Vaginal Prolapse

Symptoms, Causes and Treatment

Prolapse can present itself differently, including vaginal wall prolapse and pelvic prolapse. No matter the type, it can be hard to treat. Luckily, not all cases have symptoms, and you can take steps in your everyday life to help avoid it, such as exercise and maintaining a healthy weight.

What is vaginal prolapse?


I will tell women that a prolapse is only as important as the symptoms that it causes, and if you do not have any symptoms, you do not have a prolapse. Well, at least not one that matters, no matter how bad a doctor may think it is. Prolapse is a common problem, particularly as you age. It is a weakness of the supports of the vagina, which leads to the “inside” trying to come “out.” In the worst cases, the vagina may even turn inside out.

It is a reflection of poor design — the point to which we, as a species, have evolved. When our ancestors walked on four limbs, there were very different forces acting on the vaginal tissues. Basically, even weakened tissues were encouraged to fall “in.” This is distinct from our upright position today, where vertical forces onto our pelvic floor try to push our innards “out.” The support of our innards is not very good, most of the support coming from poorly defined muscles that one upon a time used to wag our tails.
It is a common condition. However, it is difficult to define its frequency, as there are variable reporting systems. In addition, it is often asymptomatic and only diagnosed during routine examinations.
The condition develops slowly, and I think women may quietly be adjusting to their prolapse over a long time. It does have an impact, but they have quietly adjusted to it and accepted the changes, usually by limiting physical activity.
vaginal prolapse
Vaginal Prolapse Causes | Dr Chris Nichols Gynaecologist Perth WA

What are the causes of vaginal prolapse?


Vaginal delivery

The most important and potentially controllable factor in prolapse is a vaginal delivery, particularly forceps vaginal delivery. Pregnancy alone weakens the pelvic floor, even if delivery is by c-section, but will more rarely lead to prolapse.

Obesity

Obesity is another important contributing factor, particularly if the weight is predominantly abdominal weight, as that abdominal weight needs to be supported by the pelvic floor muscles. As obesity is becoming more of a problem for our society, it has important implications.

Postmenopause

Prolapse is much more common in postmenopausal women. The vaginal tissues, which are very oestrogen-dependent, become thinner and weaker without oestrogen support.

Medical conditions

Other medical conditions can contribute significantly. Chronic constipation with chronic straining is an important provocative factor. Chronic cough associated with chronic respiratory diseases such as asthma can be a factor as well.

Family history

Family history is important. Tissues vary in their strength between people, and we have no good test to determine tissue strength. If your mother had a prolapse, you may have weaker tissues and are at greater risk.

Exercise

Exercise is generally a very good thing and better muscle tone in any of the body generally produces better muscle tone in the pelvic floor. However, heavy weight-lifting exercise can produce hernia in men and prolapse in women.

Sexual activity

Sexual activity is, again, generally a very good thing to maintain. Using the tissues encourages blood flow and helps keep tissues vital. Orgasm is an excellent way to produce the most powerful contractions of the pelvic floor.

How does a prolapse present?


There are different names to describe prolapse, with different parts of the vagina prolapsing. Most often, it affects all of the vagina to a variable degree, some parts worse than others.

Cystocele (or prolapsed vaginal wall)

This is when the front vaginal wall, or the back wall of the bladder, prolapses.

Rectocele

When the back wall of the vagina, or the front wall of the bowel, prolapses.

Uterine prolapse

The uterus and cervix slide down the vagina and may protrude out of the vagina.

Vault prolapse

After a hysterectomy, the top of the vagina may prolapse, like a uterine prolapse.

How does a prolapse present?


There are different names to describe prolapse, with different parts of the vagina prolapsing. Most often, it affects all of the vagina to a variable degree, some parts worse than others.
Cystocele Prolapse | Dr Chris Nichols Perth

Cystocele (or prolapsed vaginal wall)

This is when the front vaginal wall, or the back wall of the bladder, prolapses.

Rectocele Prolapse | Dr Chris Nichols Perth

Rectocele

When the back wall of the vagina, or the front wall of the bowel, prolapses.

Uterine Prolapse | Dr Chris Nichols Perth

Uterine prolapse

The uterus and cervix slide down the vagina and may protrude out of the vagina.

Vault prolapse

After a hysterectomy, the top of the vagina may prolapse, like a uterine prolapse.

Vaginal prolapse or rectocele symptoms


Women will complain of pressure in the pelvis. The may notice a protrusion out of the vagina. It may affect the bladder in different ways, voiding more often. Symptoms can be leaking and difficulty emptying the bladder completely.

It can also affect bowel function, making it difficult to empty the bowel. Sometimes you need to support the prolapse to allow the bowel to empty.

Decreased sensation with intercourse is another symptom, which can affect both partners. Some of the decrease in sensation in the women relates to damage of the pelvic nerves, especially if compressed and damaged after childbirth.

Tests and diagnosis


The diagnosis is largely clinical. History and examination are the mainstays of the diagnosis.

Additional tests may include possible ultrasound and bladder function test, but neither are absolutely required

How common is a vaginal prolapse and what can I do when I do have it?


Vaginal Prolapse Treatment | Dr Chris Nichols Gynaecologist Perth WA

Vaginal prolapse treatment


Treatment of prolapse has three options. Preventative strategies, listed below, remain the cornerstone of management, before and after surgical repair.

Pessaries

Surgical devices of all shapes and sizes have been used for a century to try to support prolapsing tissue. For the right woman, it can provide excellent treatment. Ring pessaries are the most common today. To be retained, the posterior wall needs to be reasonable. With a bad rectocele, the device will just be expelled.

It may be the only option if there is a significant surgical risk, especially in older women. It is possible to learn how to take the pessary out and put it back, but most women are not comfortable doing that.

It is usually not an option if a woman is sexually active, either. They can lean on the vaginal walls and produce some ulceration of the vaginal skin. They need review and change, but less often over time.

Surgical treatment

Native tissue repair

Traditional surgical vaginal prolapse repair is called native tissue repair. The name implies that the support comes from shortening the stretched tissue in the front and back of the vagina and stitching the tissues back together.

It then heals — as any operation will heal — by laying down scar tissue. Scar tissue takes time to achieve maximum strength, most achieved by around six weeks after an operation. Scar tissue is not as strong as the tissue was before the prolapse occurred, so I describe it as making the best of weak tissues, not returning to the pre-prolapse state. “You can’t make a silk purse out of a sow’s ear”.

Of all the risks associated with surgical repair, the one that upsets me the most is the potential for recurrence. Fifteen per cent of women who have prolapse repair surgery will have surgery again. Fifty per cent of those who relapse will have a third operation.

Implants

Given that native tissue repair has good but not excellent results, and given the difficulty of recurrent prolapse, there have been attempts to put implantable tissue in to support the vagina.

Fishnet-like tissue has been sewn under the vaginal skin to add support. This is the “mesh” that you may have heard of. It was borrowed from general surgery, where surgeons have and continue to use this mesh to repair hernias. Since a prolapse is a bit like a hernia, it was thought it would be good in the vagina. It is a long saga, but the mesh is no longer an option.

I am a conservative practitioner and when it came in, I did see problems with the way it was introduced. I held back until the experience of the profession was greater. I was not happy to have my patients as guinea pigs. The tide turned before I started doing mesh repairs, so I have never used it. Having said that, despite all the controversy, we have lost a valuable tool for the very difficult cases.

How to prevent vaginal prolapse?


As with many cases with your health, prevention is better than the cure.

Exercise

Exercise is the fountain of youth that we all desire. It has great health benefits, including helping to maintain strength and tone in the pelvic floor muscles.

Fibre intake

Never strain to use your bowels. Fibre in the diet helps.

Using a fibre supplement such as Metamucil is a good and healthy long-term step to ensure you never strain. It is not addictive, and ok to use long term.

Pelvic floor exercises

The pelvic floor muscles are a little obscure and many women have difficulty identifying those muscles. Hence, they are often bad at exercising them.

It is the muscles that you need to contract to stop in the middle of emptying the bladder. Your partner can tell you when you contract the muscles during intercourse. A physiotherapist who specialises in women’s health can be very valuable in helping you to learn how to control them.

Pelvic floor muscle exercises are VERY important. Unfortunately, most women lose motivation to maintain regular pelvic floor exercises over time.

Avoid lifting heavy objects

What is heavy? If you need to think about lifting it, it is heavy. Most activities of daily living are OK.

I do encourage exercise, but weight lifting as a sport is not good for a weak pelvic floor.

Be aware when gardening. Many aspects of gardening involve the need to lift objects. Think about ways around it. The pelvic floor muscles tire, so keep time in the garden short and take breaks.

Keep a healthy weight

This is possibly the most important long-term factor under your control, albeit not always easy to control.

Control chronic illness

If you are unfortunate to have problems such as chronic constipation or asthma, the better that you can control the illness, the happier your pelvic floor will be.

Maintain sexual activity.

Use it or lose it. The vagina stays more vital if used — and the most intense pelvic floor exercise is an orgasm.

Get in touch


Dr Chris Nichols Obstetrician - Gynaecologist - Fertility Specialist Perth

Dr Chris Nichols

MBBS FRANZCOG
I deliver babies at SJOG Murdoch Hospital and have gynaecology theatre lists at both Murdoch and South Perth Hospital. With the help of Fertility Specialists of WA, I established the first fertility clinic south of the river, Fertility Specialists South, located in Applecross.
Elaine McCann Practice Midwife

Elaine McCann

Practice Midwife
I have been a midwife for over 30 years and worked with Dr Chris Nichols for more than 20 years, initially on the maternity unit at SJOG Murdoch Hospital where I still work as a clinical midwife part time and more recently as his practice midwife.
Ruth McCloskey Practice Nurse

Margaret Browne

Practice Secretary
I have known and worked as a practice secretary with Dr Chris Nichols for over 20 years at SJOG Murdoch Hospital. It is an enjoyable workplace and our aim is to provide a professional and caring experience for our patients.
Ruth McCloskey Practice Nurse

Ruth McCloskey

Practice Nurse
As a practice nurse I have worked at several hospitals and clinics around Perth including SJOG Murdoch Hospital. I enjoy assisting Dr Nichols with minor procedures in the rooms.