Rectocele

Genitourinary (GU) prolapse occurs when the normal support structures for the organs inside a women's pelvis are weakened. The result is that one or more of the organs (the uterus, the bladder or the rectum) can drop down (prolapse) into the vagina. This may lead to no symptoms at all but more usually causes discomfort in the vagina as well as other symptoms, including urinary and bowel problems. There are various possible treatments for GU prolapse and the prognosis (outlook) is generally good.

What is genitourinary prolapse?

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

Genitourinary (GU) prolapse occurs when these normal support structures are weakened and are no longer effective. The result is that one (or more) of the organs inside the pelvis drops down (prolapses). The space available for the organ(s) to drop down into is the vagina. There can be different degrees of prolapse depending on how much, or how far, the organ(s) might have dropped down into the vagina. Sometimes, the prolapse can be so much that it causes the walls of the vagina, or the uterus (womb), or both, to protrude outside the opening of the vagina.

What are the different types of genitourinary prolapse?

Different types of GU prolapse can occur depending on which pelvic organ, or organs, might have dropped down into the vagina. Generally, GU prolapse can be divided into the following, depending on which part of the pelvis it affects. However, GU prolapse may affect different parts of the pelvis at the same time.

Prolapse affecting the anterior (front) part of the 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 be prolapse of the bladder into the vagina. The medical term for this is a cystocele.
  • Or, 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.
  • If a woman has had a hysterectomy (removal of the uterus), 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 prolapse into the vagina. This is known as a vault prolapse.
  • There can 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 bowel may be present in the prolapse, enclosed within the prolapse.

How many women are affected by genitourinary prolapse?

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

What causes genitourinary prolapse?

It is thought that a number of things may increase the risk of developing GU prolapse. They include the following.

Childbirth

During childbirth (giving birth through the vagina), there is excessive stretching of the ligaments, nerves and muscles (including the pelvic floor muscles) around the vagina. This stretching can damage them and make them weaker and less supportive. However, GU prolapse does not affect everyone who gives birth. It may be more likely after a difficult, prolonged labour, a forceps delivery, or if a woman gives birth to a large baby. It also becomes more likely the more times a woman has given birth.

Increasing age

The chance of having a prolapse increases as a woman gets 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.

Increased pressure inside the abdomen

Anything that causes an increase in the pressure inside a woman's abdomen and pelvis can also be a risk factor 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 women who are overweight, who have chronic (persistent) lung problems, such as a chronic cough, in women who regularly lift heavy objects, or women who frequently strain due to constipation.

Gynaecological surgery

If a woman has had a hysterectomy, or other gynaecological surgery, she 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. However, with new advances in surgical techniques, including laparoscopic (keyhole) surgery, this is becoming less of a problem.

Other risk factors

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. Also, it is thought that having a mother or a sister who has GU prolapse may increase a woman's risk.

What are the symptoms of genitourinary 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, when you have a cervical screening (smear) test.

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 your vagina or having a feeling of something 'dragging' or 'coming down'. You may actually be able to feel a lump or protrusion. You may experience pain in your vagina, back or abdomen. Sometimes, you may also notice a discharge from your vagina, which may be blood-stained or smelly. Sex may be uncomfortable or painful. Symptoms are usually worse after long periods of standing and they improve after lying down.

Other symptoms that you may experience can depend on the type of prolapse that you have. They can include the following. Note: you may have a combination of these symptoms if prolapse affects the organs in different parts of your pelvis at the same time.

Urinary symptoms

You may have urinary symptoms if your prolapse affects the anterior (front) part of your pelvis (your urethra and bladder). Symptoms may 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, and also sometimes 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 or the need to use your finger to push back the prolapse to enable urine to pass.

Also, complications may occur such as urine infections, incontinence (loss of control) of urine and retention of urine (not being able to pass urine at all, which may need treatment by inserting a catheter into your bladder to drain the urine).

Bowel symptoms

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

  • Difficulty passing stools (faeces) and having to strain to pass stools.
  • Feeling a sudden urge to pass stools.
  • A feeling that your bowels have not emptied fully.
  • Incontinence (loss of control) of stools.
  • Passing lots of flatus (wind).
  • A feeling of a blockage or an obstruction whilst you are passing stools.
  • The need to push on, or around, your vagina or perineum to enable stools to pass.

Other symptoms

If the prolapse causes your cervix (the neck of your womb) or the skin that lines your vagina to protrude from your vagina, this can lead to ulceration of your cervix or skin and sometimes bleeding and infection.

How is genitourinary prolapse diagnosed?

GU prolapse is usually diagnosed by your doctor performing a simple examination of your vagina. 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.

When they examine you, your doctor will usually insert a special instrument called a Sims' speculum into your vagina. This is a similar instrument to that used during cervical screening but it is a different shape. They will usually move the speculum to the front and back walls of your vagina, allowing them to look for prolapse. Your 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 (neck of your womb) to see if there is any prolapse of your womb. These examinations are not usually painful. If you have bowel symptoms, your 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 to check 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 - for example, some tests known as urodynamic studies. These are tests of your urine flow and they are usually done in a hospital unit. If you have bowel symptoms, a specialist may suggest some special tests to look into these.

What are the aims of treatment for genitourinary prolapse?

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

  • Are comfortable and pain-free.
  • Are able to pass urine and stools 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 prolapse.
  • Are able to continue to have children if you desire.

What are the treatment options for genitourinary prolapse?

Watchful waiting

If you have little in the way of symptoms, after discussion with you doctor, you may choose to wait and see how your symptoms develop. However, you doctor will usually suggest that they keep a careful eye on you and examine you from time to time. If you develop any new symptoms, you should see your doctor.

However, during this period of watchful waiting, there are a number of things that you may be able to do to help prevent the prolapse from getting any worse. As discussed above, there are a number of things that can cause a rise in the pressure inside your abdomen and increase your risk of GU prolapse, or make GU prolapse worse. For example:

  • If you have GU prolapse and are overweight, it may help if you lose weight. (See separate leaflet called 'Weight Reduction - How to Lose Weight' for more details.)
  • If you are constipated you should discuss this with your GP to ensure that you are receiving adequate treatment. (See separate leaflet called 'Constipation in Adults' for more details.)
  • Coughing can make prolapse worse. If you are still smoking, you should try to give up. (See separate leaflet called 'Smoking - Tips to Help you Stop' for more details.)
  • You should try to avoid heavy lifting as this may make prolapse worse. If you are able to, take a break, put your feet up and rest during the day.

A vaginal pessary

A vaginal pessary can be a very good way to manage GU prolapse. It may be used by women who do not wish to have surgery, by women who are still of child-bearing age, by women who are waiting for surgery, or by women who have other illnesses that may make surgery more risky. The pessaries are usually in the shape of a ring and are usually made of silicone or plastic. The ring is inserted into your vagina. It is left in place and helps to lift up the walls of your vagina and any prolapse of your womb. Vaginal pessaries are easily inserted and many GPs are able to insert them. They should be changed every 6 to 12 months.

If you have pain or difficulty passing urine after you have a vaginal pessary inserted, you should speak to your GP as soon as possible. You may need the pessary changing for a different size.

Vaginal pessaries do not usually cause any problems but, very rarely, they may affect the skin inside your vagina which can become ulcerated. Some women notice some discomfort during sexual intercourse.

Vaginal oestrogen creams

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

Pelvic floor exercises

All women with GU prolapse, whether they have symptoms or not, should do pelvic floor exercises. The exercises may stop mild degrees of prolapse from getting any worse. They may also relieve symptoms such as backache and abdominal discomfort. However, pelvic floor exercises are not likely to improve any prolapse that is already present. See separate leaflet called 'Pelvic Floor Exercises' for more details.

Surgery

The aim of surgery is to provide a permanent treatment (a cure) for GU prolapse. There are various operations that can be performed, depending on the type of prolapse that you have. Keyhole surgery may be possible for some of these operations. Your surgeon will be able to advise which operation is best for you. Operations can include the following:

  • A vaginal repair operation: this is where the walls of your vagina are reinforced, and tightened up, usually by making a tuck in the wall of your vagina and using stitches to hold the tuck in place. The operation is usually done through your vagina and so you do not need a cut in your abdomen. In some cases, a mesh or special tape may be sewn into the vaginal walls. Note: there are a number of different types of vaginal repair operations. There is some uncertainty about the long-term results when using mesh for some of these types of operations and there may be a risk of complications, such as the mesh eroding through the wall of your vagina. This may mean that you need further surgery and may also cause some discomfort and sexual difficulties. You should discuss the pros and cons of any operation in detail with your surgeon before going ahead.
  • A hysterectomy (removal of the uterus): this is a common treatment for uterine prolapse. In fact, GU prolapse is the most common reason why women over 50 years of age have a hysterectomy. Sometimes a hysterectomy is suggested at the same time as a vaginal repair operation.
  • An operation to lift up your uterus or vagina: there are various different types which include:
    • Sacrohysteropexy: a special mesh is used that acts like a kind of sling to help to support your uterus and hold it in place. One end of the mesh is attached to your cervix and the other to the bone at the back of your pelvis, called your sacrum. This operation is usually done through a cut in your abdomen.
    • Sacrocolpopexy: during this operation, your vagina is hitched up and held in place by fixing it to the bone at the back of your pelvis, called your sacrum. A mesh or another material is usually used to hold your vagina in place. A hysterectomy may be suggested at the same time. This operation is usually done through a cut in your abdomen.
    • Infracoccygeal hysteropexy or colpopexy: these are some newer techniques where the mesh is inserted through your vagina rather than making a cut in your abdomen. This may mean a quicker recovery.
    • Sacrospinous fixation: during this operation, your vagina is hitched up and stitched to a ligament inside your pelvis, called your sacrospinous ligament. It is usually carried out through your vagina and so no cut in your abdomen is needed.

You are likely to need to stay in hospital for a few days after your operation. Full recovery 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 a prolapse can return after surgery.

What is the prognosis (outlook) for genitourinary 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 genitourinary 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, 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.
  • If you smoke, try to stop smoking.
  • Avoid occupations that involve heavy lifting.

Further help and advice

The Bladder and Bowel Foundation

SATRA Innovation Park, Rockingham Road, Kettering, Northants, NN16 9JH Nurse helpline: 0845 345 0165 Web: www.bladderandbowelfoundation.org A UK charity for people with bladder and bowel disorders.