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  • Writer's pictureAdam May

Recognizing Your Postreproductive Problem Part 2: Pelvic Prolapse

Bulging, Dropping, and Falling Down Bellow

"I'm falling apart... literally!" said Joanne, a sixty-one-year-old fourth-grade teacher, tossing her hands up the air.

Joanne was a mother of three grown children, two delivered vaginally and the third by cesarean as a result of her baby's slow heartbeat during labor. Joanne's vaginal deliveries had been induced after their due dates, and both babies weighed over eight pounds at birth. During her first labor, she contracted for fifteen hours and pushed for over three. Her second labor and delivery were a breeze, under three hours from start to finish. She hadn't noticed any incontinence problems in the first several years after childbirth, though she struggled with constipation, and her urinary stream seemed weaker. At age forty-three, she underwent a total hysterectomy for small fibroids (benign tumors) of the uterus, which had been causing very heavy and painful periods.

Nine months later, the real problems began. She began noticing heaviness in her pelvis and lower back, and vaginal pressure after a long workday. Before long, the feeling became more constant. Though she'd never had bowel troubles before, now she needed to strain on the toilet, with a feeling that she could never fully evacuate her stool. Even more disturbing was the fact that she was soiling her underwear, despite all her efforts to keep herself meticulously clean.

"It feels like everything's gone loose down there. I don't even feel much during intercourse anymore."

Six months before our visit, while she and her husband were seeing their youngest son off to college and helping him to move boxes and furniture into the dormitory room, she had first noticed a bulging of tissue at the vaginal opening, "like a ball." Somewhat panicked, Joanne told nobody but quietly started to withdraw from her social routine. She had given up her regular early-morning walk and Saturday golf game for half a year by the time she walked into my office one October afternoon.

The only reason she'd finally come was that during her annual checkup, her internist had told her that her vagina or bladder had dropped, and had sent her to our office for further evaluation. "That sounds pretty bad," she said, with a look that made it clear she'd been agonizing over the meaning of this change, and assuming the worst about her prognosis.

"I'm a healthy person. Why did this happen to me?"

Pelvic prolapse (genital prolapse) refers to loss of support within one or more of the key pelvic structures, including the uterus, vagina, bladder, and rectum. Prolapse can lead to a wide spectrum of potential symptoms, sometimes right after childbirth but more often several years later.

For some women, it starts with simple difficulty retaining a tampon; for others, it's gradually increasing discomfort in the vagina, pelvis, abdomen, or lower back. Perhaps you've noticed some vaginal pressure at the day's end, or increasing difficulty moving your bowels despite a healthy diet and stool softeners. You may have felt pain or uncomfortable pressure during intercourse, or diminished sexual pleasure that you'd assumed was a cooling of your previously torrid sex drive but in fact was due to a specific anatomical change. Urinary symptoms accompanying prolapse may include incontinence, a weakened stream, or a sense of bladder fullness even after you've finished voiding.

Perhaps you've noticed what is often the most alarming symptom: a bulge of tissue seen or felt at the vaginal opening, anywhere from the size of a plum to an orange, or even much larger. Unfortunately, it's often not until reaching this advanced stage of prolapse that many women finally acknowledge they have a problem and seek advice.

If all of this sounds surprisingly familiar, you're not alone this problem is shared by many of your otherwise healthy friends.

After learning a bit about the nature of pelvic prolapse in upcoming posts, you'll feel relieved to understand that no, you're not falling apart at the seams, and yes, there are many ways for you to start feeling better and prevent your problem from getting worse. But right now let's briefly review the most common prolapse types.


A cystocele is often referred to as a dropped bladder, and it is one of the most common prolapse bulges among postreproductive women. A cystocele forms when the normally flat upper vaginal wall loses its support and sinks downward. This allows the bladder, which is located right above the upper vaginal wall, to drop right along with it. When a cystocele becomes advanced, the bulge may become visible outside the vaginal opening. The visible tissue is the weakened vaginal wall; the bladder is right behind this skin but cannot be seen.

The symptoms caused by cystoceles can include:

  • vaginal bulging or pressure

  • slowing of the urinary stream

  • overactive-bladder symptoms

  • an inability to fully empty the bladder


A rectocele is the mirror image of a cystocele. Cystoceles result from a weak upper vaginal wall, allowing the bladder to bulge downward, while rectoceles result from a weak lower vaginal wall, allowing the rectum to bulge upward. This creates an extra pouch in the normally straight rectal tube. Rectoceles cause symptoms related to incomplete emptying of the rectum, just like cystoceles cause incomplete emptying of the bladder. But unlike cystoceles, which tend to cause few symptoms until they become quite large, rectoceles often cause symptoms in their early stages.

Even a rectocele bulge that cannot be visualized at the vaginal opening may cause:

  • difficulty with bowel movements-including the need to strain more forcefully

  • a feeling of rectal fullness even after a bowel movement

  • increased fecal soiling

  • in some cases, incontinence of stool or gas

Those symptoms result from stool and air remaining within the rectocele pouch even after defecation, in contrast to the normal rectum, which fully empties. Larger rectoceles can bulge right through the vaginal opening and look like a cystocele, although this time it is the lower vaginal wall accounting for the bulge.


Uterine prolapse, or a dropped womb, occurs when the uterus and cervix fall into the vagina after their supporting pelvic ligaments have weakened. If the uterus drops only slightly, it may cause mild pressure in the vagina or rectum, or even lower back pain. If the uterus drops a lot, you may see the cervix itself outside the vaginal opening, or feel discomfort with intercourse. Sometimes recognizing uterine prolapse is easy you see the cervix protruding, or feel a firm bulge of tissue inside while inserting a tampon. But most of the time, your doctor makes the diagnosis during the office exam.


If you’ve already had a hysterectomy, the top of the vagina (called the vault or apex) should be attached to supportive ligaments on either side of the pelvis. These attachments prevent the top of the vagina from bulging outward beneath the constant pressure of the abdominal contents. However, if these attachments weaken and the vaginal apex drops, a bulge may form near the vaginal opening. This is called vaginal vault prolapse, a condition that happens only to women who have had a hysterectomy, and one that can cause severe pressure and bulging symptoms. Similar to cystoceles, rectoceles, and uterine prolapse, some cases of vaginal vault prolapse can be managed with simple devices; surgical repair is also common and can be performed by a number of vaginal, abdominal, and even laparoscopic techniques.


When the intestines bulge downward into the upper vagina, then you have an enterocele. It’s the last of the postreproductive pelvic bulges you should know about, and the most difficult to conceptualize.

Among all types of female prolapse, enteroceles share the most similarity with the hernias that can develop in the abdominal and groin areas of both women and men: both involve bulging of the intestines into weakened supports nearby. In a man, hernias bulge through the abdominal wall; in a woman, enteroceles bulge into the top of the vagina. The symptoms are often vague, including a bearing-down pressure in the pelvis and vagina, and perhaps a lower backache. They often exist alongside vaginal vault prolapse in women who have had a hysterectomy. “BUT I NEVER HAD A VAGINAL DELIVERY!” Significant numbers of women with prolapse, incontinence, and other pelvic-floor problems have never delivered vaginally. How could this be? First, the weight of a pregnant uterus may itself cause important changes over the course of nine months, even without a vaginal birth. Second, everyone’s tissues vary in strength and resiliency. You’ll find women who’ve had eight deliveries and no loss of bladder control, and others with major incontinence and prolapse after only one tiny baby. A recent survey of more than three thousand South Australians found that having a cesarean did not offer full protection against the silent epidemic of prolapse and incontinence. Each woman’s body responds differently to the stresses of pregnancy and delivery.


If you’ve been bothered by some loss of control over your stool or gas, chances are you’ve never mentioned it to your doctor. Neglected by physicians who rarely address this issue with their patients, and endured by patients feeling too embarrassed to mention it, anal incontinence remains underdiagnosed. In a world where almost all of our other problems are now openly discussed, including urinary incontinence, anal incontinence has been left behind as perhaps the most stigmatized postreproductive disorder, still an unspeakable problem. But the problem does exist among otherwise healthy women after childbirth—it’s reported in some form by 20 to 59 percent— though sometimes not arising until many years later. At any age, it can be among the most disabling of all disorders to cope with; accidents are difficult to mask and, of course, humiliating. Few conditions in gynecology cause as much personal and social distress. What is anal incontinence? For many women, it means the inability to avoid passing gas in public. For other women, it means the accidental loss of stools. And for others, it’s soiling of underwear despite careful hygiene. Not all cases of anal incontinence are caused in the labor room, but childbirth injury is the most common factor. Your risk for anal injury and incontinence is influenced by a number of specific obstetrical events and procedures, including forceps and vacuum delivery, episiotomies, and pushing style.


A 2001 Harvard study found that six months after childbirth, roughly one quarter of women experience diminished sexual function after a first vaginal birth. Other studies have indicated higher rates following forceps or vacuum delivery. When these changes occur right after childbirth and then resolve, the reasons are most often perfectly normal. Even the most routine changes—such as weight gain, changes to your body shape, and stretch marks—can give rise to self-image issues, which in turn can affect intimacy between partners. Normal breast-feeding can cause dryness and irritability of the vaginal skin because of decreased estrogen levels, which leads to sexual discomfort that fully reverses later on. Normal perineal healing, be it after an episiotomy or spontaneous laceration, can cause tenderness for weeks and sensitivity for months. And the normal transition to parenthood can drastically reduce the time and effort that two partners will devote to keeping the flame of their romance aglow. But sometimes postreproductive sexual problems are not part of a normal transition and don’t go away after the postpartum period ends.

Too often, women shrug them off as an inevitable aspect of their new body, unaware of not only the physical changes accounting for the problem but also of the preventive strategies and effective treatments.

Changes to the vagina or perineum 

Perineal injuries can increase the risk of sexual pain after childbirth but can be preventable. Widening of the vaginal entrance, due to stretch and separation of the perineal muscles and supports, is actually a very common anatomic change after childbirth. For most women, it poses no problem. But for some, the vagina becomes extremely lax, and intercourse is simply not enjoyable in the same way for either partner. Many women who have noticed this problem are reluctant to tell their doctor, but there are effective solutions.

Sexual effects of incontinence and prolapse 

Hormonal changes, decreased libido, and diminished sensation


So there you are. You’ve identified some of the issues that seem to have come with the territory of your postreproductive body. You’ve learned that they aren’t nearly as unusual as you thought. But how did it all sneak up on you? Whether you’re preparing for childbirth or looking back on its aftermath, you’ve probably never stopped to consider how this defining life event might affect your body and physical function long afterward.

In our next post, we'll aim our microscope at pregnancy and childbirth and make the connection between these postreproductive problems and the physical events of pregnancy and labor that first triggered them, sometimes many years earlier. As you begin to better understand the cause of your postreproductive problems, you’ll be closer to the cure.

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