‘So the bottom is falling out of your world…… or the world is falling out of your bottom’
This is usually my opening phrase when women are referred to me with a prolapse. Prolapse simply means something protruding out into a place it should not be. In gynaecology we mean the uterus (womb) and/or the vagina falling towards and sometimes out of the vaginal entrance, because the pelvic support for these structures has been compromised. When we humans stood up to walk on two legs, unfortunately in women, the brunt of gravity acting downwards impacts on the point of least resistance: the vagina.
Childbirth is definitely the biggest reason that women get a prolapse, but it is not the only one. Sometimes a woman who has had 10 babies will have no prolapse, and a woman who has had no babies does get a prolapse. Anything that increases pressure in the pelvis can be a contributory factor, including:
- Chronic coughing or constipation
- Poor quality of elastic tissues in the body in general
- Loss of collagen which occurs after the menopause as oestrogen disappears
- Activities like road running, which put a massive downward force through the pelvis
What are the Symptoms of Vaginal Prolapse
Interestingly, I see a lot of women with prolapses who haven’t noticed any changes at all. Often it’s because a GP or practice nurses, who had difficulty getting a good view of the cervix for a cervical smear test, has said something like:
“You’ve got a bit of a prolapse here…”
And with the utterance of those few innocent words comes a whole load of worry and concern for the woman!
There are two types of vaginal prolapse: front wall and back wall.
This simply refers to which side of the vagina (front or back) has prolapsed.
The main symptom of a front vaginal wall prolapse is weeing more often, and sometimes leakage on coughing and jumping. It can also predispose the woman to urine infections and cystitis.
The main symptom of a back wall prolapse is a feeling of incomplete emptying of the rectum; as if there is a pocket of poo which won’t come out. Some women instinctively put their fingers into the vagina and push backwards or hold the perineum to help it all work better. Often this will only be an issue if they are constipated.
Should this be operated on?
Well, repairing a prolapse is a big procedure, and I would only advise it if the problem is bad enough.
If a woman is not suffering from significant incontinence or frequent infections, or if once in a while, she has to help herself poo, I tend not to advise an operation. I know it is an inconvenient hassle, but it is probably best put up with. Having a back wall repair is particularly painful, and could lead to pain during sex, which would be even worse.
Of course it’s a balance. But where prolapse is concerned, you can be sure that if you fix one bit, gravity will find the next point of least resistance and you will have embarked upon a surgical prolapse career. It is truly a career, with statistically one in three women who have surgery for a prolapse coming back within 10 years. It doesn’t matter which method is used.
One final point is worth making. A prolapse is not ‘painful’. Many women are referred who went to the doctor with pain of one sort or another, and because they had some vaginal wall laxity and maybe the uterus was a little low, and the doctor could find nothing else, they are referred thinking that ‘prolapse’ is the cause of their pain. It will not be. It may feel uncomfortable and draggy, but not painful.
How do we Prevent Vaginal Prolapse?
It’s a very good idea to exercise our pelvic floor, before, during and after pregnancy. Avoiding lifting heavy items like hay bales and heavy furniture, or if you must, be sure to do it in the correct way. Pilates is undoubtedly the best organised exercise for core and pelvic floor strength.
Of course, the vagina is never the same after a vaginal delivery, or even sometimes just after carrying a baby and having a Caesarean but unless it causes a malfunction, particularly of the bladder, nothing needs to be done. The cervix may well sit a bit lower in the vagina making using tampons more difficult. If this is the only symptom, then something to stop the periods such as a Mirena coil may be all that is needed.
In conclusion, prolapses are a very common problem, but don’t worry – having children is worth it!
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