One in four women over the age of 18 reports reports suffering from a pelvic floor disorder, including pelvic organ prolapse. Despite this statistic, many women never talk to a doctor about the problem. Some women are embarrassed or believe it's a just a normal part of aging.

"Prolapse is way more common than you think, and it's increasing as the population ages," says Oz Harmanli, MD, chief of Yale Medicine Urogynecology & Reconstructive Pelvic Surgery.  "It's an area of growth and research and we are working on many exciting things here at Yale." 

For some women, pelvic organ prolapse dramatically curtails their social, working and sexual lives and decreases their overall sense of well-being. At Yale Medicine, the first thing we tell our patients is that suffering in silence isn’t necessary. Pelvic organ prolapse can be successfully treated. If surgery is required, our surgeons are highly skilled in both traditional and minimally invasive pelvic reconstructive surgeries, including robotic and transvaginal procedures.

“Seeking treatment can be very empowering for patients, and can allow them to take control of their lives,” says urogynecologist Nancy Ringel, MD, MS. “We are here to help you find the treatment option that’s right for you.”

The pelvic floor is composed of muscles, ligaments, connective tissues and nerves that hold up the bladder, uterus, vagina, small intestine and rectum. Typically taut and strong, the floor acts like a hammock, keeping organs snugly in place.

But over time—and for many reasons—the muscles can weaken and loosen and the organs can begin to slip downward, descending or herniating into the vagina.

"Almost all women as they age, or if they have gone through childbirth, lose some vaginal support," says Yale Medicine's Leslie Rickey, MD, who specializes in female pelvic medicine and reconstructive surgery and is an associate professor of urology and of obstetrics, gynecology and reproductive sciences at Yale School of Medicine. "And once the walls of the vagina start to come down to the opening and herniate out, that's when they have symptoms of a bulge, which results in a very uncomfortable feeling." 

Many factors can cause damage or weaken the pelvic floor. Some of the most common ones include:

• Childbirth: Vaginal delivery in particular can strain the muscles necessary to keep pelvic floor organs in place.
• Age: As women grow older, their estrogen levels tend to drop. This can have the side effect of weakening tissues in the body, including the pelvic floor.
• Repeated heavy lifting: Patients who put a good deal of physical strain on their lower back and pelvic area might strain the surrounding muscles to the point of failure.
• Obesity: Carrying a lot of extra weight can strain the body’s muscles and organs and increase the risk of pelvic organ prolapse.

The main symptom of pelvic organ prolapse is seeing or feeling a vaginal bulge. Patients often report feeling something “falling out” of the vagina, especially during exercise, at the end of the day, or after standing for long periods of time.

Although the bulge, or prolapse, may cause discomfort and pressure, prolapse is not typically painful. Some women describe pushing the bulge back in to help with urination or bowel movements.

If a patient is presenting with symptoms of a pelvic organ prolapse, the physician will take a complete health history and do a comprehensive physical, including a pelvic exam.

In addition to a physical exam (to see if the organs are in their proper place), doctors may use imaging studies to better understand what is happening in the pelvic area.

Our physicians believe that the simplest, least invasive treatment options should be tried first.

Treatment approaches are tailored to your specific needs and may include pelvic floor physical therapy, self-management strategies, medications and/or surgery. Some of these treatments also address incontinence, which is often present in women with pelvic organ prolapse.

Common treatments include:

• Pelvic Floor Muscle Training and Physical Therapy: Training includes a variety of exercises, including Kegel exercises (squeezing and relaxing the pelvic muscles to build strength). Patients typically go to physical therapy to learn a variety of exercises, which they then continue to do at home.
• Biofeedback Therapy: This therapy helps you locate and strengthen pelvic floor muscles. During biofeedback therapy, a tampon-shaped sensor is inserted in the vagina or rectum and a second sensor is placed on the abdomen. As you contract and relax the pelvic muscles, the electric signals from those muscles are shown on a computer screen so they can see which muscles are contracting and build up the strength and intensity of those contractions. Treatment is done weekly for about eight sessions. 
• Electrical Stimulation Therapy: This treatment is often combined with biofeedback therapy. Small electric currents are used to directly stimulate the pelvic floor muscles, training the muscles to contract. Like biofeedback, this requires weekly visits combined with pelvic floor exercises at home.
• Pessary: A pessary is a small device made most commonly from silicone. It is inserted into the vagina and holds the bladder, uterus or rectum in place. Pessaries come in many sizes and shapes and can be effective in improving symptoms of vaginal bulge.

"We insert them in the office and they typically remain inside the patient for eight to 12 weeks," Dr. Harmanli says. "Pessaries are for people who aren’t ready for surgery. The downside of pessaries currently available to us is what comes with anything staying inside too long. Not many women are comfortable or capable of removing, cleaning and putting them back in themselves. This can cause irritation, odor, and discharge."

Because of that, Dr. Harmanli has invented a pessary that is currently going through the approval process with the U.S. Food and Drug Administration. The product, he says, will be more comfortable, and can be inserted and removed by the patient at home at her own discretion. This will eliminate regular visits to the doctors’ office which is essential for the maintenance of the currently existing pessaries.

Physicians may also prescribe vaginal estrogen cream, tablets, or a ring to help post-menopausal women to strengthen their vaginal tissue.

• Surgery: When a woman does not see wearing a pessary as an option, or fails to retain it inside, surgery may be an option, though Dr. Harmanli cautions that "we are not 100-percent there yet with cure rates. You might have surgery in your 50s and then need it again in your 60s. There is a 30 percent chance of that. Right now we are charged with finding the most lasting surgery." 

But significant advances are being made in surgery and our surgeons are highly skilled in both traditional and minimally invasive pelvic reconstructive surgeries, including robotic and trans-vaginal surgeries. If surgery is necessary, we are committed to helping you understand every aspect of the process. A typical hospital stay after surgery is one night, followed by an approximately four-week recovery period, depending on the complexity of the surgery. Patients are advised not to take part in strenuous or sexual activity for up to six weeks to allow for healing.

We’ve assembled urologists, urogynecologists, reconstructive pelvic surgeons, gastroenterologists, gastrointestinal surgeons, radiologists and physical therapists who treat pelvic floor dysfunction and urinary incontinence together as a team.

Our doctors begin by listening. Then we devise an individualized treatment plan that is minimally invasive and targeted at returning patients to rich, active lives.

"Plus, at Yale, we have an established urogynecology program. We are training the future urogynecologists and that makes us stay sharp," Dr. Harmanli says. "We are a research institution and I can walk down the hall here and see scientists working hard on huge advances for pelvic floor disorders."

“Coming to Yale means coming to a world class institution where you will get excellent care,” Dr. Ringel notes. “But it also means getting access to doctors and providers that truly care about you—and about finding solutions that help you live your life more fully.”