Pelvic Organ Prolapse: Symptoms, Causes & Treatment

What Is Pelvic Organ Prolapse?

Pelvic organ prolapse is a condition where the bladder, uterus, or rectum drops from its normal position and bulges into or out of the vagina. This occurs when the pelvic floor muscles and connective tissues that support these organs become weakened or damaged, most commonly from childbirth, aging, or chronic straining.

The pelvic floor is a complex network of muscles, ligaments, and connective tissues that forms a supportive hammock at the bottom of the pelvis. This network holds the bladder, uterus, and rectum in their proper positions while allowing them to function normally. When this support system weakens, one or more of these organs can descend, creating a bulge in the vaginal wall or, in severe cases, protruding outside the vaginal opening.

Pelvic organ prolapse is remarkably common, affecting approximately 50% of women who have given birth vaginally. However, many women experience only mild prolapse without significant symptoms. Studies show that only 3-6% of women develop symptomatic prolapse that requires treatment. The condition tends to worsen gradually over time, particularly after menopause when estrogen levels decline and tissues become thinner and less elastic.

Understanding that prolapse is a mechanical problem—a weakening of support structures—helps explain why both mechanical solutions (like pessaries) and strengthening exercises can be effective treatments. It also helps women understand that prolapse is not dangerous in most cases, though it can significantly impact quality of life when symptoms become bothersome.

Types of Pelvic Organ Prolapse

There are several distinct types of pelvic organ prolapse, classified by which organ has descended and which part of the vaginal wall is affected. Many women have more than one type of prolapse occurring simultaneously, as the weakening of pelvic floor support often affects multiple areas.

Cystocele, also called anterior prolapse, is the most common type. It occurs when the bladder drops down and presses against the front wall of the vagina. Women with cystocele often experience urinary symptoms including difficulty starting urination, a sense of incomplete bladder emptying, or needing to press on the vaginal wall to urinate completely. Some women also experience stress urinary incontinence—leaking urine when coughing, sneezing, or exercising.

Rectocele, or posterior prolapse, happens when the rectum bulges into the back wall of the vagina. This can cause difficulty with bowel movements, as stool may collect in the pocket created by the prolapse. Some women find they need to press against the vaginal wall or perineum to help empty their bowels completely, a technique called splinting. Rectocele can also cause a sensation of incomplete evacuation and increased constipation.

Uterine prolapse occurs when the uterus descends into the vaginal canal. In mild cases, the cervix drops lower in the vagina, while in severe cases, the uterus can protrude outside the vaginal opening. This type often causes a noticeable feeling of pressure or heaviness in the pelvis, and women may feel or see a bulge at the vaginal opening. The cervix may develop small sores (ulcerations) from rubbing against clothing if it protrudes externally.

What Are the Symptoms of Pelvic Organ Prolapse?

The most common symptoms of pelvic organ prolapse include feeling a bulge or something coming out of the vagina, pelvic pressure or heaviness that worsens with standing, difficulty urinating or emptying the bowels, and discomfort during intercourse. Symptoms typically worsen throughout the day and improve with rest.

Many women with mild pelvic organ prolapse experience no symptoms at all and may be unaware of the condition until it's discovered during a routine pelvic exam. When symptoms do occur, they typically develop gradually and may fluctuate based on activity level, time of day, and hormonal status. Understanding the full range of potential symptoms helps women recognize when to seek evaluation.

The hallmark symptom of prolapse is the sensation of vaginal bulging—feeling like something is falling out or coming down in the pelvic area. This may be described as a ball-like feeling, pressure, or the sense of sitting on a small object. Some women can see or feel a bulge at or protruding from the vaginal opening. This bulge is typically more noticeable after prolonged standing, physical activity, or toward the end of the day, and it often improves with lying down or in the morning after sleep.

Pelvic pressure and heaviness are common complaints that significantly impact quality of life. Women often describe a dragging sensation, lower backache, or generalized discomfort in the pelvic region. This pressure may interfere with daily activities, exercise, and work. The discomfort is usually relieved by lying down and worsened by activities that increase abdominal pressure, such as lifting, coughing, or straining.

Urinary Symptoms

Bladder-related symptoms are particularly common when the prolapse involves the front vaginal wall (cystocele). Women may experience difficulty starting urination, a weak urine stream, or the need to change position to empty the bladder completely. Some women need to push the prolapse back inside or press on the vaginal wall to urinate, a condition called voiding dysfunction.

Paradoxically, prolapse can cause both urinary incontinence and urinary retention. Stress incontinence—leaking urine with coughing, sneezing, laughing, or physical activity—affects many women with prolapse. However, in some cases, a large cystocele can actually kink the urethra and prevent leakage, which may unmask stress incontinence after the prolapse is repaired. Urgency (sudden strong urges to urinate) and frequent urination are also common.

Bowel Symptoms

When prolapse involves the back vaginal wall (rectocele), bowel function is often affected. Women may experience constipation, difficulty evacuating stool, or the sensation of incomplete bowel emptying. Some women find that pressing against the back wall of the vagina (splinting) helps them pass stool more effectively—this is a strong indicator of rectocele.

In some cases, prolapse can cause fecal incontinence or difficulty controlling gas. This occurs when the pelvic floor muscles responsible for bowel control are weakened along with the structural support. These symptoms can be particularly distressing and may cause women to limit social activities.

Sexual Symptoms

Prolapse can affect sexual function in several ways. Some women experience discomfort or pain during intercourse, while others report reduced sensation. Partners may notice the prolapse during intimate contact. However, many women with prolapse continue to have satisfying sexual relationships, and intercourse is generally safe and will not worsen the prolapse.

When Should You See a Doctor for Prolapse?

See a doctor if you feel a bulge in your vagina, have persistent pelvic pressure or heaviness, experience difficulty urinating or emptying your bowels, or notice urinary or fecal incontinence. Seek immediate medical attention if you cannot urinate at all, cannot push the prolapse back inside, or develop severe pain.

While pelvic organ prolapse is rarely dangerous, it can significantly impact quality of life and sometimes indicates the need for prompt evaluation. Many women delay seeking help due to embarrassment, not realizing how common and treatable this condition is. Healthcare providers who specialize in pelvic floor disorders see these issues daily and can offer effective solutions.

You should schedule an appointment with a healthcare provider if you experience any of the following symptoms that bother you or interfere with daily activities:

• Feeling or seeing a bulge at the vaginal opening
• Persistent sensation of pelvic pressure or heaviness
• Difficulty starting urination or feeling like your bladder doesn't empty completely
• New or worsening urinary incontinence
• Difficulty with bowel movements or need to push on vagina to evacuate
• Pain or discomfort during intercourse
• Recurrent urinary tract infections
• Vaginal spotting or bleeding (especially if prolapse protrudes externally)

If symptoms are mild and not bothersome, treatment may not be necessary. However, it's still worthwhile to have a baseline evaluation so you can monitor for changes over time and learn about strategies to prevent worsening. A healthcare provider can also rule out other conditions that may cause similar symptoms.

What Causes Pelvic Organ Prolapse?

Pelvic organ prolapse is caused by weakening of the pelvic floor muscles and connective tissues that support the pelvic organs. The main causes include vaginal childbirth (especially multiple deliveries or difficult births), aging and menopause, chronic straining from constipation or heavy lifting, obesity, and genetic factors affecting connective tissue strength.

The pelvic floor is designed to withstand significant stress, but various factors can progressively weaken these support structures over time. Understanding the causes helps identify risk factors and opportunities for prevention. In most cases, prolapse results from a combination of factors rather than a single cause.

Vaginal childbirth is the most significant risk factor for developing pelvic organ prolapse. During vaginal delivery, the pelvic floor muscles, nerves, and connective tissues can be stretched, torn, or damaged. This damage may not cause immediate symptoms but can contribute to prolapse later in life. The risk increases with:

• Multiple vaginal deliveries
• Prolonged second stage of labor (pushing)
• Delivery of a large baby (over 4 kg/8.8 lbs)
• Use of forceps during delivery
• Significant vaginal tears during delivery

Aging and menopause play crucial roles in prolapse development. As women age, pelvic floor muscles naturally weaken, and connective tissues lose elasticity. Menopause accelerates this process because declining estrogen levels cause the vaginal and pelvic tissues to become thinner, drier, and less resilient. This explains why prolapse symptoms often first appear or worsen after menopause, even in women who had children decades earlier.

Chronic increases in abdominal pressure strain the pelvic floor repeatedly over time. Conditions and activities that cause this include:

• Chronic constipation and straining with bowel movements
• Chronic coughing (from smoking, lung disease, or asthma)
• Heavy lifting (occupational or recreational)
• Obesity, which increases constant pressure on the pelvic floor

Genetic factors influence connective tissue strength and help explain why some women develop significant prolapse while others with similar risk factors do not. Women with connective tissue disorders, those whose mothers or sisters have prolapse, and women of certain ethnic backgrounds have higher rates of prolapse. Caucasian and Hispanic women appear to have higher rates than African American or Asian women.

Previous pelvic surgery, including hysterectomy, can alter the support structures and increase the risk of future prolapse. Neurological conditions affecting the nerves to the pelvic floor muscles can also contribute to weakness and prolapse.

What Can You Do at Home to Help Prolapse?

Self-care for pelvic organ prolapse includes pelvic floor exercises (Kegels) to strengthen supporting muscles, maintaining a healthy weight, eating fiber-rich foods and staying hydrated to prevent constipation, avoiding heavy lifting, and using proper toileting techniques. Many women successfully manage mild prolapse with these strategies alone.

Conservative self-management is the first-line approach for many women with pelvic organ prolapse, particularly those with mild to moderate symptoms. These strategies can reduce symptoms, slow progression, and sometimes improve the prolapse itself. Even women who eventually need other treatments benefit from incorporating these habits.

Pelvic Floor Exercises (Kegel Exercises)

Strengthening the pelvic floor muscles is one of the most effective things you can do for prolapse. These exercises, often called Kegel exercises or pelvic floor muscle training, can reduce symptoms and may even improve the degree of prolapse over time. Research shows that supervised pelvic floor muscle training significantly improves prolapse symptoms and can reduce the stage of prolapse in many women.

To perform pelvic floor exercises correctly:

1. Identify the right muscles: Imagine you are trying to stop the flow of urine or prevent passing gas. The muscles you squeeze are your pelvic floor muscles. (Note: Don't actually practice by stopping urine flow regularly, as this can cause bladder problems.)
2. Contract and hold: Squeeze these muscles, lifting them up and inward. Hold for 5-10 seconds while breathing normally—don't hold your breath.
3. Relax completely: Release the muscles for 5-10 seconds before the next contraction.
4. Repeat regularly: Aim for 10-15 repetitions, 3 times per day.

Many women initially have difficulty identifying and isolating the pelvic floor muscles. Working with a pelvic floor physiotherapist can be extremely helpful—they can use biofeedback or internal examination to ensure you're exercising correctly and provide a personalized program. Consistency is key; it typically takes 3-6 months of regular exercise to see significant improvement.

Bowel Management

Preventing constipation and straining during bowel movements is crucial for managing prolapse. Straining increases pressure on the pelvic floor and can worsen prolapse over time. Strategies include:

• Eat plenty of fiber: Aim for 25-30 grams daily from fruits, vegetables, whole grains, and legumes
• Drink adequate fluids: At least 6-8 glasses of water daily
• Respond promptly to urges: Go to the bathroom when you feel the need; delaying can worsen constipation
• Use proper positioning: Place a small stool under your feet while sitting on the toilet to achieve a squatting position, which helps straighten the rectum and make evacuation easier
• For rectocele: You may need to support the back vaginal wall with a clean finger to help with bowel movements

Bladder Management

If you have difficulty urinating, certain techniques can help:

• Try double voiding: After urinating, stand up briefly, then sit back down and try again
• Lean forward slightly while urinating
• For cystocele: You may need to gently support the front vaginal wall to help empty your bladder
• Don't strain or push; relax and let urine flow naturally

Lifestyle Modifications

Other important self-care measures include:

• Maintain a healthy weight: Excess weight increases pressure on the pelvic floor
• Avoid heavy lifting: When you must lift, use proper technique—bend your knees, keep the object close to your body, and engage your pelvic floor muscles
• Quit smoking: Chronic coughing damages pelvic floor support
• Treat chronic cough: See a healthcare provider if you have a persistent cough

How Is Pelvic Organ Prolapse Diagnosed?

Pelvic organ prolapse is diagnosed through a physical examination, including a pelvic exam where the doctor assesses which organs have prolapsed and how severe the condition is. You may be asked to cough or strain during the exam. Additional tests like ultrasound or urinalysis may be ordered to assess bladder function and rule out other conditions.

Diagnosis of pelvic organ prolapse begins with a thorough discussion of your symptoms, medical history, and any factors that might contribute to pelvic floor weakness. Your healthcare provider will want to understand how symptoms affect your daily life, as treatment decisions are largely guided by symptom severity rather than the physical degree of prolapse.

The key diagnostic tool is a pelvic examination. During this exam, the doctor will visually inspect the vaginal opening and may use a speculum to examine the vaginal walls. You may be examined while lying down and/or standing, as prolapse is often more apparent when standing. The doctor will ask you to cough or bear down (strain as if having a bowel movement) to assess the full extent of prolapse and check for stress urinary incontinence.

The healthcare provider will determine:

• Which compartments are affected (front wall/bladder, back wall/rectum, apex/uterus)
• The severity of prolapse using a standardized staging system (typically POP-Q or Baden-Walker)
• The strength of pelvic floor muscles
• Whether stress urinary incontinence is present

Additional tests may be recommended depending on your symptoms:

• Urinalysis: To check for urinary tract infection or blood in the urine
• Post-void residual measurement: Ultrasound or catheterization to check if urine remains in the bladder after urination
• Pelvic ultrasound: To examine the uterus, ovaries, and pelvic floor muscles
• Urodynamic testing: Specialized tests of bladder function if urinary symptoms are prominent
• Cystoscopy: Examination of the bladder with a small camera if bladder problems are significant

These additional investigations are not always necessary and are typically reserved for cases where surgery is being considered or when symptoms don't match the examination findings.

How Is Pelvic Organ Prolapse Treated?

Treatment for pelvic organ prolapse ranges from watchful waiting for mild cases to pelvic floor physical therapy, vaginal pessaries, topical estrogen, and surgery. The choice depends on symptom severity, overall health, future pregnancy plans, and personal preferences. Many women successfully manage prolapse without surgery.

Treatment decisions for pelvic organ prolapse are highly individualized because the condition itself is not dangerous—treatment is aimed at improving symptoms and quality of life. A woman with significant prolapse but minimal symptoms may choose observation, while another with moderate prolapse causing bothersome symptoms might benefit from active treatment. Understanding all options allows women to make informed decisions.

Observation (Watchful Waiting)

If prolapse causes few or no symptoms, treatment may not be necessary. Many women live comfortably with prolapse using self-care measures alone. Regular follow-up appointments can monitor for changes, and treatment can be initiated if symptoms develop or worsen. This approach is particularly appropriate for women with mild prolapse who are not bothered by symptoms.

Topical Estrogen Therapy

After menopause and during breastfeeding, declining estrogen levels cause vaginal and pelvic tissues to become thinner and drier. Topical estrogen applied to the vagina can help restore tissue health, reduce dryness and irritation, and improve the effectiveness of other treatments. Estrogen is available as vaginal cream, tablets, or a flexible silicone ring that releases estrogen locally.

Topical vaginal estrogen is considered safe for most women because very little is absorbed into the bloodstream. It can reduce symptoms of irritation and may help pessaries fit more comfortably. Non-hormonal vaginal moisturizers and lubricants are also available for women who prefer to avoid hormones.

Vaginal Pessary

A pessary is a removable device inserted into the vagina to support prolapsed organs. Pessaries come in many shapes and sizes—rings, dishes, cubes, and other designs—and are typically made of medical-grade silicone or plastic. When properly fitted, a pessary should be comfortable and not noticeable during daily activities.

Pessaries are an excellent option for many women because they:

• Provide immediate symptom relief
• Are non-surgical and reversible
• Can be used long-term safely
• Allow time to decide about surgery
• Are appropriate for women who cannot have surgery

Finding the right pessary may require trying different types and sizes. Once fitted, regular follow-up is needed to check for any problems and clean or replace the device. Many women learn to remove, clean, and reinsert their pessary themselves, while others prefer to have this done by a healthcare provider every 3-6 months.

Most women can have intercourse with a pessary in place, though some types may need to be removed. Topical estrogen is often used alongside a pessary to prevent irritation and maintain vaginal health.

Research shows that 50-80% of women who try a pessary have successful long-term use with significant symptom improvement. Over time, some women find their prolapse improves enough that they no longer need the pessary.

Surgical Treatment

Surgery may be recommended when conservative treatments don't adequately relieve symptoms or when a woman prefers a more definitive solution. Surgical options depend on the type and severity of prolapse, the woman's overall health, and whether she desires future pregnancy or wants to preserve sexual function.

Surgical approaches include:

Native tissue repair: The surgeon uses the woman's own tissues to repair and reinforce the vaginal walls and pelvic floor support. This approach is typically done through the vagina with no external incisions. It involves lifting the prolapsed organs back into place and tightening the supporting tissues. Recovery is generally 4-6 weeks, during which heavy lifting and intercourse should be avoided.

Mesh-augmented repair: In some cases, synthetic mesh may be used to provide additional support. However, due to concerns about complications, vaginal mesh use has become more restricted. Mesh is still commonly used for certain abdominal approaches (sacrocolpopexy) with good outcomes.

Hysterectomy: Removal of the uterus is sometimes performed as part of prolapse surgery, particularly if the uterus is the primary source of prolapse or if there are other uterine conditions. However, hysterectomy alone does not treat prolapse—additional support procedures are needed. Many surgeons now perform uterine-sparing prolapse repairs for women who wish to keep their uterus.

Surgery is generally successful, with 70-90% of women experiencing significant improvement in symptoms. However, prolapse can recur after surgery, with about 10-30% of women experiencing some degree of recurrence over 10 years. Women who are younger, have more severe prolapse, or continue to have risk factors (chronic coughing, constipation, heavy lifting) have higher recurrence rates.

Can Pelvic Organ Prolapse Come Back After Treatment?

Yes, pelvic organ prolapse can recur after treatment, including after surgery. Recurrence rates vary but are approximately 10-30% over 10 years after surgery. Maintaining pelvic floor strength, avoiding constipation and heavy lifting, and managing weight can help reduce the risk of recurrence. Repeat treatment is possible if needed.

Understanding that prolapse can recur is important for setting realistic expectations. Prolapse is a result of weakened tissues, and this underlying weakness doesn't completely disappear with treatment. However, many women achieve long-term relief, and additional treatments are available if symptoms return.

Factors that increase the risk of recurrence include:

• Younger age at time of repair (longer time for recurrence to develop)
• More severe prolapse initially
• Ongoing risk factors: chronic constipation, coughing, heavy lifting, obesity
• Family history of prolapse
• Connective tissue weakness

If prolapse recurs, the same range of treatment options is available. Many women who have had surgery can be successfully treated with a pessary for recurrence, avoiding the need for repeat surgery. When repeat surgery is needed, it can still be effective, though outcomes may not be quite as good as first-time surgery.

Can You Get Pregnant with Pelvic Organ Prolapse?

Yes, pregnancy is possible with pelvic organ prolapse and poses no direct risk to the mother or baby. However, if you're planning surgery for prolapse, it's often recommended to complete your family first, as vaginal delivery can cause recurrence. Prolapse symptoms may improve during pregnancy as hormonal changes and positioning help support the pelvic organs.

Pelvic organ prolapse does not affect fertility or the ability to conceive. Many women with prolapse become pregnant and have healthy pregnancies and deliveries. The prolapse itself does not harm the developing baby or increase pregnancy complications.

Interestingly, prolapse symptoms often improve during pregnancy. Hormonal changes cause increased blood flow and fullness in pelvic tissues, which can provide some support. The position of the growing uterus also tends to push prolapse back inside. However, symptoms typically return or may worsen after delivery.

If you have significant prolapse and are considering pregnancy, or if you're planning prolapse surgery and may want future children, discuss this with your healthcare provider. Considerations include:

• Vaginal delivery can worsen or cause recurrence of prolapse
• Cesarean delivery may be recommended in some cases of severe prolapse
• Surgical repair is often best delayed until family is complete
• Pessaries may help manage symptoms during pregnancy but should be monitored

Is It Safe to Have Sex with Pelvic Organ Prolapse?

Yes, sexual intercourse is safe with pelvic organ prolapse and will not make the prolapse worse. Some women experience reduced sensation or discomfort during sex, while others notice no change. Most women can have intercourse with a vaginal pessary in place. Talk to your healthcare provider if you have concerns about sexual function.

Sexual activity will not damage prolapse or cause it to worsen. Many women with prolapse continue to have satisfying intimate relationships. However, the physical changes and psychological impact of prolapse can affect sexual function for some women.

Potential sexual concerns include:

• Reduced vaginal sensation
• Discomfort or pain during intercourse
• Self-consciousness about the prolapse
• Partners noticing the bulge
• Vaginal dryness (especially after menopause)

These issues are often manageable. Topical estrogen and vaginal moisturizers can help with dryness. Different positions may be more comfortable. Open communication with your partner can address psychological concerns. If pain occurs during intercourse, this should be discussed with your healthcare provider.

Most pessaries are designed to allow intercourse without removal, though comfort varies. If your pessary causes discomfort during sex, discuss alternatives with your healthcare provider—different shapes or sizes may work better, or you may prefer a type that's easily removed before intercourse.

Frequently Asked Questions About Pelvic Organ Prolapse