Pelvic organ prolapse: more common than you may realise

If you have found your way here, something brought you.

Maybe a dragging sensation that gets worse as the day goes on. Maybe something you can feel that was not there before. Maybe a moment in the shower, or after a long walk, where you realised something had changed. Maybe a clinician who mentioned the word prolapse and you have been quietly carrying it ever since.

Whatever brought you, you are not the only one. This is far more common than you have been told, and there is real, evidence-based help.

What is pelvic organ prolapse?

The organs in the female pelvis, the bladder, uterus and bowel, are held in place by ligaments, fascia and the pelvic floor muscles. When those support structures weaken or stretch, one or more of those organs can move down into the vagina. That descent is called pelvic organ prolapse, or POP.

It can be mild and unnoticed, or significant enough to be felt or seen. It often develops slowly, sometimes years after the events that contributed to it, which is part of why so many women find it confusing and isolating when symptoms appear.

The main types

It is common to have more than one type at the same time:

Prolapse is graded by stage, from 1 to 4, based on how far the descent has progressed. Stage and symptoms do not always match. Some women have significant prolapse on examination but few symptoms; others have considerable symptoms with a smaller anatomical change.

How common is it?

The lifetime risk of having pelvic floor surgery, for prolapse or incontinence, for women who have given birth is around 1 in 8 by age 80.

Despite all this, prolapse is often spoken about in whispers, if at all. Many women are told some version of this is just what happens after babies, or that is just age. Both dismiss something that is real, treatable, and worth taking seriously.

Why prolapse happens

Prolapse is rarely the result of a single cause. It is the cumulative effect of stress on the pelvic floor over time. The main contributors are:

Most women with prolapse have a combination of contributors. None of them are your fault.

Symptoms to look out for

• A feeling of heaviness, dragging, or fullness in the pelvis, often worse at the end of the day or after standing.
• A bulge or lump you can see or feel at or near the vaginal opening. People often say it feels like a ping pong ball inside, or like a tampon is lodged in the wrong place.
• Bladder symptoms: urgency, frequency, incomplete emptying, recurrent UTIs, stress incontinence, or the need to lift the bulge to start a wee.
• Bowel symptoms: incomplete emptying, having to splint, or constipation.
• Discomfort or a feeling of obstruction during sex, or loss of sensation.
• Low back or belly ache, particularly later in the day.
• Pelvic spasms in or around the genital and pelvic area or in the lower back.

Symptoms often fluctuate. Many women notice them worsen around their period, in perimenopause, after intense exercise, or after a long day on their feet.

The hormone and menopause connection

Oestrogen plays an important role in maintaining the strength and elasticity of the connective tissue that supports the pelvic organs, and in keeping the vaginal and urethral tissues plump and healthy. As oestrogen levels fall in perimenopause and menopause, the risk of experiencing pelvic organ prolapse increases and:

• Existing prolapse may become more symptomatic, even where the anatomical stage has not changed.
• Vaginal and urinary symptoms, including dryness, discomfort, urgency and recurrent UTIs, often appear alongside prolapse symptoms. This may be diagnosed as genitourinary syndrome of menopause.
• Tissues become more fragile and sometimes more vulnerable to irritation from pessaries.

NICE recommends considering vaginal oestrogen for women with pelvic organ prolapse and genitourinary symptoms and signs associated with menopause. It can be used as a cream, pessary, tablet or ring, and is different from systemic HRT.

The emotional reality

Prolapse is rarely just a physical experience. Many women describe:

• Shame, or a feeling that their body has failed them.
• Grief for the body they had before children, before menopause or before the prolapse.
• Anxiety about sex, or about being seen by a partner.
• Worry about exercise, or about which activities are now safe.
• Loneliness, because no one talks about it.
• Frustration at not being warned, in pregnancy, postnatally, or in perimenopause, that this could happen.

None of these reactions are dramatic or excessive. They are a normal response to a part of life that has been hidden, even though it affects a vast number of women. Talking about it, with a clinician, a therapist, a women's health physio, a friend or a peer group, is often the start of feeling less alone.

What helps

NICE and RCOG both recommend a stepped approach to prolapse, starting with the least invasive options:

When to seek help

You do not need to wait until things are unbearable. Early input from a specialist pelvic health physiotherapist gives the best outcomes for mild and moderate prolapse, and there is no benefit to suffering in silence.

• If symptoms are interfering with daily life, sleep, exercise, work, sex or wellbeing, that is reason enough.
• If something feels different and you do not know what it is, ask. You are entitled to a pelvic examination and a clear explanation.
• If you have been told nothing can be done, that is rarely true. Ask for a referral to a specialist pelvic health physiotherapist or a urogynaecology service.
• If you are postnatal, you can ask for a pelvic health assessment. Many UK areas now offer specialist postnatal pelvic health services.

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Frequently asked questions

Can pelvic organ prolapse be cured?

Mild prolapse often improves significantly with pelvic floor muscle training, lifestyle adjustments and, where relevant, vaginal oestrogen. More advanced prolapse may be managed with a pessary or, where needed, surgery. Treatment supports the pelvic organs and improves symptoms, but prolapse can return, particularly if the contributing factors are not addressed alongside it.

Can I still exercise?

Yes, and in most cases you should. Movement is good for the pelvic floor, but the type and how it is done matters. A pelvic health physiotherapist can help you modify exercise rather than avoid it. High-impact activity, heavy lifting and unsupported core work may need adapting, particularly in the early stages of treatment.

Will I need surgery?

Not necessarily. The first-line treatment for prolapse is usually conservative: pelvic floor muscle training, lifestyle changes, and a pessary or vaginal oestrogen if appropriate. Surgery is usually considered when conservative measures have not sufficiently relieved symptoms, or where prolapse is more advanced.

Does menopause make prolapse worse?

It can. Oestrogen helps maintain the strength of the connective tissue that supports the pelvic organs and the health of the vaginal and urethral tissues. As oestrogen declines, existing prolapse may become more symptomatic, and vaginal and urinary symptoms often appear alongside. Vaginal oestrogen can help where genitourinary symptoms are present.

Is it safe to have sex with prolapse?

In almost all cases, yes. Prolapse itself is not damaged by sex, although discomfort, dryness or a feeling of obstruction can affect how it feels. Vaginal oestrogen, lubricant, position changes and addressing pelvic floor function may all help. If you are using a pessary, your clinician can advise on whether it stays in or is removed.

Could I have prevented this?

No one is to blame for developing prolapse. It is the result of many contributors, some of which, like childbirth, genetics, ageing and menopause, are out of your control. Many others are affected by the lack of education available to women about how their pelvic floor works and how to protect it throughout life.

What can I do to protect my pelvic floor?

Pelvic floor training in pregnancy, postnatally and through life is protective, but it does not prevent every prolapse, and in some cases traditional kegels may not be the right starting point. A pelvic health physiotherapist can assess what your body needs, especially if you have pelvic pain, bowel issues, incontinence or painful sex.

Take what is useful. Leave what is not. Go gently with yourself. This is much more common than you probably think it is, and there is support available to help you.