Pelvic Floor Dysfunction & Pelvic Organ Prolapse

What They Are

Pelvic Floor Dysfunction refers to impaired function of the muscles and connective tissue that support the pelvic organs (bladder, uterus, rectum). This includes both weakness (leading to prolapse or incontinence) and excessive tightness (leading to pain and dysfunction).

Pelvic Organ Prolapse (POP) occurs when one or more pelvic organs descend through the vagina due to loss of support. This affects up to 50% of women who have given birth, though many cases are mild and asymptomatic.

✓✓✓Well-Established

Prevalence and definitions

Types of Prolapse

Anterior Wall Prolapse (Cystocele)

Bladder descends into vagina. Most common type.

Posterior Wall Prolapse (Rectocele)

Rectum bulges into posterior vaginal wall.

Apical Prolapse

Uterus or vaginal vault (after hysterectomy) descends.

Combined

Multiple compartments affected simultaneously.

Staging (Severity)

Stage 0: No prolapse
Stage I: Prolapse doesn't reach vaginal opening (hymen)
Stage II: Prolapse reaches vaginal opening
Stage III: Prolapse extends beyond vaginal opening
Stage IV: Complete eversion (procidentia)

Why It Matters

Pelvic floor dysfunction can significantly impact:

Quality of life - discomfort, embarrassment, activity limitations
Urinary function - stress incontinence, urgency, incomplete emptying
Bowel function - constipation, difficulty with bowel movements, fecal incontinence
Sexual function - pain, reduced sensation, embarrassment about prolapse

Common Symptoms

✓✓✓Well-Established

Well-Established Symptoms

Vaginal bulge or pressure - feeling of "something coming out"
Pelvic heaviness or dragging sensation (worsens with standing, improves lying down)
Urinary symptoms: stress incontinence (leaking with cough/sneeze/exercise), urgency, frequency, incomplete emptying, need to manually reduce prolapse to void
Bowel symptoms: constipation, difficulty with bowel movements, need to splint (manual pressure on vagina/perineum) to defecate, fecal incontinence
Sexual dysfunction: pain with intercourse, difficulty with penetration, reduced sensation, embarrassment

Risk Factors

✓✓✓Well-Established

Well-Established Risk Factors

Vaginal childbirth (strongest risk factor) - number of deliveries, prolonged second stage, large babies, forceps/vacuum delivery
Aging and menopause - loss of estrogen weakens tissues
Chronic increased intra-abdominal pressure: chronic cough (COPD, smoking), chronic constipation, heavy lifting, obesity
Prior pelvic surgery (hysterectomy)
Genetic factors - connective tissue disorders

How It's Evaluated

Pelvic Examination

Visual inspection and examination, often with straining/Valsalva maneuver to assess degree of descent and which compartments are affected. POP-Q staging system provides standardized measurement.

Additional Testing (if indicated)

• Urodynamics (if urinary incontinence present)
• Defecography (if significant defecatory dysfunction)
• Pelvic floor ultrasound or MRI (rarely needed)

General Management Approaches

Treatment is tailored to symptom severity, stage of prolapse, and impact on quality of life. Conservative management is first-line for most women. This is educational information only.

Pelvic Floor Physical Therapy (PFPT) - MOST IMPORTANT
✓✓✓Well-Established

First-line treatment for mild-moderate prolapse and all pelvic floor dysfunction. Often overlooked but highly effective.

• Teaches correct pelvic floor muscle exercises (Kegels done properly)
• Uses biofeedback to ensure correct muscle activation
• May improve mild-moderate prolapse and prevent progression
• Significantly improves urinary incontinence
• Addresses both weakness and excessive tension

Pessary
✓✓✓Well-Established

Silicone device inserted into vagina to support prolapse. Underutilized but highly effective.

• Many types (ring, Gellhorn, cube, etc.) - fitted by provider to find best match
• Provides effective symptom relief without surgery
• Requires removal/cleaning (by user or provider, depending on type)
• Can be used long-term
• Consider vaginal estrogen if postmenopausal to reduce irritation

Lifestyle Modifications

• Weight loss if overweight
• Treat constipation (fiber, fluids, stool softeners)
• Avoid heavy lifting
• Treat chronic cough (smoking cessation if applicable)

Vaginal Estrogen (if postmenopausal)

Improves tissue quality, may reduce prolapse symptoms. Essential if using pessary.

Surgical Management
✓✓✓Well-Established

Considered when:

• Conservative management fails
• Severe prolapse (Stage III-IV)
• Significantly impaired quality of life

Options include: Native tissue repair, sacrocolpopexy, obliterative procedures (colpocleisis for elderly/high surgical risk), ± hysterectomy if uterine prolapse. Recurrence: 10-30% require repeat surgery.

Key Points

Pelvic floor PT is essential first-line treatment - often overlooked by providers
Pessary is underutilized - highly effective, non-invasive option that can avoid or delay surgery
Many effective non-surgical options exist between watchful waiting and surgery
Surgery is reserved for severe cases or when conservative management fails

When to Seek Care

Schedule Appointment If:

• Vaginal bulge or pressure
• Difficulty with urination or bowel movements
• Urinary incontinence affecting quality of life
• Sexual dysfunction related to prolapse
• Pelvic heaviness or dragging sensation

Prevention After Childbirth

All women benefit from pelvic floor assessment postpartum:

• Pelvic floor PT evaluation at 6-8 weeks postpartum
• Learn correct Kegels technique
• Address any early dysfunction before it progresses

What This Page Does NOT Replace

This educational content cannot and does not:

• Diagnose prolapse type or stage
• Determine which treatment is appropriate for you
• Fit you for a pessary or teach pelvic floor exercises
• Assess your individual surgical risk or candidacy
• Replace evaluation by qualified healthcare providers and pelvic floor physical therapists

Related Resources

GSM

Vaginal estrogen improves tissue health and is important for pessary use

Perimenopause & Menopause

Estrogen loss during menopause contributes to prolapse progression

Medical Advocacy

Scripts for requesting pelvic floor PT referrals and pessary trials

Vulvodynia

Hypertonic (too tight) pelvic floor can cause pain - also treated with pelvic floor PT

What They Are

✓✓✓Well-Established

Prevalence and definitions

Types of Prolapse

Anterior Wall Prolapse (Cystocele)

Bladder descends into vagina. Most common type.

Posterior Wall Prolapse (Rectocele)

Rectum bulges into posterior vaginal wall.

Apical Prolapse

Uterus or vaginal vault (after hysterectomy) descends.

Combined

Multiple compartments affected simultaneously.

Staging (Severity)

Stage 0: No prolapse
Stage I: Prolapse doesn't reach vaginal opening (hymen)
Stage II: Prolapse reaches vaginal opening
Stage III: Prolapse extends beyond vaginal opening
Stage IV: Complete eversion (procidentia)

Why It Matters

Pelvic floor dysfunction can significantly impact:

Quality of life - discomfort, embarrassment, activity limitations
Urinary function - stress incontinence, urgency, incomplete emptying
Bowel function - constipation, difficulty with bowel movements, fecal incontinence
Sexual function - pain, reduced sensation, embarrassment about prolapse

Common Symptoms

✓✓✓Well-Established

Well-Established Symptoms

Vaginal bulge or pressure - feeling of "something coming out"
Pelvic heaviness or dragging sensation (worsens with standing, improves lying down)
Urinary symptoms: stress incontinence (leaking with cough/sneeze/exercise), urgency, frequency, incomplete emptying, need to manually reduce prolapse to void
Bowel symptoms: constipation, difficulty with bowel movements, need to splint (manual pressure on vagina/perineum) to defecate, fecal incontinence
Sexual dysfunction: pain with intercourse, difficulty with penetration, reduced sensation, embarrassment

Risk Factors

✓✓✓Well-Established

Well-Established Risk Factors

Vaginal childbirth (strongest risk factor) - number of deliveries, prolonged second stage, large babies, forceps/vacuum delivery
Aging and menopause - loss of estrogen weakens tissues
Chronic increased intra-abdominal pressure: chronic cough (COPD, smoking), chronic constipation, heavy lifting, obesity
Prior pelvic surgery (hysterectomy)
Genetic factors - connective tissue disorders

How It's Evaluated

Pelvic Examination

Visual inspection and examination, often with straining/Valsalva maneuver to assess degree of descent and which compartments are affected. POP-Q staging system provides standardized measurement.

Additional Testing (if indicated)

• Urodynamics (if urinary incontinence present)
• Defecography (if significant defecatory dysfunction)
• Pelvic floor ultrasound or MRI (rarely needed)

General Management Approaches

Treatment is tailored to symptom severity, stage of prolapse, and impact on quality of life. Conservative management is first-line for most women. This is educational information only.

Pelvic Floor Physical Therapy (PFPT) - MOST IMPORTANT
✓✓✓Well-Established

First-line treatment for mild-moderate prolapse and all pelvic floor dysfunction. Often overlooked but highly effective.

• Teaches correct pelvic floor muscle exercises (Kegels done properly)
• Uses biofeedback to ensure correct muscle activation
• May improve mild-moderate prolapse and prevent progression
• Significantly improves urinary incontinence
• Addresses both weakness and excessive tension

Pessary
✓✓✓Well-Established

Silicone device inserted into vagina to support prolapse. Underutilized but highly effective.

• Many types (ring, Gellhorn, cube, etc.) - fitted by provider to find best match
• Provides effective symptom relief without surgery
• Requires removal/cleaning (by user or provider, depending on type)
• Can be used long-term
• Consider vaginal estrogen if postmenopausal to reduce irritation

Lifestyle Modifications

• Weight loss if overweight
• Treat constipation (fiber, fluids, stool softeners)
• Avoid heavy lifting
• Treat chronic cough (smoking cessation if applicable)

Vaginal Estrogen (if postmenopausal)

Improves tissue quality, may reduce prolapse symptoms. Essential if using pessary.

Surgical Management
✓✓✓Well-Established

Considered when:

• Conservative management fails
• Severe prolapse (Stage III-IV)
• Significantly impaired quality of life

Key Points

Pelvic floor PT is essential first-line treatment - often overlooked by providers
Pessary is underutilized - highly effective, non-invasive option that can avoid or delay surgery
Many effective non-surgical options exist between watchful waiting and surgery
Surgery is reserved for severe cases or when conservative management fails

When to Seek Care

Schedule Appointment If:

• Vaginal bulge or pressure
• Difficulty with urination or bowel movements
• Urinary incontinence affecting quality of life
• Sexual dysfunction related to prolapse
• Pelvic heaviness or dragging sensation

Prevention After Childbirth

All women benefit from pelvic floor assessment postpartum:

• Pelvic floor PT evaluation at 6-8 weeks postpartum
• Learn correct Kegels technique
• Address any early dysfunction before it progresses

What This Page Does NOT Replace

This educational content cannot and does not:

• Diagnose prolapse type or stage
• Determine which treatment is appropriate for you
• Fit you for a pessary or teach pelvic floor exercises
• Assess your individual surgical risk or candidacy
• Replace evaluation by qualified healthcare providers and pelvic floor physical therapists

Related Resources

GSM

Vaginal estrogen improves tissue health and is important for pessary use

Perimenopause & Menopause

Estrogen loss during menopause contributes to prolapse progression

Medical Advocacy

Scripts for requesting pelvic floor PT referrals and pessary trials

Vulvodynia

Hypertonic (too tight) pelvic floor can cause pain - also treated with pelvic floor PT

Pelvic Floor Dysfunction & Pelvic Organ Prolapse

Pelvic Floor Dysfunction & Pelvic Organ Prolapse

What They Are

Types of Prolapse

Anterior Wall Prolapse (Cystocele)

Posterior Wall Prolapse (Rectocele)

Apical Prolapse

Combined

Staging (Severity)

Why It Matters

Common Symptoms

Risk Factors

How It's Evaluated

Pelvic Examination

Additional Testing (if indicated)

General Management Approaches

Pelvic Floor Physical Therapy (PFPT) - MOST IMPORTANT✓✓✓Well-Established

Pessary✓✓✓Well-Established

Lifestyle Modifications

Vaginal Estrogen (if postmenopausal)

Surgical Management✓✓✓Well-Established

Key Points

When to Seek Care

Schedule Appointment If:

Prevention After Childbirth

What This Page Does NOT Replace

Related Resources

GSM

Perimenopause & Menopause

Medical Advocacy

Vulvodynia

Pelvic Floor Dysfunction & Pelvic Organ Prolapse

Pelvic Floor Dysfunction & Pelvic Organ Prolapse

What They Are

Types of Prolapse

Anterior Wall Prolapse (Cystocele)

Posterior Wall Prolapse (Rectocele)

Apical Prolapse

Combined

Staging (Severity)

Why It Matters

Common Symptoms

Risk Factors

How It's Evaluated

Pelvic Examination

Additional Testing (if indicated)

General Management Approaches

Pelvic Floor Physical Therapy (PFPT) - MOST IMPORTANT✓✓✓Well-Established

Pessary✓✓✓Well-Established

Lifestyle Modifications

Vaginal Estrogen (if postmenopausal)

Surgical Management✓✓✓Well-Established

Key Points

When to Seek Care

Schedule Appointment If:

Prevention After Childbirth

What This Page Does NOT Replace

Related Resources

GSM

Perimenopause & Menopause

Medical Advocacy

Vulvodynia

Pelvic Floor Physical Therapy (PFPT) - MOST IMPORTANT
✓✓✓Well-Established

Pessary
✓✓✓Well-Established

Surgical Management
✓✓✓Well-Established

Pelvic Floor Physical Therapy (PFPT) - MOST IMPORTANT
✓✓✓Well-Established

Pessary
✓✓✓Well-Established

Surgical Management
✓✓✓Well-Established