Vaginal Prolapse: Symptoms, Types, Causes and Treatment

Vaginal prolapse, also known as pelvic organ prolapse (POP), is a common but often under-discussed condition that can significantly affect a woman’s quality of life. As the pelvic floor weakens, organs like the bladder, uterus, or rectum may descend, pressing into or outside of the vaginal canal. This article explores the symptoms, types, causes, and treatment options for vaginal prolapse, synthesizing the latest research to provide an accessible, evidence-based guide.

Symptoms of Vaginal Prolapse

Vaginal prolapse often develops gradually, and its symptoms can vary widely from person to person. Recognizing these symptoms is crucial for early intervention and effective management. While some women may experience noticeable discomfort or functional problems, others might have only mild or even no symptoms at all.

Symptom	Description	Prevalence/Severity	Sources
Vaginal Bulge	Sensation or visible bulging from the vagina	Most common symptom	3, 5, 8, 15
Pelvic Pressure	Feeling of heaviness or fullness in pelvis/vagina	Common, worsens with activity	3, 8, 15
Obstructed Defecation	Difficulty with bowel movements, need to splint	Associated with posterior prolapse	1, 12, 15
Urinary Dysfunction	Incontinence, urgency, or incomplete emptying	Can occur with any type	5, 15
Sexual Dysfunction	Pain, discomfort or decreased satisfaction	Variable, but impacts QoL	12, 15
Fecal Incontinence	Loss of bowel control (rare)	Less common	3, 1

Table 1: Key Symptoms

Vaginal Bulge and Pressure Sensation

The most characteristic and frequently reported symptom of vaginal prolapse is a sensation of a bulge or something "coming down" or protruding from the vagina. This may be visible or simply felt as pressure or fullness, often worsening when standing, lifting, or at the end of the day. Many women describe a feeling of “sitting on a ball” or report noticing tissue at the vaginal opening, especially after physical activity or straining 3, 5, 8, 15.

Bowel and Bladder Dysfunction

Depending on the type and severity, vaginal prolapse can cause significant bowel or bladder symptoms. Posterior vaginal wall prolapse is particularly linked to obstructed defecation: women may need to splint (apply pressure to the vaginal wall with a finger) to have a bowel movement, or may experience incomplete evacuation, straining, or constipation 1, 12. Urinary symptoms, including incontinence, urgency, and difficulty emptying the bladder, can occur with any type of prolapse but are especially common in anterior or apical forms 5, 15.

Sexual Dysfunction

Some women with vaginal prolapse report pain during intercourse (dyspareunia), decreased sexual satisfaction, or avoidance of intimacy due to embarrassment or discomfort 12, 15. However, the degree and type of sexual symptoms can vary widely.

Less Common Symptoms

Fecal incontinence is less common but can occur, especially in advanced posterior wall prolapse or vaginal cuff prolapse (post-hysterectomy) 1, 3. Notably, vaginal laxity is not considered an early symptom of prolapse and is rarely reported as the only symptom, even in women with significant prolapse 2.

Types of Vaginal Prolapse

Vaginal prolapse is not a single entity, but rather a spectrum of disorders depending on which pelvic organ descends and which part of the vaginal wall is affected. Understanding these types helps in both diagnosis and treatment planning.

Type	Affected Area/Organ	Key Features	Sources
Anterior Wall (Cystocele)	Bladder/vaginal front wall	Most common; bladder bulging	4, 8, 15
Posterior Wall (Rectocele/Enterocele)	Rectum or small bowel/back wall	Defecatory symptoms common	1, 5, 12, 15
Apical/Uterine Prolapse	Uterus/vaginal apex	Uterine descent or post-hysterectomy vault prolapse	9, 11, 13, 14, 15
Vaginal Cuff Prolapse	Top of vagina after hysterectomy	Pressure, bulge after uterus removal	3, 9, 13

Table 2: Types of Vaginal Prolapse

Anterior Vaginal Wall Prolapse (Cystocele)

The anterior wall prolapse, or cystocele, involves the bladder pushing against the front (anterior) vaginal wall. It is the most common form of POP. Women may notice a bulge, urinary symptoms, or recurrent urinary tract infections. Recent studies have shed light on the molecular mechanisms, including changes in the extracellular matrix and immune responses that weaken the vaginal wall 4, 8.

Posterior Vaginal Wall Prolapse (Rectocele, Enterocele)

Posterior wall prolapse occurs when the rectum (rectocele) or the small bowel (enterocele) protrudes into the back wall of the vagina. This type is particularly associated with bowel symptoms such as straining, the need to splint, or incomplete evacuation. Surgical repair often leads to significant improvement in these symptoms 1, 5, 12.

Apical Prolapse (Uterine or Vaginal Vault Prolapse)

Apical prolapse refers to descent of the uterus (uterine prolapse) or, after hysterectomy, the top of the vagina (vaginal vault). Uterine prolapse is common and may be treated by removing the uterus or by uterus-preserving approaches. Vaginal vault prolapse can occur after hysterectomy, especially if the supporting ligaments are not adequately reattached 9, 11, 13, 14.

Vaginal Cuff Prolapse

Unique to women who have had a hysterectomy, vaginal cuff prolapse occurs when the apex of the vagina loses support and descends. Symptoms often mirror those of other prolapse types—bulge, pressure—but may also include rare occurrences of fecal incontinence 3, 9, 13.

Causes of Vaginal Prolapse

Vaginal prolapse is multifactorial, involving both lifestyle and biological contributors. Understanding the underlying causes can help in both prevention and management.

Cause	Mechanism/Details	Risk Factors	Sources
Childbirth Trauma	Injury to pelvic muscles, fascia, nerves	Vaginal delivery, forceps use	8, 10, 15
Aging & Menopause	Loss of estrogen, tissue atrophy	Older age, postmenopausal	2, 10, 15
Connective Tissue Changes	Collagen/elastin degeneration	Family history, genetic factors	4, 7, 10
Increased Intra-abdominal Pressure	Chronic cough, constipation, obesity	Smoking, respiratory disease	8, 10, 15
Surgery/Hysterectomy	Loss of ligament support	Post-hysterectomy, vault prolapse	9, 10
Microecological Changes	Disruption of vaginal microbiome	Infection, pH imbalance	7

Table 3: Causes of Vaginal Prolapse

Childbirth and Trauma

The most significant risk factor for vaginal prolapse is vaginal childbirth. The stretching and tearing of muscles, ligaments, and nerves during delivery—especially with forceps or large babies—can compromise pelvic support. Repeated pregnancies and deliveries increase the risk 8, 10, 15.

Aging and Hormonal Changes

With age and the hormonal changes of menopause, pelvic tissues lose elasticity and strength. Reduced estrogen leads to atrophy and thinning of the pelvic floor, making prolapse more likely in postmenopausal women 2, 10, 15.

Connective Tissue and Genetic Factors

Some women have a genetic predisposition to weaker connective tissue, leading to early or more severe prolapse. Alterations in collagen and elastin, as well as changes in extracellular matrix metabolism and immune responses, have been implicated 4, 7, 10.

Increased Intra-abdominal Pressure

Chronic conditions that increase abdominal pressure—such as persistent coughing, obesity, constipation, and physical labor—strain the pelvic floor and accelerate tissue breakdown 8, 10, 15.

Surgical Causes

Hysterectomy, especially when the supporting ligaments are not properly reattached, can lead to vaginal cuff or vault prolapse. Post-surgical weakness of the apex of the vagina is a recognized cause 9, 10.

Microecological and Metabolic Changes

Emerging research suggests that changes in the vaginal microbiome and pH can impact pelvic tissue health and collagen metabolism, potentially influencing prolapse risk. This is a developing field that may offer future non-surgical prevention or treatment strategies 7.

Treatment of Vaginal Prolapse

Treatment for vaginal prolapse is highly individualized, ranging from conservative approaches to surgical intervention. The best approach depends on symptom severity, prolapse type, patient preference, and overall health.

Treatment	Description	Indications	Sources
Observation	Watchful waiting, monitoring	Mild/asymptomatic	15
Pelvic Floor Therapy	Exercises, physical therapy	Mild/moderate, prevention	12, 15
Pessary	Removable device for support	Non-surgical, all stages	15
Surgery	Repair, suspension, or mesh procedures	Severe/symptomatic, failed conservative	6, 11, 12, 13, 14, 15
Microecological Therapy	Probiotic or microbiome-targeted therapies (experimental)	Research, adjunctive	7

Table 4: Treatment Options

Conservative Management

Observation

For women with mild or no symptoms, observation is safe and reasonable. Regular follow-up ensures that any progression is detected early 15.

Pelvic Floor Muscle Training

Targeted exercises (Kegels) and physical therapy can strengthen the pelvic floor, providing symptomatic relief and sometimes reversing mild prolapse. These are first-line for mild to moderate prolapse and for prevention 12, 15.

Pessary Use

A pessary is a removable silicone device inserted into the vagina to provide structural support for prolapsed organs. Pessaries are effective for women who wish to avoid surgery or are not surgical candidates. They are available in various shapes and sizes and can be fitted in the office 15.

Surgical Management

When conservative measures fail or symptoms are severe, surgery may be indicated. Surgical options vary depending on the type and severity of prolapse, and patient sex life or fertility goals.

Anterior and Posterior Wall Repairs

• Native tissue repair involves suturing the patient’s own tissues to reinforce the vaginal walls. It is effective but carries a risk of recurrence 5, 12, 15.
• Use of mesh or grafts in repairs has been debated; current evidence does not support routine use of synthetic mesh for most vaginal repairs due to higher complication rates 6, 11, 12.
• For posterior wall (rectocele) repairs, transvaginal approaches are favored over transanal repairs due to better outcomes and lower risk of recurrence 12, 1.

Apical Prolapse and Uterine/Vault Suspension

• Vaginal hysterectomy (removal of the uterus) remains the standard for uterine prolapse, often with suspension of the vaginal cuff 14.
• Uterus-preserving procedures (e.g., sacrospinous hysteropexy) are increasingly popular but may have higher recurrence rates 14.
• Sacrocolpopexy (suspending the vaginal apex to the sacrum using mesh via an abdominal or laparoscopic approach) offers the best long-term anatomical results and patient satisfaction, especially for vault prolapse after hysterectomy 6, 11, 13.
• Obliterative procedures (e.g., colpocleisis) close off the vaginal canal entirely and are reserved for women who no longer desire vaginal intercourse 6.

Surgical Decision-Making

Choice of surgery should be tailored to the individual, weighing durability, risk of recurrence, sexual function, and personal preferences. Shared decision-making and preoperative counseling are essential 6, 11, 15.

Emerging and Adjunctive Therapies

Research is ongoing into therapies targeting the vaginal microenvironment, such as probiotics or interventions aimed at restoring healthy collagen metabolism. These are not yet standard of care but represent promising avenues for the future 7.

Conclusion

Vaginal prolapse is a complex condition with diverse symptoms, causes, and management strategies. Early recognition and individualized care are key to improving outcomes and quality of life.

Main Points Covered:

• Symptoms include vaginal bulge, pelvic pressure, bowel and urinary dysfunction, and, less commonly, sexual dysfunction or fecal incontinence.
• Types are classified by the affected compartment: anterior (bladder/cystocele), posterior (rectocele/enterocele), apical (uterine/vault), and vaginal cuff prolapse.
• Causes are multifactorial: childbirth trauma, aging, genetic tissue weakness, increased intra-abdominal pressure, prior surgery, and possibly microecological changes.
• Treatment ranges from observation and pelvic floor exercises to pessary use and a variety of surgical repairs; choice depends on symptom severity, type of prolapse, and patient goals.
• Surgery can be highly effective but requires careful matching to patient needs, with sacrocolpopexy often offering the best outcomes for apical prolapse.

For those experiencing symptoms of vaginal prolapse, early consultation with a healthcare provider can help tailor a management approach that fits individual needs and lifestyle.