What to Know About Pelvic Organ Prolapse

At first blush, the notion that your organs could move from their original position inside you sounds like the stuff of science fiction. But it happens quite frequently, especially among women whose pelvic organs descend or droop from their normal location over time. The phenomenon, called pelvic organ prolapse, can involve a woman's bladder, uterus or rectum descending into the vagina or bulging into the front or back of the vaginal wall. Pelvic organ prolapse, or POP, affects millions of women -- as many as 50 percent of women, according to researchers at the Cleveland Clinic -- which makes it something of a secret medical epidemic, given that it's rarely talked about in polite company.

Most women aren't aware of what prolapse is, and "it kind of freaks them out but it's really just a hernia of the vaginal wall," says Dr. Kimberly Kenton, a professor of obstetrics, gynecology and urology and chief of female pelvic medicine and reconstructive surgery for Northwestern Medicine in Chicago. "Pelvic organ prolapse is very common, especially among women who've gone through vaginal childbirth."

Indeed, the most common causes of pelvic organ prolapse are pregnancy and childbirth, and the more babies a woman has had and the larger they are in terms of birth weight, the greater her risk is. Meanwhile, obesity doubles the risk of POP because there's more weight pushing on the organs in the pelvis. In fact, anything that increases pressure within the abdomen and causes repetitive strain to the pelvic floor -- including chronic cough or constipation and occupations involving heavy lifting -- can lead to prolapse, notes Dr. Mark Ellerkmann, director of urogynecology at the Center for Women's Health & Medicine at Mercy Medical Center in Baltimore.

Pelvic organ prolapse also becomes increasingly common with age, particularly after menopause. "As we get older, our tissues aren't as strong, collagen content decreases and our muscles get more lax -- we all tend to sag in different places," Ellerkmann says. This loss of support can cause pelvic organs to stray from their normal position, especially since gravity is working against women in this respect. Similarly, having a hysterectomy can compromise support for pelvic organs high up in the vagina, thus increasing the risk of prolapse. There may be a genetic predisposition as well, so if your mother or grandmother had it, you may be at higher risk, too.

[See: 11 Changes Women Go Through in Menopause.]

Symptoms of POP can vary from one woman to another but may include a feeling of pressure in the vagina, a pulling sensation in the groin area, difficulty urinating or having bowel movements or pain with intercourse. "Like any condition, there are different degrees of prolapse," says Dr. Benjamin Brucker, an assistant professor of urology and obstetrics-gynecology at the NYU Langone Medical Center. "There are patients who have it that don't realize it."

Whether symptoms are present or not, an OB-GYN or urogynecologist can diagnose pelvic organ prolapse during a standing pelvic exam as well as one in which the woman is lying on her back. The biggest indication for treatment is if a woman is bothered by the vaginal bulge or a pelvic organ dropping down into the vagina (and perhaps having to push it back up with her hand); if a woman has vaginal prolapse but is asymptomatic, treatment isn't necessary. "All the treatments are designed to improve quality of life, so you really can't improve quality of life if you don't know there's a problem," Kenton explains.

Women typically experience symptoms when prolapse reaches a stage 2 or 3 on a 4-point scale. At this point, physical therapy (sometimes with the use of biofeedback) and Kegel exercises may be recommended to strengthen the pelvic floor muscles. If you're overweight, shedding excess pounds can help decrease pressure in the abdomen. Even in the early stages, prolapse "can worsen if it's not addressed," Brucker says. A nonsurgical treatment that's often recommended is the use of a pessary, a small device, usually made of silicone, that's placed in the vagina to support the pelvic organs. It can be inserted and removed by the woman, for regular cleaning and during sex.

[See: 5 Physical Therapy Procedures You Should Question.]

For later stages of POP that are causing truly bothersome symptoms and interfering with a woman's quality of life, surgery -- performed through the vagina or the abdomen -- may be advised. Approximately 300,000 surgeries are performed each year for prolapse in the U.S., according to the National Institutes of Health. Reconstructive surgery for prolapse involves using stitches (an approach that carries a higher prolapse recurrence rate) or inserting either the patient's own tissue or surgical mesh to bolster support for the pelvic organs.

Mesh has long been used safely to treat abdominal hernias and stress urinary incontinence, Brucker notes. But in recent years, the use of mesh in prolapse surgeries has become controversial, largely because it's associated with a significant risk of complications -- such as pain, bleeding and infection -- when the mesh is inserted vaginally. "The complications can be immediate after surgery [but] most of the patients present to us with complications months or years after mesh insertion," notes Dr. Shlomo Raz, professor of urology and director of pelvic medicine and reconstructive surgery at UCLA. The Food and Drug Administration has even issued warnings about the risks of the transvaginal placement of surgical mesh for POP.

The problem with vaginal placement of mesh is, "the vagina normally contains large amounts of bacteria; even after extensive preparation prior to surgery, the bacteria still persist," Raz explains. "During surgery the mesh is inserted through a contaminated area [and] bacteria can colonize the mesh." The mesh ends up getting covered by a protective layer of chemicals, so antibiotics can't penetrate the area or cure the mesh infection, he adds; in such cases, the mesh needs to be removed.

[See: Tampons, Pads or Menstrual Cups? A Woman's Guide to Period Products.]

For these reasons, Raz doesn't use mesh in prolapse repair. Other doctors, such as Ellerkmann, still do use mesh in some patients, particularly with abdominal surgery for prolapse, which has a lower risk of mesh-related complications. (With yet another type of surgery, the vagina is narrowed and/or closed off to provide support for prolapsed organs, which means sexual intercourse is no longer possible after the surgery, Kenton says.)

Since all surgical treatments have their pros and cons, "if you're only offered one option, you should go see another urogynecologist," Kenton says. "There are many nonsurgical and surgical treatments for prolapse -- your doctor should discuss multiple options with you. If you're being given one option, you should quickly hit the road. Women have the right to weigh the risks and benefits of each approach and make the safest, best choice for them."

Ultimately, it's a quality-of-life issue, experts say, so there's no reason to suffer silently if you think you may have pelvic organ prolapse. After all, "pelvic organ prolapse is often associated with stress, urinary incontinence and it can lead to depression and social isolation [if it's not effectively treated]," Brucker says. "The first step is to talk to a doctor who is aware of this issue and will listen to your complaints because there are nuances and subtleties to the management of this."

Stacey Colino is a freelance Health + Wellness reporter at U.S. News. You can connect with her on LinkedIn or email her at staceycolino@gmail.com.