What is Pelvic Organ Prolapse?

Pelvic organ prolapse is extremely common, affecting at least half of all women who have given birth and many women who have never been pregnant. Prolapse affects as many women in their twenties, thirties and forties as women in their fifties, sixties and seventies. Pelvic organ prolapse occurs when the basic shape of the pelvic organ support system changes. Normally, internal pressure, called intraabdominal pressure, flows through the abdomen and pelvis with every breath we take and moves through the pelvis in a very specific way. This pathway of intraabdominal pressure is created by the lower abdominal wall, the lumbar curve at the base of the spine, and the perineal wall at the back of the pelvis. Pelvic organs are held in place by both the shape of the spine and the forces of intraabdominal pressure.

When this basic structural framework changes, energy does not flow through the pelvis in quite the same way. Consequently, intraabdominal pressure strikes the organs slightly differently and instead of pinning them into place, as in normal anatomy, begins to push them out of position.

Many factors contribute to loss of spinal shape, including school desks, couches, soft chairs, inactivity, tight clothing, restrictive shoes, and improper breathing habits.

The blueprint for the human female body developed over a period of time when girls and women sat, stood, and moved in ways that supported the natural shape of the spine and pelvis. They sat using only the strength of their spine, carried loads in ways that reinforced the lumbar curve, walked barefoot or in soft-soled shoes, and resumed their daily chores shortly after giving birth.

All that has changed so that today little in our environment or activities of daily living supports our original design. As a result, women no longer have the same posture, or structural framework, that evolved to provide their pelvic organs proper support.

Pelvic organ prolapse can manifest in several different ways depending upon how the flow of intraabdominal pressure has been altered, but is by definition the pressing of pelvic organs against the vaginal walls and into the vaginal space. Prolapse is diagnosed by describing where the bulging occurs: the front wall, back wall, or top (apex) of the vagina.

Prolapse of the Anterior (Front) Vaginal Wall

Cystocele (prolapse of the bladder)

When the bladder is pulled away from its normal anatomical position over the pubic bone it falls against the front vaginal wall, eventually forming a large bulge at the vaginal opening. Women are often fearful that the bladder could actually fall out, but both the vaginal walls and their very strong attachments to the bony pelvis prevent this from happening. Inability to completely empty the bladder of urine is a common effect of advanced cystocele.

Prolapse of the Posterior (Back) Vaginal Wall

Rectocele (prolapse of the rectum)

In normal anatomy both the rectum and upper vagina are positioned within the pelvis in such a way that they are protected from the forces of intraabdominal pressure. However, as these organs lose their natural positioning, the rectum is often forced against the back vaginal wall resulting in a bulge near the vaginal opening. It is very common for stool to become obstructed in the pocket formed by the rectocele, and manual pressure applied to the back vaginal wall needed to facilitate evacuation. Mild rectocele and cystocele are commonly found together and help prevent a more severe prolapsing of the uterus.

Enterocele (prolapse of the small bowel)

The intestinal tract makes a deep turn at a point directly behind the cervix to form a small pouch called the cul-de-sac of Douglas. In rare cases, a portion of small bowel can slip into this space between the vagina and rectum, resulting in a bulge at the upper back vaginal wall. The possibility for enterocele greatly increases with hysterectomy.

Prolapse of the Apical (Top) Vagina

Uterine prolapse

When the uterus is no longer being pressed into its normal position over the bladder by the forces of intraabdominal pressure, the cervix begins a slow descent into the vagina, essentially turning the vagina inside out. Because cervical tissue is very elastic, sometimes the body of the uterus, or fundus, can remain somewhat in position while the neck of the cervix stretches down to the vaginal opening. However, due to the strength of supportive connections surrounding both the cervix and the lower vagina, it is unusual for the cervix to ever prolapse, or bulge, much beyond that point.

The original design of the female pelvic system is perfectly adapted to keep the pelvic organs in place over the course of the full human lifespan. That design changes when the external environment changes. Our modern world no longer requires girls and women to sit, stand, and move in ways that actually create and maintain the basic shape of the female body. We can recreate that design by learning how to hold the body in more natural ways.

There are no true "ligaments" that hold the pelvic organs in place. Rather, a vast envelope of tough, stretchy connective tissue surrounds and unites all the pelvic structures together. When the skeletal structure that is holding the pelvic organs in position changes, the form of the envelope changes, just like a sweater being stretched out of shape. Over a century of experimental prolapse surgery has demonstrated that cutting and stitching the pelvic envelope in an effort to better support the organs is often unsuccessful.

However, when we resume the seated and standing postures that actually created the structural design of the human female body in the first place, we bring the entire pelvis back into a position that is more conducive to organ support. Mild pelvic organ prolapse can be improved and severe conditions stabilized with this work.