Understanding Pelvic Organ Prolapse and Maintaining Pelvic Floor Health in Pregnancy

Pelvic Organ Prolapse (POP) occurs when one or more of the pelvic organs (uterus, bladder, or rectum) drop down from their normal position and press into the vagina. It is a common condition, often managed effectively.

This sheet provides information on POP, focusing on prevention and pelvic floor health during pregnancy.

1. What is Pelvic Organ Prolapse?

The pelvic floor is a group of muscles, ligaments, and connective tissue that forms a hammock supporting the organs inside the pelvis (bladder, uterus, rectum).

Prolapse happens when these supporting structures become weak or damaged, allowing the organs to descend into or outside the vaginal canal.

How Common is POP?

Prevalence: POP is very common. Studies suggest up to 50% of women who have had children show some degree of prolapse on examination, though only about 10–20% will seek treatment for bothersome symptoms.
Risk: The risk increases with age, especially after menopause.

2. Symptoms of Pelvic Organ Prolapse

POP symptoms can vary widely depending on which organ is prolapsing. The severity is graded from 1 (mild) to 4 (severe).

Common Symptoms

"Feeling a Lump or Heaviness": The most common symptom is a feeling of pressure, heaviness, or "something dropping out" in the vagina, especially at the end of the day or after exercise.
Vaginal Bulge: You may feel or see a bulge or lump coming out of the vagina.
Urinary Symptoms: Difficulty emptying the bladder, a slow stream, or, paradoxically, Urinary Incontinence (leakage).
Bowel Symptoms: Difficulty passing stool, or needing to press on the bulge in the vagina or around the rectum to complete a bowel movement (splinting).
Sexual Dysfunction: Discomfort, pain, or a feeling of looseness during intercourse.

3. Causes and Risk factors for Pelvic Organ Prolapse

POP is caused by anything that weakens the pelvic floor and/or increases prolonged pressure on it.

Cause Category	Detailed Explanation
Childbirth and Pregnancy	This is the single biggest risk factor. Trauma during vaginal delivery (large baby, prolonged pushing, assisted delivery with forceps/vacuum) can stretch and tear the pelvic floor muscles and supporting ligaments.
Increased Abdominal Pressure	Any consistent or repetitive increase in pressure pushes down on the pelvic floor. Common causes include: chronic coughing (e.g., from smoking, asthma), obesity (excess weight), and chronic constipation/straining during bowel movements.
Ageing and Menopause	Oestrogen levels drop after menopause, leading to thinning and weakening of supportive tissues (collagen).
Genetics and Lifestyle	Some women naturally have weaker connective tissue. Heavy lifting and high-impact sports can also contribute to excessive strain over time.

4. Diagnosis of Pelvic Organ Prolapse

Medical History: Your doctor will ask about your symptoms, medical history, pregnancies, and overall lifestyle.
Pelvic Examination: The doctor will examine your pelvic organs while you are lying down and then while you are asked to cough or strain (bear down). This helps determine the type and severity of the prolapse.
Further Tests (if needed): Depending on your specific symptoms, you may need tests like:
Urodynamic Studies: To check bladder function if you have urinary incontinence.
Imaging (e.g., MRI/Ultrasound): To further assess the position of the organs.

5. Maintaining Pelvic Floor Health During Pregnancy

Pregnancy and childbirth are the highest risk periods for pelvic floor damage. Taking preventative steps is key.

Action	Why It's Important
Pelvic Floor Muscle Exercises (Kegels)	Strengthening these muscles before they are damaged can help them better withstand the strain of pregnancy and labour, and recover faster afterwards. Aim to do them daily.
Healthy Weight Gain	Excessive weight gain puts constant downward pressure on the pelvic floor. Follow your doctor's advice on optimal weight gain.
Constipation Management	Avoid straining! Eat a high-fibre diet, drink plenty of water, and use stool softeners as advised to ensure easy bowel movements.
Safe Exercise	Stick to low-impact exercises (swimming, walking, prenatal yoga) that support the body without excessive bouncing or jumping, which increases downward force.
Proper Lifting Techniques	When lifting older children or heavy objects, keep the load close to your body, bend your knees (not your back), and exhale while lifting (to avoid bearing down).

6. Treatment of Pelvic Organ Prolapse

Treatment is based on the severity of the prolapse, your symptoms, your overall health, and your personal preferences.

A. Conservative Management (First Line for Mild to Moderate Prolapse)

Pelvic Floor Physiotherapy: Essential for all grades of POP. A specialised physiotherapist can teach you the correct technique for pelvic floor strengthening and prescribe an exercise program to improve muscle tone and support.
Pessary: A removable device (usually made of silicone) placed into the vagina to physically support the dropped organs. It is a non-surgical option that can be very effective for symptom relief.
Lifestyle Changes: Addressing chronic cough (e.g., quitting smoking), weight loss, and dedicated constipation management.

B. Surgical Management (For Severe or Persistent Symptoms)

Surgery aims to correct the organ position and restore support using sutures, natural tissue, or mesh. Surgical options include:

Native Tissue Repair (Colporrhaphy): Using the woman's own tissue to reinforce the vaginal walls and repair the structures.
Hysterectomy: Removal of the uterus may be part of the repair if the uterus is the main site of prolapse.
Vaginal or Abdominal Suspension: Attaching the prolapsed organ (e.g., the top of the vagina or cervix) to a strong ligament or bone in the pelvis to suspend it back up.

7. Multi-Disciplinary Assessment for Pelvic Organ Prolapse

It is vital to know that the weakness causing POP is frequently responsible for other related symptoms.

Urinary Incontinence (UI): Especially Stress Urinary Incontinence (SUI), which is leakage during effort (coughing, sneezing).
Faecal (Bowel) Incontinence (FI): Involuntary leakage of stool or gas.

These three conditions—POP, UI, and FI—are often referred to as Pelvic Floor Disorders (PFD) and frequently occur together. Treating one condition (e.g., surgically repairing the prolapse) may sometimes reveal or even worsen a previously hidden UI, or it may improve existing bowel or bladder function.

Because POP is complex and linked to bowel and bladder issues, a single specialist may not be able to offer the best, most comprehensive treatment.

The SGH Pelvic Floor Disorders Service brings together a team of specialists to look at your condition from all angles, including:

Urogynaecologists: Specialists in prolapse, female urinary issues, and surgical repair.
Colorectal Surgeons: Experts in faecal incontinence and rectal prolapse.
Women's Health Physiotherapists: Provide essential non-surgical muscle training and rehabilitation.
Other specialists (e.g., Urologists, Nurses): As needed for complete care.

This collaborative approach ensures you receive a personalized management plan that addresses all your pelvic floor symptoms, leading to a more effective and complete recovery.