What is Prolapse?

Hi Bestie! Ahh…I’ve been waiting for this chat. Today we’re talking about prolapse. Grab yourself a cup of whatever the bean you want and join me in your cozy chair. Ok—here we go!

You might be familiar with the term “prolapse.” A lot of the time, I hear folks talk about it like it is some super scary thing. Any time something goes awry with our bodies and we don’t totally understand it, that is scary! But the wonderful thing about many types of prolapse is that they can often be treated in a minimally invasive way, such as in  physical therapy.

 What is prolapse?

So what is a prolapse, or as it is more formally known, Pelvic Organ Prolapse (POP—you’re never going to look at Poptarts the same again, are you?)? Most simplistically, a prolapse is when one of the organs of the pelvis slips downward (descends) out of its normal position.

Let’s get more technical. There are two main, broad categories of prolapse: vaginal prolapse and rectal prolapse. Within the vaginal prolapse category, you can have anterior (front), apical (middle), or posterior (back) prolapse.  

Cystocele (Bladder Prolapse)

Let’s dive into each one of these. The word “anterior” is used to refer to things toward the front of your body. So an anterior vaginal prolapse is the downward slipping of the urinary bladder, which is the most anterior organ in the pelvic cavity. This is also called cystocele. If you’ve ever had a prolapse, you might have noticed a “bulge” in your vagina, or felt the sensation of heaviness or pressure in your vagina. Does this mean your bladder is slipping out of your vagina? No! You can rest assured that your bladder is not going to slip out of your vagina. There is tissue between each of the organs of the pelvis. That bulge you are experiencing is the bladder pressing into the wall of the vagina, and the tissue you see coming from the vagina is simply vaginal tissue, not the actual walls of the bladder. Somehow, I find this comforting.

Apical Prolapse

The second type of vaginal prolapse is an apical prolapse. This refers to the downward slipping and bulging of the uterus from the vagina. The uterus is located at the end of the vaginal canal and is situated roughly between the urinary bladder and the rectum. When the uterus is fully prolapsed out of the vagina, it is called procidentia.

Rectocele

The final type of vaginal prolapse is posterior prolapse. The term “posterior” refers to things positioned toward the backside of your body. In the pelvis, the rectum and small bowel are posterior to (behind) the bladder and uterus, making the prolapse of these structures the most posterior type of vaginal prolapse, lending to the name. The two main types of posterior prolapse are rectocele (the pressing of the rectum into the posterior vaginal wall) and enterocele (the pushing of the small bowel into the posterior vaginal wall). This type of prolapse occurs when the tissue of the rectum or small bowel bulges into the vagina. Similarly to an anterior prolapse, with a rectocele or enterocele, the rectum or small bowel is not actually falling out of the vagina, but is instead pushing on the posterior vaginal wall causing a bulge in the vagina. It’s important to note that a rectocele is different than a rectal prolapse.

A rectal prolapse refers to the bulging of tissue out of the anus, not out of the vagina. In a rectal prolapse, tissue of the rectum descends and can push out of the anus. Hold on, is this the same as a hemorrhoid? Great question, but no! And you bring up a great point here, so let’s discuss more. A hemorrhoid is actually a prolapsed blood vessel. Within and around the rectum there are blood vessels. These blood vessels can occasionally become swollen and irritated. A hemorrhoid can be internal (within the rectum, and you can’t see it) or external (outside of the anus, and you will see it if you are a contortionist or have a mirror). When the hemorrhoid is internal, it is often not painful and doesn’t cause those classic “hemorrhoid” symptoms, but when it is prolapsed (aka when it bulges through the anus) it can be very painful. 

How common is prolapse?

Like many pelvic floor dysfunctions, it can be difficult to lock down accurate numbers due to underreporting or even cases in which patients are symptom-free. However, multiple studies have sought to determine the prevalence of POP. Such studies have estimated that in parous females (females who have had at least one child), POP may occur as much as 50% of the time (1). These numbers are even higher for females who have given birth within the past year (2). In a study of females seeking gynecological care, as many as 65% had POP (3). Also, let’s note that these studies were done in developed countries and the research estimates rates of POP to be higher in developing countries (4). POP is highly prevalent worldwide, and is also highly treatable.

What causes prolapse?

Prolapse is, like most pelvic floor dysfunctions, a multifactorial issue. That is to say, it probably doesn’t just have one cause, but is the result of a bunch of small things. Some of these things include having a history of vaginal childbirth, a connective tissue disorder such as Ehlers Danlos Syndrome (EDS), female sex, and others. The organs of the pelvis are supported by the sling of pelvic floor muscles, so weakness in these muscles, or poor innervation to these muscles, can also be a factor in POP. There are so many other possible causes, but for now, let’s just stick to the basics.

What symptoms are associated with prolapse?

POP can result in no symptoms whatsoever, or can be the culprit behind severe pelvic dysfunction. Many folks with POP are asymptomatic. However, POP can cause the sensation of pressure or heaviness in the pelvis or vagina. One might feel a bulge in the vagina or even see something “coming out” of the vagina. Other associated symptoms may include generalized pelvic pain or low back pain.

Since prolapse may be impacted by the forces of gravity, symptoms may worsen toward the end of the day if you are on your feet for much of the day. You might also experience urinary symptoms. In the case of an anterior (bladder) prolapse, the part of the bladder pressing into the vaginal wall may retain urine. This can make it difficult to fully empty the bladder and may lead to symptoms of urinary frequency or feeling like you can’t empty the bladder all the way. You could also experience stress urinary incontinence (SUI) or difficulty voiding.

Bladder Prolapse

For those with a posterior prolapse, you could encounter similar symptoms, though with regard to defecation rather than urination. These could include a feeling of not being able to empty your rectum completely during defecation, fecal incontinence, fecal urgency, and constipation. Finally, with prolapse you may experience sexual symptoms that can include pain during vaginal penetrative intercourse, or difference in typical sensation.

With any type of prolapse, symptoms may change depending on the prolapse severity. We will talk more about this in our next chat, but for now, I’ve gotta grab a refill. Let’s catch up in a few!

XOXO,

Your Pelvic Bestie

References:

1.     Hagen S, Stark D. Conservative prevention and management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2011 Dec 7;(12):CD003882.

2.     Durnea CM, Khashan AS, Kenny LC, Durnea UA, Smyth MM, O'Reilly BA. Prevalence, etiology and risk factors of pelvic organ prolapse in premenopausal primiparous women. Int Urogynecol J. 2014 Nov;25(11):1463-70.

3.     Swift S, Woodman P, O'Boyle A, Kahn M, Valley M, Bland D, Wang W, Schaffer J. Pelvic Organ Support Study (POSST): the distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol. 2005 Mar;192(3):795-806.

4.     Wang B, Chen Y, Zhu X, Wang T, Li M, Huang Y, Xue L, Zhu Q, Gao X, Wu M. Global burden and trends of pelvic organ prolapse associated with aging women: An observational trend study from 1990 to 2019. Front Public Health. 2022 Sep 15;10:975829.

*The information contained in this article is for educational and informational purposes only and is not intended as health or medical advice. Always consult a qualified health provider regarding any questions you may have about a medical condition or health objectives.