A prolapse is a dropping of surrounding organs into the vagina. This can include the bladder (cystocele), uterus, small intestine (enterocele) or rectum (rectocele). In some cases, there is prolapse of all of these organs, causing a significant vaginal bulge, sensation of pelvic pressure, or even of something “falling out of the vagina.”
Prolapse is staged on a stage of 1-4, based on the amount of descent present.
A stage 1 prolapse means there is minimal dropping of the organ present. A stage four prolapse means the prolapsed organ has dropped as far as possible into the vagina. The images below depict the anatomy without any prolapse on the left and stage 2 prolapses of the bladder, uterus and rectum in the image on the right.
When the bladder, uterus and rectum are protruding all the way beyond the opening of the vagina or the introitus, this is known as total prolapse or complete procidentia. The treatment for total prolapse is a surgical repair to restore the anatomy of the vagina and often a hysterectomy, if the uterus is still in place.
The image below depicts a patient with complete pelvic organ prolapse of the bladder; uterus and rectum (stage 4 prolapse). The dry appearing tissue is the uterus and bladder that have been stretched and thinned out. The second image you see is the same patient following a hysterectomy and prolapse repair. She underwent a trans-vaginal hysterectomy and da Vinci sacrocolpoperineopexy.
Complications of advanced prolapse can include urinary tract infections, poor bladder emptying, pelvic pain, breakdown of the vaginal mucosa due to thinning and rubbing of the tissue, constipation, incomplete defecation, lower back pain and pain with intercourse. Initially, prolapse can be small and asymptomatic. When this is the case, the prolapse can be managed conservatively. Once prolapse has progressed, causing bothersome symptoms, vaginal or robotic prolapse surgery can be performed. The type of surgery recommended is based on each individual patient’s symptoms and findings on physical exam.