Weaknesses in the vagina and in the ligaments supporting the bladder, rectum and uterus can cause the ‘dropping’ of a pelvic organ, which is known as a prolapse . The symptoms depend on the type of prolapse but commonly there is a sensation of something coming down the vagina or a lump within it, or low back pain which improves on lying flat. Pain during sexual inter course (dyspareunia, pronounced dis-puh-roon-ea) may also occur.
The main reasons for prolapse are difficult childbirth, other types of damage to the pelvic support structures (sometimes brought about by a hysterectomy itself), ageing processes in tissues and inherited defects of the pelvic support tissues. Women who have a chronic cough or constipation seem particularly vulnerable to prolapse.
When a doctor refers to a ‘uterine prolapse’ this means that a weakness in the uterine support structures has caused the uterus to drop into the vagina, causing that tissue to move downwards. A ‘first degree uterine prolapse’ means the cervix is ‘low’, being within easy reach of a finger inserted in the vagina. In second degree prolapse, the cervix has dropped to be near the vaginal entrance. Occasionally, the uterus is completely prolapsed, which means the cervix appears at the vaginal entrance. This third degree prolapse condition is known as procidentia (pronounced pro-see-dench-ea) or uterine descent. Sitting and walking are understandably difficult and, if the protruding cervix chafes during walking, this can cause a blood-stained discharge.
Other sorts of prolapse are often described under the umbrella-term, ‘Vaginal prolapse’. They are described as:
• cystocele, in which part of the bladder drops into the vagina
• enterocele, when a loop of intestine does the same thing
• urethrocele, where the urethra (the 3-4 cm long canal through which urine passes from the bladder to the urethral opening near the entrance to the vagina) presses into the vagina
• cystourethrocele, where a cystocele and a urethrocele occur together
• rectocele, in which the wall of the rectum protrudes into the vagina.
In the case of a cystocele, urethrocele or cystourethrocele, bladder weakness is common as well as the general feeling of downward pressure in the vagina (women often liken the feeling to a lump coming down or out of the vagina). Leakage of urine may occur on coughing, laughing or sneezing, and urinary tract infections may be a recurring problem. A rectocele can produce a feeling of incomplete emptying of the rectum as a pocket of tissue may form which traps faecal matter. Some women find they can complete their bowel action by pressing firmly on the bridge of tissue between the vaginal opening and the anus.
The incident which prompted 37-year-old Marjorie to visit her doctor was an evening out with friends during which she had laughed long and loud. She felt the leakage of a small amount of urine and became embarrassed and uncomfortable. Visualising a patch on her dress that her friends and partner would see if she stood up, she spent twenty agonising minutes glued to the chair until an opportunity to casually leave the room arose. Her local doctor asked Marjorie to complete a urinary diary for a week and diagnosed a cystocele after a full pelvic examination, including a rectal examination.
Prolapse carries no risk to life, provided there is no urinary tract obstruction or current infection of the urinary tract. If prolapse is not causing symptoms, watching and waiting to check on progression is a reasonable approach. Medical as well as surgical treatments are available if necessary, and choosing the best approach depends on factors like a woman’s age, state of health, and her desire to have children and to retain the ability to have sex. If surgery is not suitable, a supporting plastic or rubber device called a pessary can be inserted in the vagina to support the uterus in its normal position. Women with uterine prolapse or a cystocele may be helped by ring pessaries, made of inert plastic. These can remain in place for several months without removal and cleaning, provided they do not produce any adverse effects such as a smelly vaginal discharge. Considerable improvement may be achieved when the pessary is combined with a vaginal oestrogen ointment and exercises to strengthen the pelvic floor.
Surgery for prolapse problems dates back more than a century and recent advances include techniques to repair muscles and ligaments, and repositioning of the pelvic organs. In some cases a vaginal hysterectomy may be suggested. The choice of surgical approach may be affected if a woman wants to remain sexually active, so this should be discussed with her doctor at an early stage.