Solving Prolapse: It’s Fallen & Can’t Get Up

Betsy Greenleaf, DO, FACOOG (Distinguished)

Hi. I’m Dr. Betsy Greenleaf. You’re one of the hosts of the Solving Sexual Dysfunction Summit. And I’m going to talk about a little bit about pelvic organ prolapse. Now, this is something that 50% of women will experience at some point in their lives, yet nobody ever talks about it. And so it can be very scary and very concerning when something like this shows up. So I’m also going to warn you, as the first board-certified female gynecologist in the country, this is something that I have treated for years. And my next slide is a little graphic. So if you don’t like anatomy slides, we’re going to just, you can just close your eyes for a minute, and I’ll tell you when you can open them again, but I’ll give you a little bit of history. I was in the process of writing a chapter in a book or a textbook on pelvic organ prolapse, and I put a picture of one of my patients who had a what was called a complete prolapse. And I had my husband, who is non-medical, proofread for me. And he came across this picture and was like, “What in the world is that? Oh, my God. Like, that woman has a penis and I’m and unfortunately, that is the result that many women think when they have what’s called a complete prolapse. A complete prolapse is where the vagina can turn completely inside out, and the uterus is now hanging between their legs.” 

And so I’m going to flash that picture right now to get an idea of what an extreme case would look like. So here is a complete prolapse of the vagina. And what you’re looking at at the bottom is the cervix, and the vagina has turned completely inside out, is now hanging between someone’s legs. So for anybody who is squeamish, I now switched off that. And you can come back and watch. So half of all women 50 years and older will develop a pelvic organ prolapse, or they refer to them as a pop. In fact, there are about 73.6 million people right now that are walking around with this. Now, this, of course, you wake up and something like this happens and your first response is, “Oh, my God, what? What is this growth? What is this?” And I get people thinking it’s cancer. They’re you know, they don’t know what it is. It’s very scary. It causes them to go to the emergency room. Well, I’m here to tell you that the good news is a pelvic organ prolapse is not an emergency, though it can be a little disconcerting and can make women feel very self-conscious of their bodies. There’s really not a lot that you’re going to do that’s going to make things worse. 

Now, lifting heavy objects, especially if you don’t hold your breath. So this has happened because the ligaments in the pelvis that are supposed to be holding everything up have torn or they’ve stretched. And this can happen over a period of years, or it can happen just like that. Like, say you lift something really heavy or bear down and have a bowel movement really hard. If you’re constipated, all of a sudden you can get something that is bulging. Now that is called a stage four prolapse. Women can get anywhere from stage one where it’s just a little bit of a weakness all the way to stage four, which completely turned out inside out. I know a lot of women will become self-conscious, especially if they have some of the lower stages, and they’re worried that having sex is going to ruin this. Typically, sex is not going to affect it. And when we’re laid down usually things go back up where they’re supposed to. So this is one of those things where I tell people it is okay to have sex, but it’s definitely something you want to get checked out either by a gynecologist or a urogynecologist. 

Another common question I get from patients is, well, I went to my gynecologist and they didn’t see it. Like what was wrong with them? Like, were they not a good gynecologist? Like, why don’t they know that I have this problem? Well, once again, I say when we lay down flat, we don’t have the pressure of gravity on our body. So things tend to go back up where they’re supposed to be. So a lot of times when you’re at the regular gynecologists, they’re not looking necessary for a prolapse. So unless you’re bearing down, have a bowel movement or like, you know, kind of coughing when you’re having an exam or what has your gynecologist like to do is have people stand up for their examinations so that we can see how far this is coming down. But what causes the pelvic organ prolapse? Well, a lot of times it’s kind of like a hammock. Like our pelvic floor is like a big giant hammock. And all our organs are just being held up by this hammock. We don’t have bones that are going across them the bottom of our pelvic floor, all we have are muscles that are holding things in place. So here’s the pelvis, and we take the pelvic organs out. Really like our bodies are open, and our muscles are the only thing that are holding things in. So from the inside and outside that’s all we have is our muscles, our skin, our nerves, and our connective tissue holding things in. So that tissue can be damaged over time.

And so things like childbearing, just being pregnant alone can. You don’t even have to give birth only to have it happen in things that cause increased public pressure, such as constipation, lifting, and coughing. Some of it is just unfortunate things like genetics or medical conditions, smoking will weaken the tissue nutrition deficiency, and sometimes just the aging process of our tissue. So, you know, when I show people this picture in my office, they often wish they never had children. And unfortunately, it’s just to show that as women, we’re built with breakaway zones because nature doesn’t care if your vagina is hanging out. Nature cares that the baby gets out. So if you look on one side of the screen, you will see on the top is a bladder. This is like if we cut the body in half and we’re like from side to side and we’re looking at from the front all the organs, the next layer down, you’re seeing the vagina, and then the next layer down you see the rectum and then you see this kind of bluish grayish tissue. Those are the ligaments that are holding each one of those organs in place. And you can see the bladder leans on the vagina. The rectum is on the vagina. Everything is just kind of like in its place with these ligaments. And then on the other side, we have a baby’s head coming through and during a vaginal birth. And so what happens is now we’re getting compression on all those organs. And often we get, you know, the body has tearaway zones. We have these ligaments that will rip, and tear to keep the baby. We need to get the baby out and so nature doesn’t care if everything’s where it’s supposed to be. So this is often where it can happen. 

Here also is the pelvic support. This is looking down into a pelvis with the organs removed, and these bluish-gray materials are all the little levels of ligaments that are often damaged during pregnancy and childbirth. I’ve seen gymnasts have problems. I’ve had people who’ve never given birth, who were in jobs where they had to lift heavy objects or maybe they were somebody who had chronic constipation or chronic bronchitis causing damage to this tissue. And then once again, looking from the side. So on one side of the screen, we have the front of the body, and then we have the back of the body. And from front to back, we have the urethra tube run through the bladder, the vagina, the cervix in the uterus, and the rectum. You can see each one of those things sit so incredibly close together so that it’s very, you know, ligaments in one area go, things drop. So a lot of times people say to me, well, they come in like all my bladders dropped or my uterus is dropped. Unless somebody specifically told you, you don’t know because that, as we call it, we may be calling it cystocele. So here’s what’s a cystocele, which is a bladder drop. It’s where the ligaments between the vagina and the bladder weaken. The bladder is that, first of all, the bladder is not going to drop out and fall on the floor. You’re good. Nothing’s going to fall on the floor. It may feel like it, but it’s not. And so the bladder starts to lean on the vagina, and the vagina is meant to stretch indefinitely because, I mean, look, a baby can fit through there. So the vagina is just going to keep stretching and stretching as much as that pressure is put on it. And so that is where the bladder is dropping. Now, you could also have what’s called a rectocele where the rectum is, the ligaments between the rectum and the vagina have been damaged, and now that’s pushing things out. Or you can have a uterine prolapse where and that’s what we saw in that picture. It’s where the ligaments holding up the uterus, sort of the top of the vagina. Now come down and turn inside out. 

So what needs to be done about this? The best thing is you don’t have to do anything. Now, some people are like “What?” My criteria for surgery on something like this is, if it’s bothering you physically or mentally enough to take the risks of surgery, that’s when you do surgery. So I’m like the anti-surgery surgeon. So I think that a lot of times we have to look at everybody’s individual case. I’ve had women that come into my practice just as bad as that one that we saw at the beginning of this lecture. And they’re like, You know what? Not bothering me. And I’m like, okay, if it’s not bothering you, well then let’s look at the next thing. Is it causing any medical problems? It’s not causing any medical problems. Then we just go. All right, let’s just check it once a year and see what’s going on, or check it every six months. So that’s a possibility. Now, let’s say it is bothering you, but you don’t want to have surgery. There are some things you can do, things like behavior modification, trying not to get constipated, and trying to keep the bowels regular so that you’re not bearing down, not lifting heavy objects. When you lift blowout as you lift so you’re not increasing your pelvic pressure, putting too much pressure on the pelvis. Sex is not something that you need to have to worry about. You can still have sex. You’re not going to hurt it. Doing legal exercise. Sometimes strengthening the pelvic floor will improve the prolapse. 

Now, I’m not going to take a complete prolapse and turn things back inside out before our stage one, two, or three prolapse. It can improve the appearance of the prolapse when those muscles in the pelvic floor are strengthened. I think we’re doing things like external support. So this is external support. There are certain things like different girdles or supports that can be worn that will just push it back up in place and make it feel more comfortable. Sometimes using a little bit of estrogen topically or DGA topical hormones in the vaginal tissue will help thicken the vaginal tissue and decrease the appearance of the prolapse. Pelvic Physical Therapy. Awesome. My favorite thing in the world can help with all sorts of conditions. Usually, something like a tampon out there now is on the market, something called the Impressa. I don’t recommend tampons themselves because a tampon can hold bacteria and we don’t want to get an infection from bacteria. But there are products like the Poise Impressa, which can be bought over the counter, is a tampon-like device that doesn’t absorb bacteria that would push the prolapse up where this tampon device is in that area and then it can hold things in place so when you’re doing activities or an exercise class. Pessaries, and we’re going to get a little bit more into pessaries and then there’s surgery. So less is more.

So what if you do nothing? So you don’t need to treat a patient or somebody who’s asymptomatic, but they do have a higher risk of recurrent bladder infections because when the bladder is dropping, the urine has to travel upheld to get out. And so sometimes we don’t fully empty the bladder so they could develop, we need to make sure they’re not developing something called hydronephrosis. And this is what’s seen in this picture where if the bladder is not emptying, the urine can be backing up into the kidneys. And over time can be straining and stressing the kidneys and stretching the kidney out, then that would be a reason that if we’re seeing that, then doing some more intervention would be a better idea. But urinary retention sometimes if the bladder is too kinked from it dropping down, that may affect a person’s ability to urinate not just not empty. Maybe they can’t urinate at all. That would be a time to intervene and also comfort some people. Some patients don’t have any problems with it. Some people find it incredibly uncomfortable. I also say if it mentally bothers you enough that the risks of other procedures are worth it, and that mental anguish is another good reason to do one of the more extreme treatments.

Now, pessaries, pessaries are kind of crazy. They are support devices that are fitted for the vagina. And nowadays we have a company that actually uses 3D technology and printing, will print one for your specific vagina because in the past we just had ones that were just standard, you know, came in different shots, shapes, and sizes. But this idea of pessaries, it just goes in and wedges in the vagina, holds everything in place and this dates back to ancient Egypt. And they used to use pomegranates, potatoes, wax balls, fabric balls, wood, and metal. I do not recommend any of those. The pessaries that are on the market today are usually latex-free silicone. They are fitted by a health care practitioner for you and they can be either taken out every single day, washed, cleaned, or put back. Some people, or left at night. For the patients who don’t have dexterity enough to take them in and out on their own, we typically leave them, and can leave them in for about three months. But on an individual basis, I don’t like leaving them past six months. Even then, there’s no hard data saying how long to leave them. I have seen people who’ve left them in accidentally for years and you know, came to me. They were first-time patient and had gotten one from another place and didn’t realize it was in there. The longer you leave it in there and the higher the risk of having a discharge, but you can also get the tissue can actually start to grow around it. I have seen that happen. So these do have to be taken out and cleaned from time to time. You can have sex with some of them in place. So that is another option.

Some of them can actually be left in place during sexual activity. So once again, they can be they basically are designed to wedge in place and hold things up some. They should never be painful and you should never know that they’re there. So once they’re in place, you shouldn’t just be like, okay, this is normal. But if you’re having pressures or unmasks incontinence, you didn’t know you’re having this and they need to be adjusted. Same thing if you’re getting constipated with them. So some of the risks and pastries can be urinary retention, fecal retention, ulceration, and if they’re left in too long if they grow around or they can also rate through the tissue and perforate the vagina if left in too long and not managed properly. And once there is no evidence of how long they can be in place. So some patients will take them out and clean them every day, week, and month on average. We will take them in and out every about every 3 to 4 months. 

Now there is a whole host of surgeries and they are called so many different things. There is a Colporrhaphy, Colpocleisis, Colpectomy, Colpopexy, Colpoplasty, Paravaginal Repair, and a whole mouthful of things. The key with surgery is that surgeries do not necessarily fix this for a lifetime. No, I trained in a day and age when we were using a lot of vaginal mesh and they were like, oh, this is the new thing. It’s going to be great and everyone’s going to be fixed and they’re never going to have a problem again. We’ve already shown that people who have a prolapse, number one, have a propensity for their tissue to rip and tear. So they’re much higher or much higher risk of having it happen again. So even though it’s been surgically fixed, we love it when patients get a lifetime out of it. We’re ecstatic. We’re happy if people get five years out of a repair. So just you know, I’ve had some women, we repair them. Things have been perfect. And then they decided to go lift up a big turkey for turkey dinner and had it come back out. So this is something you need to really consider. There are risks with surgery, there are risks of bleeding, there are risks of infection, and there are risks of pain.

If you’re having pain to begin with, don’t do surgery. If you’re having a pelvic pain condition, you want that look into way before you do any kind of surgery because surgery can worsen it. So the key is to have a really long discussion with your surgeon and ask them, what are the expectations if somebody is going to tell you, fix it and it’s going to be good for life, don’t believe them. Go find the next one, because really there’s no way to predict how the tissue is going to respond to this. This is something that we do, these surgeons do it all the time. There are different ways to do it from in through the vagina or coming in from the top. But statistically, the research doesn’t show that one is necessarily better than the other. And that brings up that tissues can be. We do see that some people have a genetic predisposition and this is why some people’s ligaments are much, much thinner than other people’s ligaments. And so just having one surgery predisposes you to have more surgery because your ligaments have already shown they have a propensity to rip and tear. So that’s then just to consider about before having surgery.

So this has been our little intro on Prolapse and some of the options that are out there. If you’re looking for a Urogynecologist that does this type of surgery, I would recommend you go to voicesforpfd.org. That is the website for the AUGS (American Urogynecologic Society). There’s also if you live in another country, there is the International Urogynecological Association (IUGA). You can look them up online and, you know, we will be talking more about this in upcoming masterclasses and lectures so follow me for more information, and stick around because we have more great sessions coming up.