stage 1, with the remaining 17 percent improving to stage 2. The research was conducted in sixty-one women using laser therapy with a 2940nm vaginal erbium laser with SMOOTH mode. Another study reported significant improvement in POP using another laser therapy method (erbium yttrium-aluminum-garnet; Er:YAG) (Fistonić & Fistonić, 2018; Mackova et al., 2020).

Electroacupuncture

Another option that holds potential for treating POP is electroacupuncture, a modified version of traditional acupuncture. Electroacupuncture combines electrical stimulation with needles at each treatment point. An electrical current runs through the needles, providing more stimulation than the standard manipulation used by an acupuncturist. Researchers are beginning to uncover its potential use in treating POP, but studies show that electroacupuncture, combined with other therapies, strengthens pelvic floor muscles and improves the status of POP (Liu et al., 2016; L.-L. Wang et al., 2020).

Ongoing Clinical Trials for Pelvic Organ Prolapse

Clinical trials are research studies intended to evaluate a medical, surgical, or behavioral intervention. They are done so that researchers can study a particular treatment that may not have a lot of data on its safety or effectiveness yet. If you’re considering signing up for a clinical trial, it’s important to note that if you’re placed in the placebo group, you won’t have access to the treatment being studied. It’s also good to understand the phase of the clinical trial: Phase 1 is the first time most drugs will be used in humans so it’s about finding a safe dose. If the drug makes it through the initial trial, it can be used in a larger phase 2 trial to see whether it works well. Then it may be compared to a known effective treatment in a phase 3 trial. If the drug is approved by the FDA, it will go on to a phase 4 trial. Phase 3 and phase 4 trials are the most likely to involve the most effective and safest up-and-coming treatments.

In general, clinical trials may yield valuable information; they may provide benefits for some people but have undesirable outcomes for others. Speak with your doctor about any clinical trial you are considering. To find studies that are currently recruiting for various treatments for Pelvic Organ Prolapse (POP), go to clinicaltrials.gov. We’ve highlighted some below.

Genital Vibrators

Apparently vibrators are not just for pleasure. Karyn Eilber, MD, at Cedars Sinai Medical Center will soon be recruiting women to assess the use of genital vibrators on POP and other pelvic dysfunctions. For three to four months, participants will use a vibrator for clitoral stimulation three times a week for at least five minutes or until orgasm is reached. Participants will be evaluated after three to four months to access the degree of POP, sexual function, and quality of life.

Laser Therapy

Because laser therapy seems to be effective and seems to have minimal side effects, research on laser therapy for POP is growing. The Hampshire Hospitals NHS Foundation Trust is recruiting patients with POP to see whether laser therapy with the FotonaSmooth Er:YAG laser is effective in improving POP and its symptoms. Four laser treatments will be given during at-home visits once every four weeks. And participants will be evaluated six and twelve months after treatment.

Electroacupuncture

Research on electroacupuncture is ongoing. Zhishun Liu, PhD, MD, at Guang’anmen Hospital of China Academy of Chinese Medical Sciences will be recruiting patients to investigate electroacupuncture for POP. Treatment will be given to patients at acupuncture points BL33, BL35, and SP6 for three months for a total of twenty-four treatment sessions: three times a week for the first four weeks, twice a week for the next four weeks, and once a week for the last four weeks of the study. Participants will be evaluated three, six, and nine months after the start of electroacupuncture treatments.

Radiofrequency Therapy

Research is just emerging on radiofrequency therapy for treating POP. Nonablative radiofrequency is used to heat tissue and to stimulate collagen growth. Juan Carlos Fernández-Domínguez, PhD, at the University of the Balearic Islands in Palma, Spain, will soon be recruiting women to further investigate the effects on POP of radiofrequency therapy with pelvic exercises. It could be one of the first clinical trials published on this topic.

Vaginal Probiotics

Although pessary use is an effective option for many people, it can impact the normal microenvironment of the vagina and lead to side effects like vaginal discharge, irritation, and odor. Elisabeth Sappenfield, MD, at Hartford Hospital is evaluating the effect of vaginal probiotics on some of the side effects of pessary use. In this trial, an over-the-counter vaginal probiotic supplement (BiopHresh) and a moisturizing personal lubricant (Restore gel) are being tested with pessary use. Participants are asked to use the vaginal lubricant and the probiotic vaginal suppository three times weekly for three months. Recruiting is currently in progress.

Vaginal Estrogen

There is some evidence that vaginal estrogen, combined with Kegel exercises, may help improve symptoms of POP. Pamela Moalli, MD, PhD, at the University of Pittsburgh is looking into this further. She’s currently recruiting women for a randomized controlled trial to see whether Kegel exercises combined with Premarin vaginal estrogen cream improve symptoms.

Resources and Related Reading

Online

1. • Voices for PFD, founded by the American Urogynecologic Society, has lots of user-friendly resources to learn about pelvic organ prolapse and other pelvic floor disorders. You can search for health care providers, find tools to help you talk with your health care provider, and sign up for the society’s their newsletter. The downloadable fact sheets are excellent educational tools for pelvic health.

2. • ACOG (The American College of Obstetricians and Gynecologists), leaders in advancing women’s health care, created exceptional animations that allow patients to understand the different types of pelvic organ prolapse and pessary treatments. They also share a patient’s story about healing after a prolapse and FAQs on surgeries for treatment.

3. • The National Association for Continence offers a thoughtful video on expressing pelvic health concerns with your doctor.

4. • The Office of Women’s Health was established by the U.S. Department of Health and Human Services to improve the health of women and girls. It addresses FAQs on pelvic organ prolapse and provides fact sheets. It also has a helpline you can call at 800.994.9662.

5. • The FDA maintains updated information on uts warning on the surgical mesh implants here.

Books

1. • Holding the Ball: How I Survived Pelvic Organ Prolapse—without Surgery! by Julia F. Kaye.

2. • The Power Source by Lauren Roxburgh offers an inspiring multifaceted approach to caring for the pelvic floor, seeing it as foundational to whole body health.

Relevant Reading on goop

Q&A’s with Practitioners and Other Content

1. • “Understanding Urinary Incontinence and Pelvic Floor Disorders” with ob-gyn Rebecca Nelken, MD. Board-certified in obstetrics and gynecology and female pelvic medicine, Nelken discusses pelvic floor disorders and options for treatment.

2. • “Ask Gerda: When Do I Need to Start Doing Kegels—and How?”. goop’s senior director of science and research, Gerda Endemann, PhD, discusses some tools to help exercise your pelvic floor.

3. • “The Secrets of the Pelvic Floor” with Lauren Roxburgh provides detailed descriptions of exercises to stretch, strengthen, and relax pelvic floor muscles.

4. • “Menopause and Perimenopause” is an article in the goop PhD library that includes information on pelvic floor health and treatments for incontinence and sexual dysfunction related to low estrogen levels.