Vaginal prolapse, pelvic organ prolapse and vaginal/pelvic relaxation syndromes

Vaginal relaxation syndromes (or pelvic relaxation syndromes) cover cystoceles, urethroceles, enteroceles and rectoceles. These ‘celes’ are forms of prolapse, whereby an organ falls from above and protrudes into the vaginal canal in varying degrees.

Pelvic organ prolapse is a condition whereby one or more pelvic organs are no longer fully supported by the connective tissue and other structures in the pelvis. These organs can then slip out of place, at times even protruding out of the vagina.

Prolapse (from the original Latin term prolabi) literally means ‘to fall out of place’.

Signs and symptoms of vaginal prolapse

• A lump at the vaginal opening or a sensation thereof
• Constipation or changed bowel habits
• Painful intercourse (dyspareunia)
• Sensation of pain or pressure eases once you lie down
• Vaginal pain increases when standing for long periods of time
• Feeling of pelvic or vaginal fullness or pressure
• Sensation of organs falling out
• Organs may bulge out of the vagina, possibly all the time, or just during coughing or sneezing
• You may be able to touch your cervix or other structures with your fingers easily via the vagina
• Leaking urine when coughing or sneezing (stress urinary incontinence)
• Frequent bladder/urinary tract infections

Prolapse feels worse later in the day after activities, and is better after lying down all night, first thing in the morning. Early signs include stress urinary incontinence (peeing when you laugh or cough or lift something heavy), changes in bowel habits (having to sit on a different angle to get it out), or being able to touch your cervix. More obvious signs are your insides coming out your vagina, pain, and bulging.

Why pelvic prolapse occurs

Pelvic relaxation syndromes can occur due to a pelvic trauma like childbirth, obesity, ageing, pelvic surgery, injury, connective tissue disorders, collagen disorders, or straining on the toilet for long periods of time. ^​1​

There could also be anatomical abnormalities or malformations of tissue, pressure coming down from the abdomen due to respiratory or abdominal organ problems, sacral nerve disorders, and connective/collagen tissue problems.

Pelvic organ prolapses (“vaginal relaxation syndromes”) often occur together. Organs start to ‘fall out’ of the vagina (vaginal prolapse) when the connective tissue (fascia) is weak and the supportive ring at the top of the vagina is weakened. Often prolapse occurs in more than one area in the pelvis.

Pregnancy and giving birth (especially when delivering a large baby) area very common cause of vaginal prolapse, but pelvic organ prolapse can and does happen in young women without children too. Connective tissue disorders, poor posture, weak pelvic floor muscles or a lack of oestrogen in the body can also contribute to pelvic relaxation syndromes.^​2​

Post-menopausal women may be at higher risk because oestrogen in the body drops after menopause. Oestrogen helps keep our skin strong, particularly vaginal and vulvar skin.

A hysterectomy may cause vaginal prolapse because it involves removal of the uterus, which is an important part of the pelvic and vaginal support structure.

In essence, the underlying cause of vaginal prolapses is the weakening or damage to the vaginal support structure (muscles, ligaments and tissues). We need this stabilising network to hold the pelvic organs in place.

Types of pelvic relaxation syndrome

There are several types of pelvic relaxation syndromes, with each specific to an area. These pelvic organ prolapses occur due to laxity of the ligaments, muscles and fascia that support the organs, including the pelvic floor muscles. It is estimated that almost 10 per cent of women with a pelvic relaxation syndrome require surgery to correct it.^​3​

1. Cystoceles – bladder – pubocervical fascia weakness (often associated with uterine prolapse, either due to a tear or weak connective tissue), where the bladder prolapses down
2. Urethroceles – urethra (almost always accompanied by a cystocele, called a cystourethrocele) – pubocervical fascia weakness, where the urethra also prolapses
3. Enteroceles – small intestine and peritoneum – pubocervical fascia and rectovaginal fascia weakness, tissue between uterus and rectum, or the bladder and rectum after hysterectomy (often found with rectoceles), where part of the small intestine pushes down into the perineal area
4. Rectoceles – the rectum – problems with the levator ani muscles between the rectum and vagina, particularly during childbirth (often found with enteroceles), the rectum pushes into the perineal area, creating a sack

Degrees of prolapse in vaginal relaxation syndromes

• 1st Degree – entry into the upper vagina
• 2nd Degree – to the vaginal entrance (introitus)
• 3rd Degree – organs come out of the vaginal entrance

What is fascia and how is it involved in vaginal relaxation syndromes?

If you have ever cooked with raw chicken, you would have seen the threads of white tissue that run between muscles. This is fascia. It is a 3-D netting of fibrous tissue that holds our whole body in place, to a greater or lesser degree. When it gets stretched out or weakened, the tissue it holds in place falls, since it is not strong enough. Fascia can only be regrown, not repaired, because it doesn’t have a blood supply the way our other tissue does.

Additionally, if you have ever had a ‘Chinese burn’ where you grab someone’s wrist with both hands, and twist the skin in opposite directions (mostly kids do this to each other!), that burning feeling is caused by the stretching of your fascia. It can get quite tight, but it can also get very loose.

Treatments for pelvic organ prolapse and vaginal relaxation syndromes

Pelvic physiotherapy for vaginal prolapse

At diagnosis, it’s important to immediately find yourself a reputable pelvic physiotherapist. You will likely get a referral after diagnosis of a pelvic organ prolapse. You may get pessaries, which are silicone devices that are fitted to you specifically to hold your insides in place.

Pelvic physiotherapy may be recommended by your doctor if you only have a mild symptoms of prolapse or in the process of waiting for surgery.^​4​

Pelvic floor exercises for vaginal prolapse

You will be given pelvic floor exercises to do each day to help strengthen your pelvic floor.  Pelvic floor exercises are performed by tightening and loosening the pelvic floor muscles, much like when you are trying to stop the flow or urine or preventing bowel movement.

This exercise helps strengthen your pelvic floor and abdominal muscles that support your abdominal and pelvic organs. You need to be checked that you are performing these exercises correctly by your pelvic physiotherapist.

Silicone pessaries for vaginal relaxation syndromes

The special pessaries are small devices made out of latex, silicone or soft plastic inserted into the vagina to help hold the uterus in place. Pessaries need to be removed and cleaned every so often to avoid risk of infection.

Pessary treatment is usually done in women who are not sexually active, but every circumstance is different, so speak to your practitioner.^​5,6​

Oestrogen-replacement therapy for vaginal prolapse

Because we need oestrogen in our pelvic organs to keep the tissue strong, oestrogen therapy may be considered appropriate. This is usually applied as a cream or tablet. 

Oestrogen-replacement therapy is usually recommended to women who had hysterectomy or postmenopausal.

Laser, light and radiofrequency treatments after pelvic organ prolapse

Laser, light and/or radiofrequency treatments may be available depending on your case to boost local tissue, but these treatments can only get so deep into the vaginal walls.

You need a doctor who operates a ThermiVa radiofrequency device, or the Juliet or Mona Lisa laser, or has new/novel treatment strategies to combat pelvic organ prolapse without surgery.

These treatments for vaginal relaxation syndromes are new, and their effectiveness for pelvic weakness and long-term outcomes are uncertain.^​7​

Surgery and mesh for pelvic organ prolapse

If none of the less intrusive options above have helped alleviate your symptoms, surgery may be recommended by your specialist. Surgery could include the installation of pelvic mesh. Mesh has also become popular as a support structure, however controversy now surrounds pelvic mesh.^​8,9​

Other surgeries may involve closing gaps in connective tissue.

Types of pelvic organ prolapse surgery, pros and cons

There are five types of surgery choices for women with vaginal prolapse. Four would allow you to enjoy penetrative sex even after surgery, one would not.

     1. Colporrhaphy is otherwise known as vaginal wall repair, consisting of  stitches made in the vaginal wall to strengthen it. The advantage of this procedure is that it can be done together with another surgery, should you have another condition needing surgery in the area. The disadvantage is that the prolapse may return.

     2. Hysterectomy involves complete removal of the uterus. You will need general anaesthesia for this (you will be asleep throughout the procedure). A major disadvantage to having this surgery is that this would permanently make you unable to bear children, and also increases the risk of early menopause even if your ovaries are not removed.

     3.  Surgery using a synthetic graft is done to women with more severe forms of vaginal prolapse. This may also be recommended to women who have had their prolapse return after other types of prolapse surgery. The surgery involves putting a physical support in your pelvic organ area, with the advantage of this surgery being that it is more effective than colporrhaphy. The disadvantage is that there is still likelihood of further prolapse. There might also be a chance that the mesh support they put in you would irritate your vagina, and so the doctor  may  need to cut this part of the mesh off.^​10​

     4. Sacrocolpopexy has a very high success rate. About 90 per cent of women who undergo this surgery are cured of prolapse. This procedure involves putting mesh on your sacrum for permanent vaginal support. This is usually done for women who have a moderate  to severe prolapse.^​11​

     5. Colpocleisis is usually performed on  and recommended to older women with pelvic organ prolapse, as having this surgery means you can no longer have penetrative sex. Your vagina will be stitched closed or at least a major part of it to stop organs from falling out.^​12​

All of the above surgeries still run the risk of having a relapse of your original problem (or have a new prolapse develop). All also involve a small risk of developing bladder problems. All, except for colpocleisis, also have a two  per cent risk of experiencing pain during sex, but this can be treated further.

How natural medicine can help with vaginal relaxation syndromes

See a naturopath, herbalist or other practitioner of your choice who can help you with supportive herbal medicines, nutritional supplements where appropriate, and extra activities to assist your body to heal.

Natural treatments to help support healing/promote strong tissue in pelvic organ prolapse

• Pelvic floor exercises are your friend – but see a specialist physiotherapist for correct exercises for you
• Uterine herbal tonics to tonify your uterine wall – see your herbalist for a personalised herbal medicine concoction
• Supplements could include special protein/collagen supplementation like bovine gelatin capsules, bone broth and other high-collagen (specific amino acids) formulations to improve collagen production capacities
• Ensuring sufficient protein intake – protein builds your body structures
• Ensuring diet covers all nutrients, particularly zinc, vitamin C
• Acupuncture
• Osteopathy

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