Genitourinary (GU) Prolapse

What is genitourinary prolapse?

The organs inside a woman's pelvis include the uterus (womb), the bladder and the bowel. Normally, these are supported and held in position by structures including ligaments and the pelvic floor muscles.

What are the different types of GU prolapse?

Different types of GU prolapse can occur depending on which pelvic organ, or organs, have dropped down into the vagina. Generally, GU prolapse can be divided into:

Prolapse affecting the anterior (front) part of pelvis

• There can be prolapse of the urethra (the tube along which urine passes from the bladder to the outside) into the vagina. The medical term for this is a urethrocele.
• There can also be prolapse of the bladder into the vagina. The medical term for this is a cystocele.
• Both the urethra and the bladder can prolapse into the vagina at the same time. The medical term for this is a cystourethrocele.This is the most common type of GU prolapse.

Prolapse affecting the posterior (rear) part of the pelvis

• There can be prolapse of the rectum (the back passage) into the vagina. The medical term for this is a rectocele. This is the third most common type of GU prolapse.

Prolapse affecting the middle part of the pelvis

• There can be prolapse of the uterus (womb) into the vagina. This is called a uterine prolapse and is the second most common type of GU prolapse. Uterine prolapse can then be described by the degree of prolapse that is present:
  • First degree prolapse is when the cervix (neck of the womb) remains within the vagina.
  • Second degree prolapse is when the cervix protrudes from the vagina.
  • Third degree prolapse is when the womb has prolapsed completely and lies entirely outside the vagina.
  
  
  
• If you have had a hysterectomy (removal of the womb), the end of the vagina that would normally attach to the cervix (the neck of the womb) is closed up during the operation. This now blind-end of the vagina is referred to as the vaginal vault. The vaginal vault can also prolapse into the vagina. This is known as a vault prolapse.
• There can also be prolapse of the Pouch of Douglas (the space between the rectum and the uterus) into the vagina. The medical term for this is an enterocele. Loops of the bowel can be present in the prolapse enclosed within the prolapse sac.

How many women are affected by GU prolapse?

It is difficult to estimate how many women are affected by GU prolapse because many of them do not visit their doctor for help. It is estimated that up to 5 in 10 women who have had children have some degree of prolapse but that only 1-2 in 10 women seek medical advice.

What causes GU prolapse?

The most common cause of GU prolapse is childbirth. During childbirth, there is excessive stretching of the ligaments, nerves and muscles (including the pelvic floor muscles) around the birth canal, or vagina. This stretching can damage them and make them weaker and less supportive. GU prolapse does not affect everyone who gives birth. It is more likely after a difficult delivery.

Anything that causes an increase in the pressure inside a woman's abdomen and pelvis can also contribute to the development of GU prolapse by putting a strain on the supporting ligaments and muscles. The most common reason for this increased pressure is during pregnancy and childbirth. However, the same increase in pressure can also occur in people who are overweight, people with chronic (persistent) lung problems such as chronic cough, people who lift heavy objects, or people who frequently strain due to constipation.

The chance of having a prolapse increases as you get older. The lack of oestrogen hormone that occurs after the menopause affects the pelvic floor muscles and structures around the vagina, making them less springy and supportive.

If you have had a hysterectomy, or other gynaecological surgery such as a bladder repair, you may be more likely to develop GU prolapse. This is because the surgery may have weakened the ligaments, pelvic floor muscles and other support structures for the pelvic organs. With new advances in surgical techniques, including laparoscopic (key-hole) surgery, this is becoming less likely.

Very rarely, GU prolapse can occur because of a congenital problem (a problem that someone is born with) that causes deficiency in the body of a substance called collagen. Collagen is needed to help form the ligaments that normally support the pelvic organs.

What are the symptoms of GU prolapse?

You can have a prolapse and not have any symptoms from it. It may just be noticed by a doctor when you are examined for another reason, for example, during cervical screening.

However, it is common for women to have some symptoms. There are certain symptoms that women with all types of prolapse can have. These include a feeling of a lump in the vagina or a feeling of something dragging or coming down. You may experience pain in the vagina, back or abdomen. You may also notice a discharge from the vagina that may be blood stained or smelly. Sex may be uncomfortable or painful.

Symptoms are usually worse after long periods of standing and improve after lying down.

Other symptoms that you may experience depend on the type of prolapse that you have.

Urinary symptoms

You may have these symptoms if your prolapse affects the anterior (front) part of the pelvis (the urethra and the bladder). Symptoms include:

• The need to pass urine often, both during the day and at night.
• Leaking of urine on coughing, sneezing, laughing, straining or lifting.
• Feeling a sudden urge to pass urine, which may be associated with leaking urine before getting to the toilet.
• A flow of urine that stops and starts.
• A feeling that your bladder has not emptied properly and the need to pass urine again soon afterwards.
• The need to change position whilst sitting on the toilet to enable urine to pass.

Bowel symptoms

You may have these symptoms if your prolapse affects the posterior (rear) part of the pelvis (the rectum). Symptoms include:

• Difficulty passing stools (faeces).
• Feeling a sudden urge to pass stools.
• A feeling that your bowels have not emptied fully.
• Incontinence (loss of control) over stools.
• A feeling of the prolapse protruding from the anus after passing stool.

Are there any complications of GU prolapse?

If the prolapse causes the cervix (neck of the womb) or the skin that lines the vagina to protrude from the vagina, this can lead to ulceration, bleeding and infection. If the prolapse affects the bladder or the urethra, complications may occur such as urine infections, incontinence (loss of control) of urine and retention of urine (an acute inability to pass urine which may require treatment with a catheter). If the prolapse affects the rectum, there can be difficulty passing stool and incontinence of stool.

How is GU prolapse diagnosed?

GU prolapse is usually diagnosed by your doctor performing a simple vaginal examination. They will usually ask you to lie on your left side with your knees bent slightly towards your chest. If you have a severe degree of prolapse, your doctor may also ask to examine you whilst you are standing.

The doctor will insert a special instrument called a Sim's speculum into your vagina. This is a similar instrument to that used during cervical screening but is just a different shape. They will move the speculum to the front and back walls of your vagina, allowing them to look for prolapse. The doctor may ask you to cough or strain. They may use another instrument, a bit like a small pair of tongs, to pull slightly on the neck of your cervix (the neck of your womb) to see if there is any prolapse of the womb.

These examinations are not usually painful. If you have bowel symptoms, the doctor may suggest that they examine your back passage using a gloved finger.

Will I need any investigations?

If you have any urinary symptoms, as described above, your doctor may ask you to collect a specimen of urine to be sent off to the laboratory and checked for signs of infection. They may also suggest that you have a blood test to check your kidney function. They may refer you to a specialist for some more detailed tests on your urine and bladder. These tests are known as urodynamic studies. They are tests of your urine flow and are usually done in a hospital unit.

What are the aims of treatment for GU prolapse?

The aims of treatment for GU prolapse are to ensure that you:

• Are comfortable and pain free.
• Are able to pass urine and stool adequately and have no problems with urinary or faecal incontinence.
• Are able to have sex comfortably.
• Do not experience any complications relating to the prolapse such as urine infections or ulceration of the prolapsed organ.
• Are able to continue to have children if you desire.

What are the treatment options for GU prolapse?

Removal of any exacerbating factors

As discussed above, there are a number of things that can cause a rise in your intra-abdominal pressure and increase your risk of GU prolapse. If you have GU prolapse and are overweight you should make an effort lose weight. If you are constipated you should discuss this with your GP to ensure that you are receiving adequate treatment. If you have chronic lung disease and are still smoking, you should try to give up.

Pelvic floor exercises

Pelvic floor exercises should be done by all women with GU prolapse. They may stop mild degrees of prolapse from getting any worse. They may also relieve symptoms such as back ache and abdominal discomfort. However, pelvic floor exercises are not likely to improve any prolapse that is already present. Pelvic floor exercises are discussed and described in a separate leaflet.

Vaginal pessaries

Vaginal oestrogen creams

If you have mild prolapse, your doctor may suggest that you apply some oestrogen cream to the vagina for 4 to 6 weeks. This may help any feelings of discomfort that you may have. However, your symptoms may return once the cream is stopped.

Surgery

The aim with surgery is to provide a definitive (curative) treatment for GU prolapse. There are various operations that can be performed depending on the type of prolapse that you have. The anterior (front) and posterior (rear) walls of the vagina can be reinforced using, either the existing tissues around the vagina, or using a mesh or special tape that is sewn in. Any lax, or stretched, tissue is removed during the surgery. The prolapsed organs can also be stitched or attached to stronger ligaments within the pelvis. A hysterectomy (removal of the uterus) is also a common treatment for uterine prolapse. In fact, GU prolapse is the most common reason for women over 50 years old to have a hysterectomy. Keyhole surgery may be possible for some of these operations.

You are likely to need to stay in hospital for a few days after the operation. Full recovery from the operation may take up to six to eight weeks. You should avoid heavy lifting and sexual intercourse during this time. There is a small chance that the prolapse can return after surgery.

What is the prognosis (outlook) for GU prolapse?

Left untreated, GU prolapse will usually gradually get worse. The outlook is best for younger women who are of a normal weight and are in good health. The outlook is worst for older women, those in poor physical health and those who are overweight. GU prolapse can return after surgery in about 16 in 100 women.

Can GU prolapse be prevented?

There are a number of things that may possibly help to prevent GU prolapse. However, not all of these have been proven. Simple things that you can do are:

• Regular pelvic floor exercises, especially if you are planning to get pregnant, are pregnant, or have given birth.
• If you are overweight you should try to lose weight.
• Eat a high fibre diet (plenty of fruit and vegetables and wholegrain bread and cereal) and drink plenty of water to avoid constipation and reduce the risk of straining.
• If you smoke, you should stop smoking.

It is not clear whether hormone replacement therapy helps to prevent GU prolapse. Some doctors believe that if you have a longer labour, a forceps or ventouse delivery, or an episiotomy during labour you are more likely to have problems with GU prolapse. There is a move towards trying to avoid these risk factors during labour.

Further help

The Continence Foundation

307 Hatton Square, 16 Baldwins Gardens, London ECIN 7RJ
Helpline: 0845 345 0165 (Monday to Friday, 9.30 am - 1.00 pm)
Web: www.continence-foundation.org.uk
Helps people who have any problem with their bladder or their bowels.