Q: Dear Dr. Romanzi: What is vaginal prolapse and can Kegel phitness prevent it?

A: I’d like to answer this in two parts and with an edited excerpt from my book on incontinence and prolapse, titled: “Plumbing and Renovations“.

Pelvic organ, or vaginal, prolapse is an umbrella term for the different components of vaginal prolapse, including uterine prolapse, dropped bladder (cystocele) vaginal laxity (perineal body atrophy), rectocele and enterocele. Some women have a bit of each, others have only one or two components, but which ever and to whatever degree, pelvic organ prolapse is “a woman’s hernia”.

Normal Anatomy

Normal pelvic anatomy (shown here) is a harmony of bodily functions buttressed by the Kegel muscles of the Levator ani. The uterus drapes gently over the top of the bladder, and the bladder, vagina and rectum are separated from each other by thin, sturdy fibromuscular walls composed of collagen, skin cells and smooth muscle. These walls hold the rectum and bladder in place, and tend to weaken with childbearing and age. At the vaginal opening, below the level of the muscles, is the perineum, a connective tissue separator of the anus and vagina which tends to thin out with childbearing and age. Above the muscles we find the uterus, held in place by the uterosacral ligaments much as a chandelier is held up by strong cables. The female pelvic support system is considered in compartments when doctors are figuring out what is out of place and how best to amend the condition. The anterior compartment contains the bladder and urethra; the posterior compartment contains the rectum and anus, the basement is the perineum and the ceiling contains the uterus.

Cystocele (dropped bladder)

A cystocele is a dropped bladder, often noticed during sex or toileting as a balloon like bulge at the vaginal opening. This happens when the connective tissue between bladder and vagina wears out or pulls off of the sidewall of the pelvis, leaving only the vaginal skin to hold up the bladder, which is too elastic to do the job well, and so the bladder bulges down toward the vaginal opening.

A similar thinning of connective tissue can occur between rectum and vagina causing a rectocele. In this next illustration, we see a rectocele along with an absence of perineum connective tissue between the anus and vagina with a bulging of the vaginal opening.

Rectocele Perineal Descent (Vaginal Laxity)

Rectocele and perineum atrophy are often seen together, with symptoms of vaginal laxity, looseness during sex , a bearing down pelvic pressure with strenuous activity, and difficult defecation. In fact, many women with rectocele will press up on the perineum or backward on the vaginal wall toward the rectum during bowel movements to compensate for the bulging and make defecation easier. Doctors call this “splinting”. If you are doing this, you may have a rectocele or a thin perineum.

When the uterosacral ligaments stretch out, the uterus descends inside the vagina, and is often reported by patients as a firm mass at the vaginal opening, coming down either on the toilet or during strenuous activities like jogging or heavy lifting. This is uterine prolapse.

Uterine Prolapse

It is very common for women with uterine prolapse to report that the uterine slippage waxes and wanes, not there some days and very low and bothersome on others. It usually pulls back in when you lie down, and is often “in in the morning and out by the evening”. It is sometimes associated with a low back ache in the area of the tailbone.

Join me tomorrow for the second part of this discussion on prolapse, when I discuss the possibilities of why this happens and what, if any, effect Kegel exercises have on any of these conditions.