The Institute for Women's Health

What is Prolapse

Pelvic organ prolapse is the descent and possible protrusion of the pelvic organs onto the vaginal walls that sometimes results in their protrusion through the vaginal opening. It results from the weakening, stretching and detachment of the muscles and ligaments of the pelvic floor that hold those pelvic organs (the vagina, the uterus, the bladder, the urethra, the rectum) in place.

Pelvic organ prolapse can receive different names depending on the part of the vagina that is most affected. Examples are: “prolapse”, “vaginal prolapse”, “vaginal vault prolapse”, “dropped vagina”, “uterine prolapse”, “dropped uterus”, “bladder prolapse”, “dropped bladder”, “cystocele”, “rectal prolapse”, “rectocele”, “dropped rectum”, “enterocele”. They are not necessarily synonyms (see Types of prolapse).

Symptoms vary. The most common one is a sensation of a bulge at or through the entry of the vagina. Some patients have described it as a “ball”, a “baby’s head”, “an egg” or a “roma tomato” coming out of the vagina. Other possible symptoms can include: vaginal pressure, lower back pain, vaginal pain, pain with sex, incomplete bladder emptying, urinary urgency and frequency, difficulty having a complete bowel movement, constipation. There are surgical and non surgical options for the treatment of prolapse.

Types of Prolapse

It is common to have different types of prolapse at the same time and different types of prolapse may require different treatments. Most experts and research agree that addressing the apical vaginal prolapse is a key to increase the success in the treatment of any prolapse.

Apical vaginal prolapse – It is also called “uterine prolapse,” “vaginal vault prolapse” (if there is no uterus), “enterocele,” “dropped uterus” or “dropped vagina.” It occurs when the ligaments supporting the top of the vagina weaken and stretch leading to the uterus or the top (or cuff) of the vagina “falling down” and sometimes out. On top of the symptoms of bulging, if the vagina or the cervix of the uterus is exposed in the “outside” they can develop ulcerations.

Anterior vaginal wall prolapse

It is also often “cystocele,” “urethrocele,” “cystourethrocele” or “dropped bladder.” It occurs when the ligaments supporting the anterior vagina and the base of the bladder weaken, leading to the bladder “falling down” onto the vagina. It can cause urinary symptoms such as incomplete bladder emptying, urinary frequency and urgency.

Posterior vaginal wall prolapse

It is also sometimes called “rectocele” or “enterocele.” It occurs when the tissue supporting the posterior vagina and part of the rectum weaken leading to the rectum “falling down” onto the vagina. It can cause defecatory symptoms such as constipation, having to strain to have a bowel movement or even the need to put a finger in the vagina or the rectum to facilitate emptying the bowels.

Rectal prolapse

It results from the failure of the tissue keeping the rectum in place leading to the protrusion of the rectum through the anus (not the vagina, that would be a posterior vaginal wall prolapse or “rectocele”). Rectal prolapse, at the beginning, can be confused with a hemorrhoid. It is a red soft tissue with the shape of a donut. It can cause painful bowel movements, blood or mucus on the stool or underwear, loss of bowel control.

Treatment of pelvic organ prolapse

While several things can be done to decrease the risk of prolapse from developing (See prevention of pelvic organ prolapse), there are currently to types of treatments for this condition:

  • Pessaries
  • Surgeries

Surgeries for Pelvic Organ Prolapse

In Pelvic Reconstructive Surgery there is no “one surgery fits all”. There are multiple surgeries that can be done to treat Pelvic Organ Prolapse. Some of them are done vaginally and some are done abdominally. They can involve the use of synthetic or biologic grafts (“mesh”) or not. They can take a few minutes to several hours. The choice of the procedure will be based on the part of the vagina that is most affected by the prolapse, on how severe the prolapse is, what are the symptoms, and a detailed discussion with your physician about the advantages and disadvantages of each one of the procedures he can offer.

Types of surgery:

  • Sacrospinous ligament suspension
  • High uterosacral ligament suspension
  • Sacrocolpopexy
  • Anterior vaginal wall repair
  • Posterior vaginal wall repair

What is stress urinary incontinence?

Stress urine incontinence is a type of involuntary urine leakage that occurs with certain types of movements (typically coughing, sneezing, laughing, lifting, bending or running). So the stress it refers to is not mental, it is stress (pressure) on the bladder.Normally we don’t leak because there are muscles around the urethra (the “bladder tube”) that are engaged automatically when the bladder is stressed (with cough, sneeze, etc) and block the involuntary passage of urine. But that mechanism of continence can weaken and fail leading to those bothersome urine accidents.

The main risk factors to develop stress urine incontinence are age (more likely the older you get), childbirth (more likely the more children you deliver), obesity (more pressure on the bladder), a history of certain prior pelvic surgeries and chronic constipation.

Fortunately there are many treatment options for stress urine incontinence. These are:

  • Kegel exercises
  • Pelvic floor muscle training with biofeedback
  • Pessaries for incontinence
  • Periurethral injections
  • Surgery

What is Overactive Bladder

Overactive bladder (OAB) is a condition in which the patient has to go to the bathroom very frequently and usually with a very strong sense of urgency (“I’ve got to go right now!”). A lot of patients with overactive bladder are awaken up at night (sometimes several times) with the strong desire to empty their bladder which can prevent them from having a good sleep.

Depending on how sudden that feeling is, how far the toilet is or how fast the patient is, the urge to urinate can end up with an episode of incontinence, that is, leaking urine in the way to the bathroom or as the pants are being pulled down. That is called urgency (or urge) urinary incontinence.

OAB is a very common condition (although a lot of people are embarrassed to talk about it). It affects 8% to 50% of women It is more prevalent in the elderly than in the young and in multiparous women (the more children, the more likely women are to develop its symptoms).

“Straighforward” OAB can be initially evaluated and treated (usually with medication) by general gynecologists, and primary care physicians. If the initial treatment does not work or if there are symptoms of urinary obstruction (difficulty emptying the bladder), blood in the urine, recurrent urinary tract infections, bladder pain or if the symptoms have gotten worse after a C-section, hysterectomy or bladder surgery (a “bladder lift” or a “sling”), I would recommend prompt and more thorough evaluation by a Urogynecologist.

Treatment options for overactive bladder and urgency urinary incontinence:

  • Bladder retraining (timed voiding, behavioral modifications)
  • Medications
  • Posterior Tibial Nerve Stimulation
  • Sacral Nerve Stimulation
  • Bladder Botox injections

What is Urgency Urinary Incontinence

Overactive bladder (OAB) is a condition in which the patient has to go to the bathroom very frequently and usually with a very strong sense of urgency (“I’ve got to go right now!”). A lot of patients with overactive bladder are awaken up at night (sometimes several times) with the strong desire to empty their bladder which can prevent them from having a good sleep.

Depending on how sudden that feeling is, how far the toilet is or how fast the patient is, the urge to urinate can end up with an episode of incontinence, that is, leaking urine in the way to the bathroom or as the pants are being pulled down. That is called urgency (or urge) urinary incontinence.

OAB is a very common condition (although a lot of people are embarrassed to talk about it). It affects 8% to 50% of women It is more prevalent in the elderly than in the young and in multiparous women (the more children, the more likely women are to develop its symptoms).

“Straighforward” OAB can be initially evaluated and treated (usually with medication) by general gynecologists, and primary care physicians. If the initial treatment does not work or if there are symptoms of urinary obstruction (difficulty emptying the bladder), blood in the urine, recurrent urinary tract infections, bladder pain or if the symptoms have gotten worse after a C-section, hysterectomy or bladder surgery (a “bladder lift” or a “sling”), I would recommend prompt and more thorough evaluation by a Urogynecologist.

Treatment options for overactive bladder and urgency urinary incontinence:

  • Bladder retraining (timed voiding, behavioral modifications)
  • Medications
  • Posterior Tibial Nerve Stimulation
  • Sacral Nerve Stimulation
  • Bladder Botox injections

What is a Pessary?

Pessaries are medical devices designed to support the vaginal walls (along with the uterus, the bladder or the rectum) to treat prolapse and for urinary incontinence. They are placed in the vagina in a similar way as a diaphragm or a tampon. They come in many different shapes and sizes and you may need to try more than one before finding the one that is best for you. That is the process of pessary fitting (just like when you buy clothes or shoes you need to try them on to see if they fit you well). Once the pessary is placed, they should be so comfortable they should not even be felt. Some pessaries allow for vaginal intercourse when they are in place.

Occasionally pessaries may fall out, which is not a big problem, nor an emergency. It just means that you should probably try another pessary (another size of shape that fits you better) or consider other options. Pessaries should always be fitted by someone who has experience with different types (a Urogynecologist, a physician assistant, a nurse). Pessaries need to be cleaned from time to time and then replaced. This can be done by the doctor that first fitted it, or by patients themselves, depending on their comfort and dexterity.

What is Pelvic Floor Muscle Therapy?

Very often, conditions of the pelvic floor (i.e. incontinence of urine or stool, vaginal prolapse, or vaginal pain) can be improved by training the muscles that surround the bladder, the vagina and the rectum.

Pelvic muscle rehabilitation sessions coached by specialized Physical Therapists or Nurses can help patients strengthen and relax the pelvic muscles so they can function better. Usually the sessions are repeated weekly for three months and are assisted by state-of-the-art devices that help the patients visualize what they are doing with the pelvic muscles as well as help them keep track of their progress.

What is Posterior Tibial Nerve Stimulation (PTNS)?

Some bladder and rectal problems are thought to be caused partly by a “miscommunication” between the bladder and/or the rectum and the brain. The communication occurs through the pelvic nerves and the spinal cord.

There are 2 treatment options that target the nerves in order to restore bladder control. One of them is PTNS, the other one is Sacral Nerve Stimulation.

Percutaneous Tibial Nerve Stimulation consists of twelve weekly 30-minute office sessions with one accupuncture-like needle above the ankle while mild electrical stimulation is given (and felt in the ankle and foot area). During that time patients are sitting on a comfortable armchair and can be leisurely reading, listening to music, knitting, texting or talking on the phone.

What is Sacral Nerve Stimulation?

Some bladder and rectal problems are thought to be caused partly by a “miscommunication” between the bladder and/or the rectum and the brain. The communication occurs through the pelvic nerves and the spinal cord.

In Sacral Nerve Stimulation or Neuromodulation a specially designed stimulator (Interstim) is placed surgically under the skin of the lower back/gluteal area very much like a bladder and/or rectal “pacemaker”. The stimulation (set a gentle comfortable level) can be felt in the vagina, the anus, or the area in between. The battery device usually lasts about 5 years before needing replacement. The surgical placement of the “bladder pacemaker” takes 45-60 minutes.

Before deciding if the stimulator is going to be implated, patients should undergo a prior testing of the peripheral nerves to determine if they are good candidates for the implant of the stimulator.

What is Urodynamics?

Urodynamics (or urodynamic testing) is a study to better understand the cause of some pelvic floor problems (usually urine leakage or incomplete bladder emptying). It involves filling the bladder with water and then void while two small catheters record the pressure in the bladder, urethra and vagina.

It is done in the office and it takes about 20 minutes to complete. There is only, if any, mild discomfort associated with it and there is a very small risk of developing a bladder infection afterwards.

What is Cystoscopy?

To work up certain conditions of the bladder and the urethra (the bladder tube), it is sometimes necessary to visually inspect them. This is accomplished by inserting a very small camera through the urethra and into the bladder.

A cystoscopy (or cystourethroscopy) usually takes five to ten minutes. It is an office procedure that is very well tolerated and no anesthesia is needed. A few patients will have some discomfort during of after it and there is a small risk of developing a bladder infection.

What is Urogynecologist?

A Urogynecologist is an Obstetrician/Gynecologist who has further specialized (completing a 3-year Fellowship) to evaluate and treat women with problems related to the pelvic floor. These problems are usually related to the function and/or the position of the bladder, the vagina, the uterus and the rectum such as urinary or fecal incontinence, frequent urination, bladder pain or vaginal prolapse.

What kind of training does a Urogynecologist have?

Urogynecologists have completed a 4-year residency in Obstetrics and Gynecology. Then they get additional training and experience in the evaluation and treatment of conditions that affect the female pelvic organs, and the muscles and connective tissue that support those organs.

The additional training is done through a formal program called Fellowship (which is like a specialized residency after a more general residency like Obstetrics/Gynecology). Accredited fellowships are three years long and have been approved by the American Board of Obstetrics and Gynecology or the American Board of Urology. In the past there were also non-accredited Fellowships (not approved by the specialty boards and only one or two years in length).

Since 2013 there is one extra step for those who want to be recognized as Urogynecologists or specialists in Female Pelvic Medicine and Reconstructive Surgery. There is a Board examination. Some Gynecologists and Urologists without Fellowship training who report having enough experience in the field have been allowed to sit for the exam.

You are entitled to know the level of training of your treating physician. Ask your physician or our staff about their level of training.

When is it good idea to visit a Urogynecologist?

  • When your Gynecologist or Primary Care Physician recognize your problem and, initially or after attempting conservative therapy, decide that it is time to consult a specialist.
  • When the symptoms impact negatively your quality of life.
  • When you have suffered these problems for a long time but have felt embarrassed discussing them with other doctors.
  • When you feel that you are not able to completely empty your bladder.
  • When you develop these symptoms during pregnancy or soon after.
  • When you develop these symptoms after pelvic surgery (hysterectomy, “bladder lift”, sling, etc.).
  • When you want a second opinion.
  • When you want to know the most updated evidence-based information in the field of Urogynecology / Female Pelvic Medicine and Reconstructive Surgery.

What is the difference between a Urogynecologist and a Female Urologist?

Some Urologists, after their residency, go on to do a 2-year Fellowship in Female Urology. They do share expertise with Urogynecologists in the treatment of several conditions of the pelvic floor, specially in urinary incontinence, overactive bladder and interstitial cystitis. However, due to their urological, rather than gynecological, training background, Female Urologists usually have greater expertise in the management of problems of the kidney and the ureters (the tubes that connect the kidneys with the bladder), while Urogynecologists have more experience in the management of prolapse (dropped bladder, dropped uterus), vaginal surgery and bowel control problems. These differences in expertise are, however, greatly dependant on where and for how long each specialist has trained. So it is worth discussing this background with whoever you choose to take care of your pelvic floor problems.

What is the Female Pelvic Medicine and Reconstructive Surgery?

Most commonly know as Urogynecology, Female Pelvic Medicine and Reconstructive Surgery is the official name of the specialty, as recognized by the American Board of Medical Specialties. Yes, it is long name and it is hard for most people to remember it, but it does describe what Urogynecologists and Female Urologists focus on. And it was a compromise, since the former would not be called Urologists and the latter would not be called Gynecologists!