My Female Organs Are Falling Down

© 2009 WebMD, LLC. All rights reserved.

Have you ever looked "down there" with a mirror (or had a lover say to you) that there seemed to be a "bulge" or "ball of tissue" at the vaginal opening? The medical name for this condition is pelvic organ prolapse (POP). POP is purported to effect up to 50% of women who have had a vaginal delivery (Maher, 2008). In other studies of women in general, rates of POP with marked symptoms are reported to be 3.6 - 6%.

The first concern is that one's uterus, or other pelvic parts, might be falling out. In one of the more severe forms of POP the uterus can drop so far down into the vaginal canal that the cervix will scrape against the woman's underpants! Fortunately this is one of the least common forms of POP. So if you were to see a "bulge" of tissue what is that likely to mean to you? The goal of this blog is to share facts about the types of POP, the risk factors, and what treatment options you might have if POP seems to be linked to other, bothersome symptoms.

How do I know what type of prolapse I have?
When you go see your GYN or clinic you might expect questions about: urinary or bowel incontinence, difficulty emptying the rectum, or sexual problems. This can suggest areas which are involved with the "bulge". An exam should be done with you standing and/or bearing down when you are on the exam table. If loss of urine is a concurrent problem then a urinalysis may be done along with a Q-tip test and/or a measure of urine left in the bladder after you have go to the bathroom.

There are several types of prolapses. When the upper part of the vaginal canal loses its muscle tone or attachments holding the vagina up (especially common among women with hysterectomies) that is called vaginal prolapse. If muscle support is poor, or interrupted, the bladder can prolapse down through the "roof" of the vagina causing a cystocele. The urethra may drop down as well (urethrocele). If the weakness is in the "floor" of the vagina the rectum can bulge upward. As was mentioned above, the uterus and cervix can slump down through the vaginal canal.

What are the risk factors for pelvic prolapse?
The most consistently cited risk factors are: increasing age, being overweight, and increased number of vaginal deliveries. Number of deliveries by C-section does not increase prolapse risk (Luckacz, 2006). Other associated factors can include irritable bowel syndrome, constipation, and overall poor health (Rortveit, 2007). African American women are less likely to have symptomatic pelvic prolapse (Rortveit, 2007). One small study even found that having a history of stretch marks doubled one's risk for prolapse (Salter, 2006).

"Stretch marks," you might be thinking "why would that be?" The bones of the female pelvis do a great job protecting lower abdominal contents, but they do not provide support. The pelvic organs are supported by the muscles in the pelvic floor and the ligaments which can attach from the organs to the bones. It has been theorized that pelvic muscle and ligament strength may be linked to strength of collagen. Collagen, along with fibrillin, is decreased in women with stretch marks (Mitts,2005).

What can be done if I have a mild form of prolapse, or do not want to have surgery?
According to the American College of Obstetrics and Gynecology (ACOG, 2007): "Pessaries can be fitted in most women with prolapse, regardless of prolapse stage or site of predominant prolapse." A pessary is a doughnut shaped device which can be made of various materials. There are also pessaries shaped like a cube, and similar to a shoe horn. If one has ever used a diaphragm for birth control, inserting and removing a pessary may seem familiar. Like a diaphragm, a pessary should be fit by a GYN as they come in different sizes.

Kegel exercises have been recommended for POP but, unlike urinary stress incontinence, there are few large studies demonstrating the effectiveness of Kegels. According to one recent study of 48 women, pelvic floor exercise/Kegels significantly improved symptoms of prolapse (Hagen, 2009). Kegels may not be as successful as they are with urinary incontinence for once the attachment ligaments are damaged, strengthening the pelvic muscles may not fix the prolapse.

What about surgery?
If one has a prolapse of the uterus, hysterectomy may be suggested. Care is taken to refasten the top of the vaginal canal to other structures so it does not droop down after the hysterectomy.

If the prolapse is coming from the top or "roof "of the vagina, pelvic fascia tissue can be used to bridge the weak area. If the prolapse is coming from the lower or "floor" of the vagina (causing a bulging of the rectum into the vaginal canal), the rectal muscles can be used to close the defect.

More recently synthetic mesh has been used to support the weakened areas. Mesh has been used extensively for repair of abdominal hernias. Overall, the use of mesh seems to decrease the reoccurrence of cystocele when an anterior ("top") of the vagina repair is done (Maher, 2008). The primary concern for mesh is that long term follow up in large numbers of POP women is lacking. Cases of the mesh eroding through vaginal tissues have been reported (Altman, 2007). By October of 2008 the FDA released a notification to GYN surgeons relating adverse events connected to mesh use as reported by manufacturers of different types of mesh. Some of these unwanted events included erosion, infection, and pain. Not surprisingly, the strength and health of the woman's own tissues will have an impact. Her own tissues will have to be incorporated into the mesh to form a strong bond.

In one study of 2,460 of women in their 50's, about 3% of women reported having surgery for POP (Fritel, 2009). Further, women who had such symptoms of POP as problems having a bowel movement or urinating, and abdominal pain reported a much lower quality of life than other women. In one very large study (Barber, 2009), 85% of women considered themselves "much better" when compared to before their surgery. Bottom line, surgery of some type can be very helpful if a woman has symptoms from her prolapse.

My mom and her sisters had prolapse; can I do anything to prevent it happening to me?
We cannot change our genetics, age, or number of vaginal births! Sadly there are not many scientific studies testing different forms of POP prevention. The strategies for prevention that are most often suggested include:

• Kegel exercises up to four times daily. The hope is that by strengthening muscles in the pelvic floor that those muscles can help delay, or reduce, the onset of prolapse. For information about how to do Kegels correctly check out this article: Kegel Exercises - Topic Overview


• Physical exercise. Regular exercise can help keep one's body weight down, and being overweight is linked to prolapse. Exercise is also reputed to keep muscles and ligaments more flexible.


• Decrease straining to have a bowel movement. Constipation, or having to bear down, increases pressure in the abdomen which "pushes down" on pelvic organs. Eating a healthy diet with whole grains, fruits, and vegetable not only helps constipation, but can improve body weight.


• Treat chronic coughs. If one is a smoker - quit. If there is another reason for a chronic cough - have it treated. A cough increases the pressure inside the abdomen which can "push down" on pelvic organs. There are studies linking smoking with poorer tissue integrity after POP repair (Araco, 2009).


• Use a correct technique for heavy lifting. Straining to lift increases pressure within the abdomen. Here is a good over view of safe lifting: Back Problems - Proper Lifting


• Hysterectomy surgery considerations. If one is having a hysterectomy there are studies which suggest that attaching the uterine ligaments to the top of the vagina may help to keep the vagina from dropping down (Yazdany, 2008).

If you would like more information about pelvic prolapse, consider checking these articles:

• Repair of Vaginal Wall Prolapse (Vaginal Vault Prolapse)
• Pelvic Organ Prolapse

Related Topics:

• GYN Issues with Jane Harrison-Hohner, RN, RNP
• Get the Women's Health newsletter in your inbox weekly

Can A Vagina Be Too Big?

Faithful readers of this blog may remember that Masters and Johnson examined the vaginal sizes of 100 women who had never been pregnant. These women showed an un-stimulated vaginal length of 2 ¾-3 ¼ inches , with a ¾ inch width at the back of the vagina. During the sexual excitement phase the vaginal lengths increased to 3 ¾- 5 ¾ inches, with the width at the back of the vagina being 2 ¼-2 ½ inches. This correlates with our most common diaphragm sizes which are between 2 ½ -3 ½ inches in length.

"But I'm not worried about vaginal length," you might be thinking. "My problem is that I think my vagina is too loose - or too wide. Is that possible? If so what can I do?" Let's examine some of the medical data available to answer these questions.

Is my vagina too loose?
The vagina is like a collapsed, expandable tube lined with skin; the tissue below the skin is loose and contains large veins. Next are smaller circular muscles surrounded by stronger bands of muscle which run the length of the vagina. In addition, the lower third of the vagina is surrounded by a ring of muscles. This is covered by more connective tissue and blood vessels. Damage to these muscles, or if they become thin and weak, can allow the bladder ("cytocele") or rectum ("rectocele") to pouch into the vagina. Thus you can understand the importance of strong vaginal muscles. The ring of muscles around the vaginal opening contract during orgasm and may contribute to the intensity of an orgasm.

So what is too loose? This can be a matter of opinion based upon the input of a sexual partner, or one's observations of vaginal tone. Researchers have devised some ways to measure vaginal tone such as a pressure sensitive intravaginal balloon device, and ultrasound measurements of vaginal area ("pelvic floor") muscle thickness. A study of 30 women aged 20-42 found that better developed vaginal muscles were linked to having orgasms, and getting physical exercise. Conversely, increased age and having been pregnant were linked to decreased strength of vaginal muscles (McKey and Dougherty 1986).

A more recent study using ultrasound measurements (Bernstein,1997) found similar connections. Muscle thickness decreases with age, especially in women older than 60. Women with urinary incontinence had thinner pelvic floor muscles than women who were not incontinent.

Will exercising the vaginal muscles make my vagina tighter?
Two ultrasound studies of women who exercised their vaginal muscles did find that their muscles were thicker and stronger after pelvic floor muscle training. Among women with urine leakage, their thinner muscles became the thickness of healthy women's pelvic floor muscles. Additionally, they had less urine leakage - whether the problem was from stress or urge types of incontinence. The use of vaginal cones and/or Kegel exercises to increase muscle strength were both found to improve tone and decrease urine loss. While some of these studies did not measure vaginal tightness per se, when muscle bulk is increased, a woman can voluntarily contract those muscles to make the vaginal opening tighter.

Do tighter vaginal muscles really improve sexual response?
Despite the fact that most every discussion of Kegel exercises includes improved sex, there are not many scientific studies to back up this claim. One recent publication (Dean, 2008) reported on sexual function and pelvic muscle factors for some 2,800 women. Women who delivered only by Caesarean section (and their partners) perceived they had better vaginal tone leading to improved sexual satisfaction. Women who were currently doing pelvic muscle exercises scored much better on sexual satisfaction questions than women who did not. Women with incontinence (probably thinner muscles) scored the worst on the sex questions.

I've tried Kegel exercises but they don't work for me.
Assuming that the Kegel exercises have been done correctly, it may be time to move to other options. One low tech choice is weighted vaginal cones. This is a set of weights, shaped more like a tampon than a cone, where one inserts the lightest version then uses the vaginal muscles to hold it up inside. This is done twice daily. When this is easy the next heaviest cone is used - and so on. This is to be done while going about normal activities so that gravity provides an additional challenge to keeping the weight up inside.

More technology is involved in the electrical stimulator. A tampon shaped probe is inserted in the vagina and small electric shocks cause the muscles to contract then relax. This is done about 20 minutes up to several times a week. One patient of mine who used this device found it sexually pleasurable.

Less commonly used may be the "magnetic chair" ("Neocontrol"). This chair uses magnetic action to stimulate the muscles. I know this sounds very "woo, woo", but there is good data showing its effectiveness. This device is not for home use; treatments are given twice weekly by specially trained health care personnel.

Will plastic surgery make my vagina smaller?
Many genital plastic surgery techniques are based upon GYN surgical procedures used for medical problems such as reconstruction after cancer treatment, gender change, repair of cystocele/rectocele, etc. Unfortunately there are few good studies showing benefit where there is no overt medical problem.

One study of 53 women in Santiago, Chile (Pardo, 2006) was done specifically for complaints of wide vagina and decreased sexual satisfaction. The surgeons did two procedures. The first was inside the vagina where tissue along the roof was stitched tighter. This is similar to the type of repair done for a cystocele. Secondly, tissue around the vaginal opening and between the vagina and anus was stitched tighter. This is similar to the type of repair done for episiotomies after childbirth. Six months after surgery 94% claimed they experienced a tighter vagina, and had regained or improved orgasms. Yet some 4% of the women said they regretted the surgery.

The problem with this type of study is that sexual response can be very subjective. There is no easy way to measure sexual satisfaction in a group of diverse women. Every woman knew she got the surgical treatment so six months may not be a long enough time for any placebo response to wear off.

The American College of Obstetricians and Gynecologists (ACOG, 2007) has noted the lack of both safety and effectiveness data for genital plastic surgery. The possible complications for such surgery might include: infection, changes in sensation, pain with intercourse, and scar tissue. One GYN who has been performing genital plastic surgery for a number of years (Goodman, 2009) concluded that agreed upon terminology and training standards are still lacking.

What are you going to do, Jane?
As a big advocate of resistance/weight training to build muscles, I personally think exercise is a better place to start than surgery. As always, if a woman has concerns about sexual function, vaginal/genital structures, etc she should bring these up to her GYN. A GYN sees the wide range of "normal" in vaginal appearances. Yet, if one is having sexual problems due to genital changes, your GYN needs to know that is an issue.

If you are interested in exercising your vaginal muscles here are some instructions to get your started: Kegel Exercises - Topic Overview.

Related Topics:

• Better Sex for Women?
• GYN Issues with Jane Harrison-Hohner, RN, RNP
• Get the Women's Health newsletter in your inbox weekly