Prolapse & Pelvic Floor

Understanding pelvic organ prolapse

Pelvic organ prolapse occurs when the muscles, ligaments, and connective tissues of the pelvic floor weaken, allowing one or more pelvic organs to descend from their normal position. The pelvic floor acts as a supportive hammock for the bladder, uterus, and rectum. When this support is compromised, organs may bulge into or beyond the vaginal canal.

Prolapse is more common than many women realise. Up to 50% of women who have given birth have some degree of prolapse, although not all experience symptoms.

Types of prolapse

• Cystocele (anterior prolapse) — the bladder descends into the front wall of the vagina; the most common type
• Uterine prolapse — the uterus drops downward into the vaginal canal
• Rectocele (posterior prolapse) — the rectum pushes against the back wall of the vagina
• Vaginal vault prolapse — the top of the vagina drops after hysterectomy
• Enterocele — the small intestine herniates into the upper vaginal wall

Prolapse is graded from stage I (mild descent) to stage IV (complete eversion), guiding the choice of treatment.

Risk factors and symptoms

Several factors contribute to pelvic floor weakening:

• Vaginal childbirth — particularly prolonged labour, large babies, or instrumental deliveries
• Menopause — declining oestrogen levels reduce tissue elasticity and strength
• Chronic straining — from constipation, chronic cough, or heavy lifting
• Obesity — increased intra-abdominal pressure
• Genetic predisposition — connective tissue disorders or family history
• Previous pelvic surgery, including hysterectomy

Common symptoms include:

• A sensation of heaviness, pressure, or “something coming down” in the pelvis
• A visible or palpable bulge at the vaginal opening
• Difficulty emptying the bladder or bowel completely
• Urinary incontinence or increased frequency
• Discomfort or reduced sensation during intercourse
• Lower back pain that worsens throughout the day

Conservative treatments

For mild to moderate prolapse, or when surgery is not desired or appropriate, several non-surgical options can provide significant relief:

• Pelvic floor rehabilitation — guided exercises with a specialised physiotherapist strengthen the muscles supporting the pelvic organs. Regular Kegel exercises, when performed correctly, can stabilise or even improve mild prolapse
• Vaginal pessary — a silicone device inserted into the vagina to support prolapsed organs. Available in various shapes and sizes, pessaries are fitted individually and can be used long-term. They are a safe, reversible alternative to surgery
• Lifestyle modifications — weight management, treating chronic cough or constipation, and avoiding heavy lifting help reduce the strain on the pelvic floor
• Local oestrogen therapy — vaginal oestrogen cream or pessaries improve tissue tone and elasticity in postmenopausal women

Surgical treatment

Surgery is recommended when prolapse is symptomatic, advanced (stage III–IV), or unresponsive to conservative measures. The choice of technique depends on the type and severity of prolapse, the patient’s age, overall health, and future plans:

• Native tissue repair — reinforcement of the pelvic floor using the patient’s own tissues; suitable for anterior and posterior compartment prolapse
• Sacrocolpopexy — a laparoscopic procedure that uses a synthetic mesh to suspend the vaginal vault or uterus from the sacral promontory; considered the gold standard for vault prolapse with excellent long-term durability
• Vaginal hysterectomy with vault suspension — when the uterus has prolapsed and is no longer desired; often combined with anterior or posterior repair
• Uterine-sparing procedures — techniques such as sacrohysteropexy or Manchester repair that correct the prolapse while preserving the uterus, an option increasingly requested by younger patients

Urinary incontinence

Urinary incontinence frequently accompanies pelvic floor weakness and can occur alongside or independently of prolapse. The two main types are:

• Stress urinary incontinence (SUI) — leakage triggered by coughing, sneezing, laughing, or exercise, caused by weakened urethral support
• Urgency incontinence (overactive bladder) — a sudden, strong urge to urinate that is difficult to control

Treatment depends on the type and severity: pelvic floor exercises, bladder training, medication for urgency symptoms, and surgical options such as mid-urethral sling procedures for stress incontinence. A thorough urodynamic assessment helps guide the most appropriate approach.