Prolapse of Female Genital Organs

Genital prolapse is a HERNIA that occurs when pelvic organs (uterus, bladder and rectum) slip down from their normal anatomical position and either protrude into the vagina or press against the wall of the vagina. The pelvic organs are usually supported by ligaments and the muscles, connective tissue and fascia which are collectively known as the pelvic floor. Weakening of or damage to these support structures allows the pelvic organs to slip down.

The condition is most common in postmenopausal women who have had children, but can also occur in younger women and women who have not had children. It is estimated that at least half the women who have had more than one child have some degree of genital prolapse (although only 10-20% complain of symptoms).
Types

There are a number of different types of prolapse. The prolapse of a pelvic organ may occur independently or along with other pelvic organ prolapses. Prolapses are graded according to their severity; first, second, third or fourth degree (grade or stage) prolapse.

1. Uterine prolapse: involves the descent of the uterus and cervix down the vagina
2. Cystocele: where the tissues supporting the wall between the bladder and vagina weaken, allowing a portion of the bladder to descend and press into the wall of the vagina.
3. Urethrocele: where the urethra (tube leading from the bladder to the outside of the body) descends and presses into the wall of the vagina.
4. Rectocele: where the tissues supporting the wall between the vagina and rectum weaken allowing the rectum to descend and press into the wall of the vagina.
5. Enterocele: Where part of small bowel descends between the uterus and the rectum into the wall of the vagina.
6. Vaginal vault prolapse: where the top of the vagina descends in women who have had a hysterectomy.

Types of prolapse


Symptoms.

     Symptoms of prolapse differ according to the organs involved and the severity of the prolapse.

• A dragging sensation or feeling that something is falling down - these feelings are especially noticeable after long periods of standing at the end of the day and with physical exertion. 
• Lump or bulge in the vagina or vaginal entrance. 
• Aching discomfort in the pelvic region. 
• Urinary problems - the change in position of the bladder that can occur with prolapse may lead to frequent urination, incomplete emptying of the bladder and urinary infections. Stress incontinence is a common association with proalpse (up to 60% in large degrees of prolapse). The incontinence may be evident i.e. leaking of urine when coughing, sneezing, laughing or masked by the prolapse that kinks the urethra (tube leading from the bladder to the outside of the body) like kinking a hose and stopping the water flow. If surgery is indicated for the prolapse a specific surgical procedure for the incontinence may be indicated at the same time of surgery for prolapse 
• Bowel problems - a rectocele can result in difficulty in emptying the bowel. 
• Dull backache. 
• Sexual problems - prolapsed pelvic organs can limit the depth of penetration or make penetration difficult or uncomfortable. The loss of pelvic tone can result in decreased sensation and women who have stress incontinence may experience a loss of urine during intercourse. 
• Psychological - prolapse can result in a loss of self-esteem and a negative self image. 

All these symptoms are not specific to the prolapse and they may persist after its treatment if they are not due to the prolapse.

Causes.

Prolapse occurs due to a weakness or damage that has occurred to the structures which hold the pelvic organs in place. There are a number of contributing factors including:

• Pregnancy and childbirth -The most significant causal factor for prolapse is having children. During pregnancy, hormonal changes and the extra weight and pressure of the baby can contribute to the weakening of the pelvic floor. In addition, a vaginal delivery can result in the supporting pelvic structures being stretched or torn. Damage to the pelvic floor occurs particularly in long second stages of labour, instrumental deliveries (the use of forceps or vacuum extraction) and in the delivery of large infants. Often damage that occurs during pregnancy and childbirth goes unnoticed at the time, with symptoms only developing later in life, following menopause.
• Menopause/ageing - The female hormone oestrogen plays an important role in maintaining the strength of the pelvic floor. At menopause, a woman’s oestrogen levels decrease and, as a result, the pelvic floor becomes weaker. The lack of oestrogen at this time often exacerbates existing damage that may have occurred as a result of childbirth or other factors. The pelvic support structures also relax due to the natural ageing process. 
• Pressure in the abdomen - Factors such as obesity, chronic coughing (eg. coughing associated with smoking or conditions like bronchitis or asthma), the lifting of heavy objects, straining during a bowel movement and the presence of pelvic masses (i.e., fibroid) all place pressure on the pelvic floor. If these pressures are sustained over a long period of time they can weaken the pelvic floor. They would also cause recurrence of the prolapse after being treated 
• Genetic - Some women are born with a weakness in their pelvic floor muscles and so are at a higher risk of prolapse. Congenital weakness explains why some young women and women who have never had children develop a prolapse. 

A surgically repaired cystocele and a rectocele/eneterocele.