Vaginal Prolapse Causes & Diagnosis
A vaginal prolapse is a weakness around the vagina that allows the uterus, rectum, bladder, urethra, small bowel, or the vagina itself to fall from their normal positions. In and around a woman's vagina is a support network of muscles, ligaments, and skin, all holding organs, tissues, and structures in place in the pelvis. If parts of this system weaken or break, these can fall – or prolapse, and if neglected, they can fall farther and farther into the vagina or even through the vaginal opening.
Vaginal prolapse can affect sexual and bodily functions such as urination and defecation and can also result in pelvic pressure and discomfort as common symptoms. Some women are candidates for nonsurgical treatment, while for many others, surgery is the best option.
Approximately one-third of women develop some degree of vaginal prolapse, usually after menopause, childbirth, or a hysterectomy and usually after age 40. Some do not experience any symptoms, while many women who do experience symptoms are too embarrassed to seek treatment.
Causes & factors of prolapse
The main support for the vagina and the surrounding tissues and organs within the pelvis is called the levator ani. When parts of this network are weakened or damaged, a condition called pelvic floor relaxation can take place. This simply means the vagina and surrounding structures lose some or all of their support. The loss of support in turn may cause the supports for the rectum, bladder, uterus, small bladder, urethra, or a combination of them to become less stable. Common factors include:
- Menopause: Because estrogen helps to keep the muscles and tissues of the pelvic support structure strong, the loss of this hormone after menopause means the support structures may weaken.
- Hysterectomy: The uterus is an important part of the support structure at the top of the vagina. A hysterectomy involves removing the uterus. Without the uterus, the top of the vagina may gradually fall toward the vaginal opening. This condition is called a vaginal vault prolapse. As the top of the vagina droops, added stress is placed on other ligaments. Hysterectomy is also commonly associated with a condition called an enterocele, in which the small bladder herniates near the top of the vagina.
- Childbirth: Childbirth stresses the tissues, muscles, and ligaments in and around the vagina. Long, difficult labors, multiple births and large babies are especially stressful. Childbirth is the risk factor most commonly associated with cystoceles. A cystocele is a condition in which the bladder prolapses into the vagina. A cystocele is usually accompanied by a urethrocele, in which the urethra becomes displaced and prolapses. A cystocele and urethrocele together are called a cystourethrocele.
Other risk factors of a vaginal prolapse include:
- Advanced age
- Strenuous physical activity
- Nerve and tissue dysfunction
- Other pelvic surgery
- Abnormalities of the connective tissue
Kinds of vaginal prolapse
- Cystocele is a falling of the bladder, caused by a prolapse of the front wall of the vagina. When this happens, the bladder can prolapse into the vagina, and usually the urethra also prolapses (called a urethrocele). A prolapse of both the bladder and urethra is known as a cystourethrocele. Urinary stress incontinence is a common symptom of this condition.
- Rectocele is the prolapse of the rectum, which occurs as a result of a prolapse of the back wall of the vagina. The rectal wall pushes against the vaginal wall and creates a bulge, which can be noticeable during bowel movements.
- Enterocele is a herniated small bowel, the result of a weakening of the upper vaginal support structure. Enterocele, which usually occurs after a hysterectomy, is the result of a separation of the front and back walls of the vagina, allowing the intestines to push against the vaginal skin.
- Prolapsed uterus involves a weakening of a group of ligaments at the top of the vagina, causing the uterus to fall. In turn, this commonly allows both the front and back walls of the vagina to weaken. There are four stages of uterine prolapse:
- First-degree occurs when the uterus droops into the upper portion of the vagina.
- Second-degree takes place when the uterus falls into the lower part of the vagina.
- Third-degree prolapse is defined by the cervix, located at the bottom of the uterus, sagging to the vaginal opening. Sometimes the cervix protrudes outside the body in a condition known as procidentia, or complete prolapse.
- Fourth-degree is the stage in which the entire uterus protrudes entirely outside the vagina. This condition is also called procidentia, or complete prolapse.
- Vaginal vault prolapse often occurs after a hysterectomy and the surgical removal of the uterus, which supports the top of the vagina. As the top of the vagina falls toward the vaginal opening, the vaginal walls begin to weaken, and the top of the vagina may protrude out of the body through the vaginal opening. A vaginal vault prolapse often accompanies an enterocele. About one in ten women suffer a vaginal vault prolapse following a hysterectomy.
Symptoms of Vaginal Prolapse
The symptoms of prolapse vary depending on the type, and some women experience no symptoms. The most common symptom is the sensation that something in the vagina is out of place, sometimes accompanied by a protrusion or pressure in the same area. General symptoms include:
- Recurrent urinary tract infections
- Pressure in the vagina or pelvis
- A lump at the opening of the vagina
- A decrease in pain or pressure when reclining
- Painful intercourse
Symptoms cam also be specific to certain types of prolapse:
- Urinary stress incontinence is a common symptom of a cystocele.Constipation is the most common symptom of a rectocele.
- Difficulty emptying bowel may indicate an enterocele, vaginal vault prolapse, or prolapsed uterus. Some women with this symptom discover they have to push their fingers against the back wall of the vagina to evacuate the bowel – a technique known as splinting.
- Difficulty emptying bladder could be symptomatic of a cystocele, urethrocele, enterocele, vaginal vault prolapse, or prolapsed uterus.
- Pain that increases during long periods of standing could be the signs of an enterocele, vaginal vault prolapse, or prolapsed uterus.
- Protrusion of tissue at the back wall of the vagina is a common symptom of a rectocele.
- Protrusion of tissue at the front wall of the vagina can indicate a cystocele or urethrocele.
- Enlarged, wide, and gaping vaginal opening is a common symptom of a vaginal vault prolapse.