Pelvic Organ Prolapse: 5 common myths explained
Images from voicesforpfd.org
By Aldene Zeno, MD
Pelvic organ prolapse is like a hernia but in the vagina. They’re similar to abdominal hernias, which happen due to a weakness in the abdominal wall. For example, a common hernia in pregnant or postpartum women is an umbilical hernia, which can happen when there’s a weakness at the belly button and the underlying bowel pushes or “herniates” out. Just like the pelvic floor, the abdomen is made of several layers, including muscle, as well as dense fibrous layers called fascia. In the pelvis these muscles and fascia are often collectively referred to as “the pelvic floor.”
Prolapse is a term that can describe other structures, for example, rectal prolapse, or a prolapsed disc in the spine. For the purposes of the discussion below, when I say prolapse I mean pelvic organs prolapsing through the vagina.
Patients explain their prolapse symptoms to me in many ways: “It’s like a penis hanging out” (yes, even my 70+ year old grandmas have no problem using correct anatomical terms!). “It’s a vaginal bulge.” “I have a ball in my vagina.” Here are 5 common myths a bout pelvic organ prolapse.
Myth 1: Hysterectomy causes prolapse
…we don’t actually have solid evidence that hysterectomy causes prolapse
This is an issue often debated among experts. One large study among over 16,000 women found no association. On the other hand, in this large Swedish study, women who underwent vaginal hysterectomy (i.e. uterus removed entirely through the vagina), and especially if they’d had multiple prior vaginal deliveries, were at 4x risk of subsequent surgery for prolapse. However, surgeons often perform vaginal hysterectomy on women who likely have some degree of prolapse, and we know that multiple vaginal births increase the risk of prolapse. Did these women getting vaginal hysterectomies actually have undiagnosed prolapse? Since the study is based on hospital records going as far back as the 1970s, it’s unclear whether the women had untreated prolapse to begin with as opposed to the hysterectomy later causing prolapse.
The challenge with studies looking at risk factors for prolapse is that prolapse tends to develop over several years, sometimes decades. There are few studies in all of medicine that follow cohorts of people (and especially women) for a long time contemporaneously. What we do know is that the most common time for women to develop prolapse is around the time of menopause (40s — 60s), and the most common time for women to have surgery for prolapse is in their 60s. The most common age for all hysterectomies also happens to be among women in their 40s/50s, often due to fibroids or heavy bleeding. So when taken all together, we don’t actually have solid evidence that hysterectomy causes prolapse.
Myth 2: “My uterus/bladder/rectum dropped”
Pelvic reconstructive surgeons and urogynecologists do surgery to improve support for pelvic organs.
I put this as a myth because patients often think I need to fix their uterus/bladder/rectum in order to fix their prolapse. More specifically, many women think that they have to have their uterus taken out in order to fix their prolapse. While it is true that the highest quality studies on prolapse surgeries are where the uterus is removed, these studies had to do with a specific type of prolapse, called apical prolapse. Additionally, prolapse surgeries have been around for hundreds of years, and over these years many uterine-sparing techniques have been developed. There is currently an emphasis on offering uterine-sparing techniques as a surgical option in the right patients, which has several benefits.
To explain this to patients, I often go back to the hernia analogy. If someone has a hernia in their abdominal wall, the surgeon will often reinforce the weakness in the wall, either using the patient’s own tissue or with mesh. The solution to fix a hernia is not to take out the underlying bowel. A physical therapist may work with a patient on strengthening abdominal muscles. The same is true for prolapse. Pelvic reconstructive surgeons and urogynecologists do surgery to improve support for pelvic organs. Pelvic floor physical therapy can be helpful for prolapse as well.
Myth 3: It’s harmful to have sex with prolapse
If anything, being sexually active with prolapse may help increase blood flow to the vaginal tissues
One of my dearest patients has had multiple abdominal surgeries, including prior surgery for prolapse, and unfortunately, she has developed severe recurrent prolapse. On a stage 0 to 4, she has stage 4. Given her other health issues she has elected to live with her prolapse. It unfortunately became worse around the time that she married later in life. However, this has not stopped her from being sexually active.
If anything, being sexually active with prolapse may help increase blood flow to the vaginal tissues. This is helpful as prolapsed vaginal skin can become dried and thinned. Additionally, prolapse is a process that likely happens over many years, sometimes, decades. I know some penis owners would like to take credit for “wrecking someone’s vagina,” but our daily life activities often put much more wear and tear on the pelvic floor.
The unfortunate truth is that many women feel self-conscious about having sex with pelvic organ prolapse. It is well known that living with prolapse affects mental health, feelings of intimacy, and can also impact a woman’s ability to work or socialize. All of these are legitimate concerns beyond whether sex is scientifically ok or not with prolapse, and even more reason that women should have access to care for this condition.
Myth 4: If it’s not treated early, everything will fall out
The key for deciding to get treatment for prolapse depends on symptom bother.
Many astute physicians or other healthcare providers will refer their asymptomatic patients with prolapse to me. In general, we know that the most benefit from prolapse surgery is to improve on the vaginal bulge symptoms, particularly when the prolapse is within a centimeter of the hymen and beyond. The fact is, some studies have found up to 50% of women may have some degree of prolapse on exam. However, not everyone will feel or be bothered by that prolapse — about 18% of U.S. women will ever undergo surgery for prolapse according to this study. There is some thought among experts that prolapse is under-treated. However, we also know that there are a large proportion of women who may have a bulge visible to their doctor on exam, but the patient otherwise would not have known about it.
The science on preventing prolapse is limited. We know that there are certain risk factors like childbirth, particularly instrumented vaginal birth like forceps or vacuum. The biggest risk factors are older age and being female. However, some people develop prolapse even without having ever been pregnant. My youngest patient with prolapse to date was a 19 year-old who developed prolapse after she’d begun an intense weight-lifting program. There is no evidence that intervening early with surgery is better, particularly when someone does not have symptoms.
I am, however, a strong proponent of pelvic floor physical therapy with the goal of prolapse prevention and in mitigating symptoms in early stages. The science behind this is mixed, but I think it just makes sense. Our pelvis carries the weight of our entire bodies. Everything above it literally sits on top of the pelvis, and everything below is connected to the pelvis through the major muscles of the upper legs. Our everyday activities use these muscle groups and can impact our pelvic floor.
A good pelvic physiotherapist will do more than just pelvic floor squeezes (also called Kegel exercises). When choosing a physical therapist or pelvic PT program, I think of it as finding a salon for curly hair. Many PT’s will claim to also do pelvic PT, but a good pelvic PT will have a targeted focus on all things pelvic floor. If you have curly hair, you know you can’t just walk into any salon and expect to find a skilled beautician for your curls. A good place to start is looking under “Patient Resources” on the American PT Association’s Academy for Pelvic Health.
Myth 5: Pelvic organ prolapse is a “natural”/inevitable part of womanhood
There is nothing natural about living your best life while suffering through something that is treatable.
As I mentioned above, pelvic organ prolapse affects up to 50% of women, so yes, it is common. It is not necessarily a disease process. However, it is considered a pelvic floor disorder. For more on that, you can look here.
When people say that it’s “natural,” to me it sounds like they believe nothing can or should be done about it. Pelvic organ prolapse is known to severely impact women’s quality of life. Women are also living longer than ever, and many of my patients expect to live some of their best years through their 50s/60s/70s. There is nothing natural about living your best life while suffering through something that is treatable.
Getting proper treatment for prolapse requires a capable care team, including a urogynecologist. Treatments may range from non-surgical methods to surgery. A fellowship-trained surgeon in this area should offer several surgical options, and most of those should be either same-day or short stay procedures. One of my favorite sayings in surgery is, “A good surgeon knows when not to operate” — a good surgeon should also give you non-surgical options. You can find more info on providers in your area here at the “Voices for PFD” website.
