Pelvic Organ Prolapse: Symptoms, Causes & Treatment Options

What Is Pelvic Organ Prolapse?

Pelvic organ prolapse is a condition where the pelvic organs (bladder, uterus, or rectum) drop from their normal position and push against or protrude through the vaginal wall. This happens when the muscles and connective tissues of the pelvic floor become weakened or damaged, most commonly after vaginal childbirth.

The pelvic floor is a complex network of muscles, ligaments, and connective tissue that forms a supportive hammock at the base of the pelvis. This structure holds the pelvic organs—including the bladder, uterus, and rectum—in their proper positions. When these support structures weaken or become damaged, one or more of these organs can descend, creating what is medically termed a prolapse.

Understanding the anatomy helps clarify why prolapse occurs. The pelvic floor muscles work together with ligaments and fascia (connective tissue) to maintain organ position against gravity and increased abdominal pressure from activities like coughing, lifting, or straining. When any part of this support system fails, the organs they support can shift downward.

Pelvic organ prolapse is remarkably common, affecting approximately 50% of women who have given birth vaginally. However, many women have mild prolapse without any symptoms. Research indicates that about 11% of women will undergo surgery for prolapse by age 80, suggesting that while the condition is widespread, severe symptomatic cases requiring intervention are less common.

The condition varies significantly in severity. Some women notice only a mild sense of pressure or fullness, while others experience a visible bulge outside the vagina. The impact on daily life ranges from minimal to substantial, depending on the degree of descent and the specific organs involved.

Types of Pelvic Organ Prolapse

Pelvic organ prolapse is classified based on which organ has descended. Understanding these types helps in both diagnosis and treatment planning, as different types may cause distinct symptoms and require specific approaches.

Cystocele (Bladder Prolapse): This is the most common type of prolapse, occurring when the bladder drops from its normal position and presses against the front wall of the vagina. Women with cystocele often experience urinary symptoms such as difficulty emptying the bladder completely, frequent urination, or stress urinary incontinence (leaking urine when coughing, sneezing, or exercising).

Rectocele (Rectal Prolapse into Vagina): In this type, the rectum bulges into the back wall of the vagina. Rectocele commonly causes bowel-related symptoms, including difficulty with bowel movements, a feeling of incomplete evacuation, and sometimes the need to press on the vaginal wall to complete a bowel movement.

Uterine Prolapse: This occurs when the uterus descends into the vaginal canal. In severe cases, the uterus can protrude outside the vaginal opening, a condition called procidentia. Uterine prolapse may cause a sensation of heaviness, lower back discomfort, and visible tissue at the vaginal opening.

Vaginal Vault Prolapse: This type occurs in women who have had a hysterectomy. The top of the vagina (vault) loses support and descends. It can occur months or years after hysterectomy.

What Are the Symptoms of Pelvic Organ Prolapse?

The main symptoms of pelvic organ prolapse include feeling a bulge or pressure in the vagina, heaviness in the pelvic area, difficulty urinating or having bowel movements, urinary or fecal incontinence, discomfort when sitting, and lower back pain. Symptoms often worsen throughout the day and improve with rest.

Symptoms of pelvic organ prolapse vary considerably based on the type and severity of the prolapse. Some women with anatomically significant prolapse report few or no symptoms, while others experience substantial discomfort that affects their daily activities. Understanding the range of possible symptoms helps women recognize when to seek evaluation.

The hallmark symptom is a sensation of vaginal bulging or a feeling that something is "falling out." Many women describe this as a feeling of pressure or heaviness in the pelvis. This sensation typically worsens with prolonged standing, physical activity, or as the day progresses, and often improves when lying down or after a night's rest.

A visible or palpable bulge at or beyond the vaginal opening is another common sign, particularly with more advanced prolapse. Some women notice tissue protruding when bathing or during toileting. The bulge may be soft and reducible, meaning it can be pushed back into the vagina, at least temporarily.

Urinary symptoms are particularly common with anterior (front wall) prolapse affecting the bladder. These include difficulty initiating urination, a weak urine stream, the need to strain to empty the bladder, and incomplete bladder emptying that leads to frequent urination. Paradoxically, some women experience urinary incontinence—leaking urine with coughing, sneezing, or physical activity—while others find that prolapse actually prevents incontinence by kinking the urethra.

Bowel symptoms typically accompany posterior (back wall) prolapse. Women may need to strain excessively to have a bowel movement, feel that evacuation is incomplete, or need to press on the vaginal wall (a technique called splinting) to help pass stool. Some women experience fecal incontinence or difficulty controlling gas.

• Vaginal bulging: Sensation of something protruding or falling out
• Pelvic heaviness: Feeling of pressure or fullness, especially when upright
• Urinary difficulties: Trouble starting urination, weak stream, incomplete emptying
• Bowel difficulties: Straining, incomplete evacuation, need for manual support
• Discomfort sitting: Pressure or feeling of sitting on a ball
• Lower back pain: Dull aching that worsens with standing
• Sexual difficulties: Discomfort during intercourse, reduced sensation

When Should You See a Doctor for Pelvic Organ Prolapse?

You should see a doctor if you feel a bulge in your vagina, have difficulty urinating or emptying your bladder, cannot push the prolapse back in, experience sudden inability to urinate, or if your symptoms significantly affect your quality of life. Urgent care is needed if you cannot urinate at all.

Many women notice mild prolapse symptoms but are uncertain whether medical evaluation is necessary. Understanding when to seek care helps ensure appropriate treatment while avoiding unnecessary anxiety about minor symptoms that may not require intervention.

Schedule a routine appointment with your gynecologist or primary care provider if you notice any of the following: a bulge or pressure sensation in your vagina that bothers you; difficulty emptying your bladder or frequent urination; constipation or difficulty with bowel movements that doesn't respond to dietary changes; discomfort during daily activities or sexual intercourse; or any visible tissue at the vaginal opening.

During your evaluation, the healthcare provider will take a detailed history of your symptoms, including when they started, what makes them better or worse, and how they affect your daily life. They will perform a pelvic examination to assess the type and degree of prolapse. This examination is typically done while lying down and again while standing or bearing down to see the maximum extent of prolapse.

It's worth noting that not all prolapse requires treatment. Many women with anatomical prolapse have no bothersome symptoms and can simply be monitored over time. The decision to treat is based primarily on how much symptoms affect your quality of life rather than the anatomical degree of descent.

What Can You Do at Home to Manage Pelvic Organ Prolapse?

You can help manage mild prolapse symptoms through pelvic floor exercises (Kegel exercises), avoiding heavy lifting, maintaining a healthy weight, eating high-fiber foods to prevent constipation, and using proper toileting techniques. These lifestyle measures can reduce symptoms and may slow prolapse progression.

Conservative self-management strategies form the foundation of prolapse treatment and are often recommended as first-line therapy for mild to moderate symptoms. These approaches are safe, have no side effects, and can significantly improve symptoms for many women. Even those who eventually need more aggressive treatment benefit from incorporating these measures into their daily routine.

Pelvic Floor Exercises (Kegel Exercises)

Pelvic floor muscle training is one of the most effective conservative treatments for prolapse symptoms. These exercises strengthen the muscles that support the pelvic organs, potentially improving or stabilizing symptoms. Research from Cochrane systematic reviews demonstrates that supervised pelvic floor muscle training can improve prolapse symptoms and reduce the anatomical degree of descent in some women.

To perform Kegel exercises correctly, first identify the right muscles by trying to stop your urine stream midway. The muscles you engage are your pelvic floor muscles. Once you've identified them, you can exercise them in any position. Contract these muscles, hold for 3-5 seconds, then relax for the same duration. Aim for 10-15 repetitions, three times daily. As muscles strengthen, gradually increase the hold time to 10 seconds.

Many women find it challenging to perform these exercises correctly on their own. Consider asking your healthcare provider about a referral to a pelvic floor physical therapist who can provide personalized instruction and ensure you're exercising the correct muscles effectively.

Lifestyle Modifications

Avoid heavy lifting whenever possible, as this significantly increases intra-abdominal pressure and can worsen prolapse. When you must lift, engage your pelvic floor muscles first and exhale during the lift rather than holding your breath.

Maintain a healthy weight. Excess body weight increases pressure on the pelvic floor. Studies show that weight loss can improve prolapse symptoms, particularly urinary symptoms.

Prevent and treat constipation to avoid chronic straining during bowel movements. Eat a diet rich in fiber (fruits, vegetables, whole grains), drink adequate fluids (at least 6-8 glasses daily), and respond promptly to the urge to have a bowel movement rather than delaying.

Toileting Techniques

Several practical strategies can make urination and bowel movements easier:

• For difficulty urinating: Try standing up after you think you've finished, lean forward, then sit back down and try again. Some women find that pressing gently on the lower abdomen helps empty the bladder more completely.
• For difficulty with bowel movements: Use a small footstool to elevate your feet while on the toilet—this straightens the rectum and makes evacuation easier. If needed, you can gently support the back vaginal wall with a finger during bowel movements.
• Respond promptly when you feel the urge to have a bowel movement rather than waiting.

What Causes Pelvic Organ Prolapse?

Pelvic organ prolapse is caused by weakening of the pelvic floor muscles and connective tissues. The main risk factors include vaginal childbirth (the most significant factor), aging and menopause, obesity, chronic constipation, heavy lifting, chronic coughing, and genetic predisposition affecting connective tissue strength.

Pelvic organ prolapse develops when the support structures of the pelvis—muscles, ligaments, and connective tissue—become weakened or damaged. This weakening is rarely due to a single cause but results from the cumulative effect of multiple factors over time. Understanding these causes helps identify women at higher risk and guides preventive strategies.

Vaginal childbirth is the most significant risk factor for prolapse. The process of labor and delivery stretches and can damage the pelvic floor muscles, nerves, and connective tissues. The risk increases with the number of vaginal deliveries, prolonged labor, large babies (especially over 4 kg/8.8 lbs), and delivery requiring forceps or vacuum assistance. However, prolapse can also occur in women who have never given birth, though much less commonly.

Research suggests that 50% of women who have given birth vaginally have some degree of prolapse, though many have no symptoms. The damage often occurs during delivery but may not manifest as symptomatic prolapse until years or decades later when additional factors compound the initial injury.

Aging and menopause contribute significantly to prolapse risk. As women age, muscle mass naturally decreases, including the pelvic floor muscles. The decline in estrogen after menopause causes thinning and weakening of the vaginal tissues and supporting structures. This explains why symptomatic prolapse most commonly presents in postmenopausal women, often decades after childbirth.

Increased abdominal pressure from various sources can accelerate prolapse development. Obesity places constant additional pressure on the pelvic floor. Chronic constipation leading to repeated straining during bowel movements has similar effects. Chronic coughing from conditions such as asthma, bronchitis, or smoking damages pelvic floor support over time. Occupations or activities involving heavy lifting also increase risk.

Genetic factors play an underappreciated role. Some women have naturally weaker connective tissue, which may be related to collagen composition. Conditions such as Ehlers-Danlos syndrome and Marfan syndrome, which affect connective tissue throughout the body, are associated with higher prolapse rates. Family history of prolapse is a significant risk factor—women whose mothers or sisters had prolapse are more likely to develop it themselves.

• Vaginal childbirth: The single most important risk factor, especially with multiple births
• Advancing age: Natural muscle weakening with time
• Menopause: Estrogen decline weakens tissues
• Obesity: Excess weight increases pelvic pressure
• Chronic constipation: Repeated straining damages support
• Heavy lifting: Occupational or recreational
• Chronic cough: From lung disease or smoking
• Genetic predisposition: Family history of prolapse
• Previous pelvic surgery: Including hysterectomy

How Is Pelvic Organ Prolapse Diagnosed?

Pelvic organ prolapse is diagnosed through a pelvic examination where the doctor assesses the vaginal walls while you bear down or cough. The standardized POP-Q system grades prolapse severity on a scale from 0 to IV. Additional tests may include urinalysis, bladder function tests, and sometimes imaging studies like ultrasound.

Diagnosis of pelvic organ prolapse begins with a thorough medical history and physical examination. The evaluation aims to determine the type and severity of prolapse, identify associated symptoms, and guide treatment decisions. Most diagnoses can be made through physical examination alone, though additional testing may be needed in some cases.

Your healthcare provider will ask about your symptoms in detail: what you feel, when symptoms occur, what makes them better or worse, and how they affect your daily activities. They will also review your medical history, including number of pregnancies and deliveries, previous pelvic surgeries, bowel and bladder function, and any relevant medical conditions.

The pelvic examination is the cornerstone of diagnosis. The examination is typically performed first while you are lying on your back and then repeated while you are standing or bearing down maximally (Valsalva maneuver) to reveal the full extent of prolapse. The provider uses a speculum to examine the vaginal walls separately, assessing the front wall (where bladder prolapse appears), back wall (where rectal prolapse appears), and cervix or vaginal vault.

Healthcare providers use the Pelvic Organ Prolapse Quantification (POP-Q) system, an internationally standardized method for documenting prolapse severity. This system measures the position of specific points in the vagina relative to the hymen during maximum straining. Prolapse is staged from 0 to IV:

• Stage 0: No prolapse
• Stage I: Most distal prolapse is more than 1 cm above the hymen
• Stage II: Most distal prolapse is within 1 cm of the hymen
• Stage III: Most distal prolapse protrudes more than 1 cm beyond the hymen
• Stage IV: Complete eversion (total prolapse)

Additional testing may include urinalysis to rule out urinary tract infection, which can cause similar urinary symptoms. If you have significant urinary symptoms, urodynamic testing may be performed to evaluate bladder function, particularly if surgery is being considered. This testing can reveal issues like stress incontinence that might emerge or worsen after prolapse repair.

Imaging studies are not routinely needed but may be helpful in complex cases. Pelvic ultrasound can assess the pelvic organs and identify other conditions. MRI provides detailed images of pelvic floor anatomy and may be used in planning complex surgical repairs.

How Is Pelvic Organ Prolapse Treated?

Pelvic organ prolapse treatment options include watchful waiting for mild cases, pelvic floor physical therapy, vaginal pessaries (supportive devices), vaginal estrogen for postmenopausal women, and various surgical procedures for those who don't respond to conservative measures. Treatment choice depends on symptom severity, overall health, and personal preferences.

Treatment for pelvic organ prolapse is highly individualized and depends on several factors: the severity of your symptoms, the degree of prolapse, your general health, your desire for future pregnancy, and your personal treatment preferences. The good news is that many effective options exist, and treatment is not always necessary—many women with prolapse have few or no symptoms and can safely be observed without intervention.

Watchful waiting is appropriate for women with prolapse that causes minimal or no symptoms. Since prolapse is not dangerous and doesn't necessarily progress rapidly, observation with periodic reassessment is a reasonable approach. During this time, lifestyle modifications and pelvic floor exercises may prevent worsening.

Vaginal Estrogen Therapy

For postmenopausal women, the vaginal tissues become thinner and drier due to reduced estrogen levels. This can worsen prolapse symptoms and make the vaginal walls more susceptible to irritation. Topical vaginal estrogen—available as creams, rings, or tablets inserted into the vagina—can restore tissue health and reduce symptoms from prolapse.

Vaginal estrogen strengthens the vaginal mucosa and supporting tissues, reduces irritation and discomfort, and may make other treatments (like pessaries) more comfortable. Because the dose is low and stays primarily in the vaginal area, vaginal estrogen is considered safe for most women, including many with a history of breast cancer, though you should discuss this with your healthcare provider.

Vaginal Pessary

A pessary is a removable device inserted into the vagina to support the prolapsed organs. Pessaries are available in many shapes and sizes to accommodate different types and severities of prolapse. They provide an effective non-surgical option that can be used long-term or as a bridge to surgery.

Pessaries work by holding the pelvic organs in their proper position mechanically. When properly fitted, a pessary should be comfortable—you shouldn't feel it during daily activities. Success rates range from 50-80% for symptom improvement, with many women using pessaries successfully for years.

After insertion, you will have a follow-up visit to ensure proper fit and comfort. The pessary needs to be removed and cleaned periodically—some women learn to do this themselves at home, while others prefer to have it done by their healthcare provider every few months. Pessaries are typically used with vaginal estrogen cream to keep tissues healthy and prevent irritation.

Possible side effects include vaginal discharge, odor, and occasional irritation. Rarely, if a pessary is left in place too long without removal, it can cause vaginal erosion. With proper care and regular follow-up, serious complications are uncommon.

Surgical Treatment

Surgery may be recommended when conservative treatments fail to adequately relieve symptoms, or if you prefer a more definitive solution. Several surgical options exist, and the choice depends on the type of prolapse, your overall health, whether you desire future pregnancy, and surgeon expertise.

Native tissue repair involves surgically repositioning the prolapsed organs and reinforcing the supporting tissues using your own tissue. This can be performed vaginally or abdominally. Vaginal surgery typically has faster recovery, while abdominal approaches (especially laparoscopic or robotic) may provide more durable results for certain prolapse types.

Sacrocolpopexy is considered the gold standard for apical (top of vagina) prolapse repair, especially in younger women or those who have had prior failed repairs. This procedure uses surgical mesh to attach the vaginal apex to the sacrum (lower spine), providing strong support. It is typically performed laparoscopically or robotically.

Hysterectomy (surgical removal of the uterus) may be performed as part of prolapse repair when the uterus has descended. However, hysterectomy alone doesn't treat prolapse—it must be combined with procedures to support the vaginal vault. Alternatively, uterine-sparing procedures are increasingly available for women who wish to preserve their uterus.

Surgery is typically performed under regional (spinal) or general anesthesia. Many prolapse repairs are now done as outpatient procedures, meaning you go home the same day. Recovery time varies but typically involves avoiding heavy lifting and strenuous activity for 6-12 weeks.

Success rates for prolapse surgery range from 70-90% for symptom improvement, though anatomical recurrence rates are higher. About 10-30% of women will eventually need repeat surgery, depending on the type of procedure and other factors.

Can Pelvic Organ Prolapse Come Back After Treatment?

Yes, pelvic organ prolapse can recur after treatment, including after surgery. Recurrence rates vary from 10-40% depending on the procedure performed and individual risk factors. However, repeat treatment options are available, and many women who experience recurrence can be successfully treated again.

Recurrence is one of the challenges of prolapse management. Even with optimal treatment, the underlying factors that caused prolapse—weakened tissues, ongoing pressure from activities—continue to exist. Understanding recurrence helps set realistic expectations and emphasizes the importance of ongoing preventive measures.

Pessary use can be continued long-term with good success, though some women eventually find that the pessary no longer fits properly or provides adequate support as prolapse progresses. In such cases, a different pessary size or type may help, or surgical repair can be considered.

Surgical recurrence rates vary significantly by procedure type, surgeon experience, and patient factors. Native tissue repairs have higher recurrence rates than mesh-augmented procedures, though mesh carries its own risks. Women who have risk factors for prolapse (obesity, chronic constipation, chronic cough, heavy lifting) have higher recurrence rates after any procedure.

If prolapse recurs after surgery, options include pessary use, repeat surgery with a different technique, or watchful waiting if symptoms are mild. Repeat operations can be successful, though they carry somewhat higher complication risks.

Can You Get Pregnant with Pelvic Organ Prolapse?

Yes, you can get pregnant and have a healthy pregnancy with pelvic organ prolapse. Prolapse does not affect fertility or pose risks to your pregnancy or baby. If you're planning pregnancy, it's generally recommended to delay surgical repair until you've completed childbearing, as pregnancy and delivery can affect surgical outcomes.

Pelvic organ prolapse does not prevent pregnancy or cause problems during pregnancy. Women with prolapse can conceive normally, carry pregnancies successfully, and deliver healthy babies. However, there are several considerations for women with prolapse who are planning pregnancy or are currently pregnant.

During pregnancy, hormonal changes and the weight of the growing uterus can temporarily worsen prolapse symptoms in some women. Conversely, some women find that symptoms improve as the enlarged uterus lifts out of the pelvis. After delivery, prolapse may improve, stay the same, or worsen, depending on various factors including delivery method and pre-existing tissue strength.

If you have symptomatic prolapse and are planning pregnancy, it's generally advisable to manage symptoms conservatively with pelvic floor exercises and, if needed, a pessary during pregnancy. Surgical repair is typically delayed until you've completed your family, as pregnancy and especially vaginal delivery can affect surgical outcomes.

Regarding delivery method, having prolapse alone is not typically an indication for cesarean section. However, decisions about delivery should be made in consultation with your healthcare provider based on your complete medical situation.

Is It Safe to Have Sex with Pelvic Organ Prolapse?

Yes, it is safe to have sex with pelvic organ prolapse. Sexual intercourse does not worsen prolapse or cause damage. Some women experience reduced sensation or mild discomfort, but many continue to have satisfying sexual activity. If you use a pessary, many types can remain in place during intercourse.

Sexual activity is a common concern for women with prolapse, but intercourse is safe and does not damage the pelvic floor or worsen prolapse. The prolapsed tissue is pushed back during intercourse and returns to its usual position afterward. There is no evidence that sexual activity accelerates prolapse progression.

However, prolapse can affect sexual experience in several ways. Some women report reduced vaginal sensation due to stretched tissues. Others feel self-conscious about the visible bulge or worry about their partner's perception. Depending on the type and degree of prolapse, certain positions may be more comfortable than others.

If you use a pessary, you may wonder about intercourse. Some pessary types are designed to remain in place during sexual activity, while others should be removed. Ring pessaries, for example, can typically stay in place. Discuss this with your healthcare provider when choosing a pessary if sexual activity is important to you.

If you experience discomfort during intercourse, vaginal estrogen (for postmenopausal women) can improve tissue health and reduce dryness that contributes to discomfort. Water-based lubricants can also help. Open communication with your partner about comfort and positioning makes intimate activity more enjoyable.