Question: I have a two-year-old son and recently went for my smear test. At the test the doctor told me I had vaginal prolapse. I didn’t ask her about it at the time and now I wonder if I need to do anything about it. I haven’t noticed anything myself. What is this and what should I do about it?
Dr Grant replies: As you do not have any symptoms, and are feeling well, there is no need to do anything for now. Many women with prolapse are asymptomatic and treatment is generally not indicated in these women. The common complaint heard from patients is generally ‘a feeling or sensation of fullness/bulge/pressure in the vagina’ or ‘something coming down the vagina.’ I am guessing that you had a normal vaginal birth with your two-year-old son.
During your smear test, I assume your doctor thought the appearance of your cervix was slightly lower in the vaginal vault than is typically seen during smear taking.
The medical terminology for this is Pelvic Organ Prolapse (POP), meaning there is some degree of herniation of the pelvic organs into, or sometimes even beyond, the vaginal walls. There are a few different types of POP but most likely your doctor saw some apical compartment descent. The apex can be either the uterus and cervix, cervix alone, or vaginal vault. The apex descends (or prolapses) into the lower vagina, to the hymen, or beyond the vaginal introitus (entrance).
Pelvic Floor Dysfunction (PFD) is an umbrella term that describes POP, urinary incontinence, anal incontinence and sexual dysfunction (or any combination). Often some form of POP co-exists with urinary incontinence.
Reportedly, one in three women suffer with PFD following three vaginal births. The pelvic floor consists of a group of muscles with two distinct layers that act a bit like a shelf to hold the pelvic organs in their correct position. After carrying a baby for nine months and giving birth these muscles can become over-stretched causing them to become a little bit thinner and weaker. If you have never had a baby, the natural ageing process, a tendency towards chronic constipation, obesity and the menopause can all exacerbate underlying problems with the pelvic floor.
Other risk factors for POP include a family history, underlying congenital anomalies, some connective tissue disorders, (e.g. Ehlers-Danlos syndrome).
Although the risk of POP increases with the number of vaginal childbirths, it is unclear whether or not, delivery by Caesarean section will prevent the occurrence of prolapse. This may very well be because methods to prevent the progression of prolapse has not been well studied. Treatment is generally indicated for women with symptoms of prolapse or associated conditions (urinary, bowel, or sexual dysfunction). On a positive note, some studies have demonstrated spontaneous regression of the earlier stages of POP in up to 10pc of women.
Non-surgical treatment options for POP include pelvic floor muscle training and the vaginal pessary. A specialist physiotherapist can help train you to work on your pelvic floor by explaining how to do kegel exercises, providing a pelvic floor stimulator or biofeedback device to help control and monitor your muscle contractions. Interestingly, they often see patients with pelvic floor muscles that are over-active or too tense and a different type of training is needed for these patients. When performed regularly and correctly muscle training can be very effective.
Surgical options include natural slings or vaginal suspension procedures. Should you need vaginal suspension surgery, the good news is it’s a short procedure and has over 92pc success rate. Surgical intervention is advised only when your family is complete.
Dr Jennifer Grant is a GP with Beacon HealthCheck