Dr. M.J. Bazos, MD. Patient Handout


About Your Diagnosis
The uterus, bladder, and rectum are located around the vaginal canal and so are able to prolapse, or herniate, into the vaginal canal. If the uterus has prolapsed, it is called “uterine prolapse.” If the bladder has prolapsed, it is called a “cystocele.” If the rectum has prolapsed, it is called a “rectocele.” The prolapsed organ can cause a bulge of tissue out of the vaginal opening. Often this is when the prolapse is first noticed, when the patient feels “something like a ball of tissue out of the vaginal opening.” Sometimes the prolapse will be noticed by the physician when the Pap and pelvic examination
are performed. If the organ has prolapsed, but it has not prolapsed out of the vaginal canal, usually the patient is unaware of it. Childbirth is the most common cause of prolapse. The delivery of the baby stretches and may tear the muscles and connective tissue that support the pelvic organs. In addition to childbirth, aging and becoming postmenopausal contribute to the prolapse.
Prolapse does not happen soon after childbirth; usually it occurs when women are postmenopausal, but it can occur in premenopausal women.

Living With Your Diagnosis
Women with mild or moderate prolapse may complain of pelvic pressure, low backache, or pain, or actually complain that they feel like “something is falling out.” These symptoms may worsen at the end of the day, especially in women who have been on their feet all day. Sometimes urinary incontinence (leakage of urine) will accompany the other symptoms if there is loss of support to the bladder neck area. If a rectocele is present, difficulty evacuating the rectum may occur because the rectum is herniating into the vaginal canal. With severe prolapse, a “bulge” is felt out of the vaginal canal. This bulge can be the uterus and cervix (the cervix is the opening to the uterus), the front wall of the vaginal canal with the bladder behind it, or the back wall of the vaginal canal with the rectum behind it. Sometimes the bulge can be felt intermittently because the prolapsed organ actually can go back up into the pelvis. Women with prolapse often notice that if they are on their feet a lot, they notice a lot of bulging. When they lie down, the bulge may disappear back into the vaginal canal. With severe prolapse of the bladder, some patients may experience difficulty emptying the bladder (voiding). This occurs because when the bladder has prolapsed very low, the prolapse can kink the urethra (the passage from the bladder to the outside). If the urethra is kinked, it can be difficult to empty the bladder, or patients notice a slow stream. (It is similar to a garden hose that is kinked and water will not run through it.)

If the prolapse is mild or moderate (so no organsn are actually bulging out of the vaginal canal) and the patient is not experiencing bothersome symptoms such as pelvic pressure, backache, urinary incontinence, or difficulty voiding, the prolapse can be observed and no treatment is needed. If the prolapse is severe and the pelvic organ is bulging out of the vaginal canal, most patients are extremely uncomfortable and want treatment to relieve their symptoms. Even if the pelvic organ is not prolapsed out, but the patient is experiencing bothersome pelvic pressure or backache, the patient may desire treatment. If the prolapse is mild or moderate, sometimes properly performed “Kegel” exercises (tightening the pelvic floor muscles) can relieve the symptoms enough so no further treatment is necessary. Women with prolapse should perform 30–50 Kegels each day. To build up the muscles it is important to hold each Kegel for 5–10 seconds. Have your healthcare provider check to make sure you are doing your Kegel exercises correctly. It is also important to do a Kegel anytime you lift anything (a bag of groceries, baby, stack of books, luggage), or when you cough, sneeze, or laugh. If Kegel exercises do not help, physical therapy may be an option. Physical therapy for the pelvic floor may include biofeedback and electrical stimulation. Sometimes, if Kegel exercises alone do not strengthen the pelvic floor muscles enough, physical therapy can further strengthen the muscles. If Kegel exercises and/or physical therapy are not effective in relieving the symptoms, using a pessary
or surgery are options. Pessaries are devices that are worn inside the vaginal canal to support the prolapsed organs. Pessaries come in many different shapes and sizes. Some pessaries can be removed by the patient, so the patient only has to visit the gynecologist once or twice each year. Some pessaries can only be removed by a health care pro-vider, so the patient will have to come into the office every 3–4 months to have the pessary removed,
cleaned, and replaced. If a pessary is used, estrogen cream should be used to prevent erosions of the vaginal walls and to prevent infection. If the pessary fits correctly, it should be very comfortable. However, not all women with prolapse can use a pessary because the pessary falls out with activity, i.e., with walking, bearing down to have a bowel movement. Surgery is often recommended when a pessary cannot be fit to the patient (feels uncomfortable when it is in or falls out). Sometimes patients do not want to use a pessary and desire surgery to correct the prolapse. Usually the surgery is performed vaginally, but generally still requires a 2- or 3-day hospitalization and a 4- to 8-week recovery period. Occasionally, surgery will not correct all the symptoms, such as urinary incontinence or difficulty evacuating the rectum. Also, occasionally the prolapse can recur, although this usually happens years later.

The DOs
• Do the Kegel exercises (tightening the pelvic floor muscles—it should feel as though you are pulling in or up the rectum) as directed: 30–50 each day, holding each Kegel for 5–10 seconds.
• Do the Kegel when you lift anything (stack of books, luggage, bag of groceries, baby) or when you cough, sneeze, or laugh.

The DON’Ts
• Don’t lift heavy objects (heavier than 20–25 lb).
• Don’t miss your appointment if you are fit with a pessary. If you wait too long before being examined, vaginal wall erosions or vaginal infection may develop.

When to Call Your Doctor
• If you are having difficulty emptying your bladder. This usually only gets worse with time, and if you are unable to empty your bladder at all, you will need to have a catheter placed into the bladder (temporarily) to empty it.
• If you notice vaginal bleeding. This may indicate that there is an erosion from the pessary (if you have one) or an erosion on the prolapsed organ.
• If the pessary falls out or is uncomfortable.