• International Urogynaecological Association (IUGA) has lots of great patient information around surgery. A full list of their information sheets can be found here.

  • Pelvic Organ Prolapse

  • Pessaries

• Wellington Hospital also has a patient information sheet about pessaries

A prolapse is when part of the vagina loses the support it should have and starts to protrude outwards. The bladder sits directly in front, the uterus (and cervix) sit directly above, and the bowel/rectum sits directly behind the vagina - any of these three structures (often more than one) can be pushing on the walls of the vagina and contributing to the prolapse.

The vagina has lots of structures that support against prolapse; broadly speaking there are three key areas:

• Deep support at the level of the cervix and uterus made of strong ligaments

• Middle support with connective tissue that supports the walls of the vagina and provide a barrier between the vagina and surrounding structures (bladder in front and rectum behind)

• Pelvic floor and perineal muscles that provide a muscular layer of support to the lower vagina

Damage can happen to one or more of these layers. Common contributing factors are pregnancy and childbirth (especially if forceps are used, or there are large tears), excessive strain due to heavy lifting, obesity or chronic cough, and general weakening of the tissues with age, especially after menopause (as oestrogen levels drop, and oestrogen increases the blood supply and general health of these tissues).

Prolapse is very common, and can range from causing no symptoms to very severe symptoms that impact on every day life. The goal of treating prolapse is to improve quality of life and to specifically address the symptoms that are having the most impact. Common symptoms include:

• Feeling of a bulge coming from the vagina; often not painful but very unpleasant

• Urinary incontinence, or difficulty passing urine

• Difficulty moving the bowels, in severe cases a need to manually put pressure on the prolapse to allow the bowels to empty

• Sexual difficulties

There are generally three avenues for treatment of a prolapse: conservative management; pessaries; and surgery. The conservative measures are recommended for anyone with a prolapse, including if they choose to use pessaries or have surgery.

Conservative Management

This involves measures to avoid anything making the prolapse worse as well as strengthening the pelvic floor, and oestrogen supplementation (usually as a vaginal cream) for post-menopausal women. These measures alone can give a good improvement in symptoms for some patients.

Avoiding things that make the prolapse worse include:

• Avoiding heavy lifting (which may be difficult for people who do heavy lifting as part of their work, or as part of their hobbies; but often for these people avoiding heavy lifting will be a key factor in preventing the prolapse getting worse regardless of what other treatment options are used)

• Avoiding constipation - this may include dietary changes (more water, more fibre, fibre supplements) and laxatives

• Managing chronic cough - avoiding medications that might contribute to cough, making sure asthma or COPD is well managed

• Weight loss - Obesity increases the risk of prolapse, and weight loss alone can improve symptoms for many people if overweight

Strengthening the pelvic floor is done with Kegel exercises and pelvic physiotherapy. Pelvic physiotherapists will do a full assessment of the pelvic floor and look at how bowel and bladder function can be improved.

Oestrogen is usually given with Ovestin cream vaginally. Ovestin is also available as "pessaries" (not the same as the pessary used to treat the prolapse, but confusingly given the name) - these are small capsules that are placed in the vagina. The Oestrogen used for Menopausal Hormone Therapy (also known as Hormone Replacement Therapy - HRT) including tablets or patches can also be used for this purpose. Oestrogen increases the blood supply to the tissues around the vagina, which makes them stronger and less susceptible to damage.

Pessaries are small devices that sit in the vagina to help support the vagina in its normal position, and prevent the prolapse from coming down. The most common type of pessary is a ring that is made from silicone or a similar material. There is a huge variety of sizes and types of pessaries, and these depend on the anatomy of the vagina and prolapse as to which is most appropriate. It may take some trial and error to find the best pessary - if the pessary is too small it may fall out, if it is too large it can be uncomfortable. Some pessaries specifically address different components of the prolapse.

Once a pessary is in, it should not be noticeable or cause any discomfort. It should improve symptoms. If it is uncomfortable or painful, or protruding out it may need to be changed to a different size or type.

While a pessary is in, oestrogen cream (Ovestin) should be used twice weekly. One of the risks of a pessary is the development of irritation of the skin inside the vagina (erosions) due to the pessary. Oestrogen cream reduces the risk of this. Erosions can cause bleeding or discharge that may have a strong odour. These symptoms should prompt a review with your doctor. When a pessary is in use, it is recommended to have a check every 6-12 months, where the pessary is removed and a speculum examination is performed to check for erosions. If erosions are found, usually the pessary needs to be removed for at least two weeks to allow the erosions to heal, sometimes antibiotics are needed if there are signs of infection.

Some people are very comfortable removing and replacing pessaries themselves; others prefer to leave the pessary in at all times. Removing and replacing the pessary yourself is a relatively simple thing to learn, but can be tricky the first few times. For most pessary types it is possible to have sex without removing the pessary, although some people will prefer to remove it.

See our prolapse surgery page for more information.