Prevalence and Statistics

How common is pelvic organ prolapse (POP) globally?

Globally, about 40% of women have pelvic organ prolapse. Per the research, this trend seems to be decreasing from the year 1990 to 2019. One study found that about 46% of the population had pelvic organ prolapse on examination, but only 12.5% of the population was symptomatic. 

The three countries with the highest age standardized incidence rate of pelvic organ prolapse were Russian, Belarus, and Estonia; the three countries with the lowest ASIR were Guatemala, Cyprus, and Nepal. 

Pelvic organ prolapse in different age groups

Aging is the most common risk factor for POP, followed by parity and obesity. 

The number of women aged 70-79 seeking medical attention for POP was the highest, followed by women aged 60-69. There is a steep increase in the number of women who have pelvic organ prolapse after menopause due to lack of estrogen in the vaginal tissues. 

Prevalence of prolapse after childbirth

Compared with cesarean delivery, women who give birth vaginally have a higher likelihood of experiencing pelvic organ prolapse. Additionally, those who undergo operative vaginal births (forceps, vacuum) have a higher incidence of POP. 

A larger vaginal hiatus (vaginal opening) is associated with POP, which is more likely after a vaginal birth compared to a cesarean birth. 

Other symptoms more likely after vaginal birth include stress urinary incontinence and overactive bladder, while anal incontinence is more likely to occur after an operative vaginal birth. 

Risk Factors for Pelvic Organ Prolapse

Risk factors for pelvic organ prolapse

Risk factors for pelvic organ prolapse include vaginal birth (increased with forceps/vacuum use), menopause, genetics (I’ve seen a link between hypermobility and prolapse), hysterectomy, and chronic straining. Ironically hysterectomy is a surgical treatment for prolapse. 

Impact of childbirth on prolapse risk

Childbirth, specifically a vaginal birth, can increase the risk of prolapse. It is well documented in research that a larger genital hiatus (vaginal opening) increases the likelihood of a prolapse. These tissues can become stretched with a vaginal birth, even more so with an operative vaginal birth (forceps, vacuum). 

Push times less than 20-30 minutes or over two hours can also increase the likelihood of a levator ani avulsion, which is the deepest layer of pelvic floor muscles that support the pelvic organs. This muscle group attaches to the back of the pubic symphysis, wraps around the pelvic organs, and then attaches to the other pubic symphysis on the other side of the pelvis. 

Without one attachment point, the pelvic organs are not supported and can “fall” leading to pelvic organ prolapse. 

Obesity and its correlation with pelvic organ prolapse

Obesity is associated with increased intra-abdominal pressure, which puts added pressure on the pelvic floor. Weight loss does not improve anatomical position of the pelvic organs, but will improve the symptoms associated with prolapse (heaviness, pressure, etc).

Genetics and family history of prolapse

In the clinic we see a consistent correlation of women with hypermobility and pelvic organ prolapse. Typically, hypermobility shows up as joint hypermobility and pain but due to the ligament laxity in the pelvis, the pelvic organs can “fall” into the vaginal canal. 

Recognizing and Diagnosing Prolapse

Early signs and symptoms of pelvic organ prolapse

Early signs and symptoms associated with POP include 

• bowel and bladder difficulties

• pelvic pressure or heaviness, seeing a bulge

• low back pain

• some patients say it feels like something is about to fall out of the pelvis

Typically, pelvic pain is not a symptom of POP. This does not mean a woman with prolapse does not have pelvic pain, however they are most likely not associated. 

How to get diagnosed with pelvic organ prolapse

Pelvic organ prolapse can be diagnosed via a digital vaginal examination. Typically, when assessing the bladder, digital pressure is applied to the posterior (back) portion of the vaginal canal over the rectum and the patient is asked to bear down to see movement of the bladder. The same is done to assess a rectocele with digital pressure applied to the anterior (front) of the vaginal canal. This examination is typically performed with a patient lying on their back. 

Due to the effect gravity has on the pelvic organs, we recommend an examination in standing to get a more accurate assessment of what is happening when gravity is at play considering this is how we live and when most of our patients are more symptomatic. 

Understanding the stages of pelvic organ prolapse

The most basic way to stage a prolapse is based on anatomical descent or the pelvic organ(s) relative to the hymenal remnants. Prolapse is staged 0-4 with 0 being the least severe and 4 being the most severe. 

Stage 0

No prolapse is demonstrated 

Stage 1

Prolapse, but definitely inside the vagina 

Stage 2

Prolapse, at the entrance of the vagina 

Stage 3

Prolapse, but definitely outside of the vagina 

Stage 4

Full organ eversion outside of the vagina 

Can you have a prolapse without symptoms?

Most definitely, yes. In fact, most women that have prolapse are not symptomatic. The numbers vary depending on the study, but one study reports that 46% of the population had prolapse based on examination while only 12% of these women were symptomatic. 

Oh, and a prolapse can come and go – read more about that here. 

Treatment and Prevention

Surgical and non-surgical treatments for prolapse

Treatment options for pelvic organ prolapse include surgery, a pessary, or pelvic floor therapy. 

The surgery performed varies based on type of prolapse and surgeon, but the most common I see is a sacrocolpoplexy. 

A pessary is a medical device that is fitted to each individual patient. It’s like a sports bra for the pelvic organs. There are different sizes and shapes of pessaries and each person needs a different type of pessary or size of pessary depending on what is going on, their goals, and symptoms. You can read more about pessaries here.

Pelvic floor physical therapy is a conservative treatment approach that is recommended before, after, or instead of surgery for prolapse. PT will look different for each person, but typically PFPT for prolapse will cover core strengthening, constipation management, correct breathing mechanics, and pelvic floor muscle coordination. 

Pelvic floor exercises to prevent or treat prolapse

Unfortunately there is no one size fits all approach to treating prolapse with exercise. Each exercise program should be tailored to the individual, however there is usually a coordination component that needs to be addressed with each patient. Kegels get all the press in the pelvic floor world, however that’s usually not the answer (or I wouldn’t have a job). The pelvic floor muscles should relax and contract, and should function inside of a bigger core unit with the diaphragm and abdominal muscles. Read lots more about that here.  

How lifestyle changes can reduce prolapse risk

Managing constipation and limiting straining is key for reducing the risk of prolapse. Chronic straining/breath holding consistently will put added pressure down onto the pelvic organs and the ligaments that support them and increase prolapse. 

Chronic constipation means a full rectum is sitting on top of the pelvic floor muscles (like a weight) making it harder for the muscles to do their job to support the organs. 

Long-term management of pelvic organ prolapse

Long term management of pelvic organ prolapse looks very similar to prevention. Managing constipation, correct posture, core strengthening, breathing exercises, limiting straining, and potentially using a pessary will ultimately be long term management of pelvic organ prolapse. 

Good news! We are currently taking new patients with prolapse in Rockwall, Canton, and Sulphur Springs. If you are interested in scheduling an appointment, please request an appointment here and someone from our team will reach out to you to get you scheduled.