All About Prolapse

By Barbara C. Bourassa

According to estimates from doctors at Brigham & Women's Hospital, 20 to 30 percent of all women suffer from some degree of prolapse-a condition in which the pelvic organs, such as the bladder or the uterus, are no longer adequately supported by the surrounding muscles and ligaments. Prolapse takes different forms, and there are different levels of severity. But all women, because of how the pelvic region works, can benefit from understanding the condition's risk factors, symptoms, and treatments.

The bones of a woman's pelvic region create a stiff ring, sort of like the outside edges of a trampoline, in which the pelvic organs are suspended and supported by the pelvic muscles and ligaments. There are two big risk factors for prolapse: "the intrinsic strength of these pelvic tissues, or the genetic component, or the stresses and strains that these tissues are subject to, such as childbirth and aging," says Joan Marie Bengston, MD, an associate gynecologist with Brigham & Women's Hospital in Boston. During a vaginal birth or repeated vaginal births, for example, or just over time with aging, the muscles and ligaments can be weakened or become damaged. If they lose a significant amount of strength, they may not be able to hold the uterus, bladder, urethra, or rectum in the proper position. In a common form of prolapse, called uterine prolapse, the uterus drops from its position in the pelvic region and protrudes into the vagina.

One of the main symptoms of prolapse is pressure and bulging, or the "feeling that things are falling out," says Dr. Bengston. Other times, the presence of the uterus in the wrong place interferes with sexual intercourse. For other women, prolapse may cause urinary or fecal incontinence as the misplaced uterus interferes with the function of the bladder or rectum. In severe cases, a woman might suffer from multiple symptoms.. "Sometimes sorting out the symptoms and the physical findings can be difficult," she notes.

In addition to the traditional risk factors, Dr. Bengston notes that some people may have a genetic predisposition to prolapse caused by weak connective tissue. An article in the May 2007 issue of Harvard Women's Health Watch details two recent studies that appear to confirm this fact. Researchers at the University of Rochester, who studied 101 pairs of postmenopausal sisters, found that "when prolapse occurred, there was very high concordance within sister pairs." (Full results of the study were published in the December 2006 issue of Obstetrics and Gynecology.)

There are many treatment options for prolapse, but each woman is different, and some are better tolerated than others. The first, as with any medical condition, is to live with it, says Dr. Bengston. This means accepting that the condition "won't get better, and it might get worse," she notes.

Exercises to strengthen the pelvic muscles, such as Kegels, can sometimes help. Kegel exercises are designed to tone or strengthen the pelvic floor muscles. Unlike your abdominal muscles you can't see or feel these muscles-they are located deep inside the pelvis, stretching from the spine to the pubic bone.

Many doctors use a pessary for treating or diagnosing prolapse. A pessary is a small, ring-shaped device made from silicone or latex. It fits inside the vagina and works by supporting the urethra, or neck of the bladder. "We sometimes use a pessary as a diagnostic tool," notes Dr. Bengston. "It can help determine which symptoms are linked the prolapse and which aren't, and it's completely safe."

For severe cases of prolapse that don't respond to other options, the treatment may involve surgery to repair the connective tissue. Although many women find relief through surgery, Dr. Bengston estimates that 20 to 30 percent of women who undergo surgery will have a recurrence. This is due, in part, to the techniques used to repair tissue. Dr. Bengston uses the analogy of a worn-out spot on the elbow: you can stitch the threads together or use a patch. Traditionally, a surgeon would use sutures to stitch together the damaged tissue. A newer technique involves using a patch, or graft, such as those used to repair hernias. This option is more secure, but there are drawbacks, as any form of alternative tissue, whether biologic or synthetic, will not behave the same as native, or human, tissue. Because the vagina "is a very dynamic organ, we tend to use grafts in women who are not sexually active, or who have failed the traditional surgery with sutures," she notes.

If you think you suffer from prolapse, be sure to consult with your own doctor or medical practitioner for more information.