Pelvic Organ Prolapse and Pelvic Floor Treatment in Chicago

A feeling of pressure or bulging in the vagina, something that seems to be coming down by the end of the day, leaking urine when you cough, difficulty emptying your bladder or bowel — these are pelvic floor problems, and they are common enough that many women assume they are simply what happens after childbirth or with age. They are common. They are also treatable, and most women can be helped without surgery.

Dr. Adeeb Alshahrour, MD FACOG, completed advanced surgical training in urinary incontinence and pelvic organ prolapse surgery at the University of Guadalajara in 2005. At the Women's Health Center of Chicago on West Fullerton Avenue, he evaluates and treats the full range of pelvic floor disorders, from first-line conservative care through reconstructive surgery.

What pelvic organ prolapse is

The pelvic floor is a sling of muscle, ligament and connective tissue that holds the bladder, uterus, vagina and rectum in place. When that support weakens or tears, the organs descend into or through the vaginal canal. That descent is prolapse.

It is named for which organ has dropped and where:

Cystocele — the bladder bulges into the front wall of the vagina. The most common type. Often associated with urinary symptoms.
Rectocele — the rectum bulges into the back wall of the vagina. Frequently causes difficulty emptying the bowel, sometimes to the point where women press on the vaginal wall to complete a bowel movement.
Uterine prolapse — the uterus itself descends into the vagina.
Vaginal vault prolapse — after hysterectomy, the top of the vagina loses its support and descends. This is why the way a hysterectomy is performed, including how the vaginal apex is suspended, matters years later.
Enterocele — small bowel pushes into the upper vaginal wall, often alongside vault prolapse.

More than one type is present in most women. Treating only the obvious bulge and ignoring a second compartment is a common reason repairs disappoint.

Symptoms

A sensation of pressure, heaviness or fullness in the pelvis or vagina
A visible or palpable bulge at or outside the vaginal opening
Symptoms that worsen through the day, with standing, lifting or straining, and ease when lying down
Urinary leakage with coughing, laughing or exercise; urgency; frequency; incomplete emptying; a slow or hesitant stream
Difficulty with bowel movements, straining, incomplete evacuation, or needing to splint with a finger
Discomfort or reduced sensation during intercourse
Low back or pelvic aching

Prolapse is not usually painful. Sharp pelvic pain generally points elsewhere and should be evaluated on its own terms.

Risk factors

Vaginal childbirth, especially multiple deliveries, a large baby, prolonged second stage, or forceps or vacuum assistance. This is the single largest contributor.
Age and menopause. Falling estrogen thins the vaginal tissues and reduces the quality of connective tissue support.
Obesity. Sustained increased intra-abdominal pressure loads the pelvic floor continuously.
Chronic straining from constipation, chronic cough, smoking, or repeated heavy lifting at work or in training.
Prior pelvic surgery, including hysterectomy.
Connective tissue differences. Some women have inherently weaker collagen support and develop prolapse with far less provocation, sometimes without ever having given birth.

How prolapse is staged, in plain language

We use a standardized system that measures how far the leading edge of the prolapse sits relative to the hymen, the natural landmark at the vaginal opening. Simplified:

Stage 0 — no descent. Everything sits where it should.
Stage 1 — some descent, but the leading edge is still well inside, more than a centimeter above the opening.
Stage 2 — the leading edge is at or near the opening, within a centimeter above or below. This is where most women start to feel a bulge.
Stage 3 — the prolapse extends more than a centimeter past the opening but is not fully out.
Stage 4 — complete eversion; the vagina is essentially turned inside out.

Stage does not decide treatment on its own. A woman with stage 3 prolapse who is not bothered by it may reasonably choose observation. A woman with stage 2 whose symptoms interfere with her work and exercise deserves active treatment. We treat symptoms, not measurements.

Treatment, from conservative to surgical

Observation

If prolapse is mild and not bothering you, watching it is a legitimate choice. Prolapse does not inevitably progress. Weight management, treating constipation, stopping smoking and avoiding heavy straining all reduce the load on the pelvic floor.

Pelvic floor physiotherapy

Supervised pelvic floor muscle training is first-line for early prolapse and for stress urinary incontinence, and it works. It is meaningfully more effective than being handed a leaflet about Kegels — a pelvic floor physical therapist confirms you are contracting the right muscles (many women are not), builds a progressive program, and addresses coordination and breathing along with strength. Expect a course of several months before judging results. We refer to pelvic floor physical therapists in the Chicago area.

Pessaries

A pessary is a flexible silicone device fitted into the vagina to support the prolapsed organs. It is underused and genuinely effective. Most women with symptomatic prolapse can be fitted successfully, and satisfaction is high in those who continue with it.

Fitting is done in the office and usually takes one or two visits to get the size and shape right. You can be taught to remove, clean and reinsert it yourself, or come in for periodic checks. Pessaries suit women who want to avoid surgery, who are not surgical candidates, who are not finished having children, or who want relief now while they decide. Vaginal estrogen is often used alongside a pessary to keep the tissue healthy — see menopause management and hormone therapy.

Surgery

Surgical repair is for women whose symptoms are significant and who have not been adequately helped by conservative measures, or who prefer a definitive solution. Options depend on which compartments are involved, whether the uterus is present, whether you want to preserve the option of intercourse, and your overall health.

Broadly, repairs are done through the vagina or through the abdomen (usually laparoscopically), and they either reconstruct the native tissue support or use graft material. Apical suspension — resuspending the top of the vagina or the cervix — is central to a durable repair. If the uterus is being removed as part of the procedure, see hysterectomy. Incontinence is often addressed at the same time when it coexists.

About transvaginal mesh — the honest version

In 2019 the FDA ordered manufacturers to stop selling surgical mesh placed transvaginally for the repair of pelvic organ prolapse in the United States, after concluding that the manufacturers had not demonstrated a reasonable assurance of safety and effectiveness compared with native tissue repair. Reported complications included mesh exposure through the vaginal wall, pain, infection and pain with intercourse, some of which required multiple surgeries to address and were not always fully correctable.

Two clarifications matter, because this history is frequently muddled:

The action applied to mesh placed through the vagina for prolapse. It did not apply to mesh slings used for stress urinary incontinence, or to abdominally placed mesh in sacrocolpopexy, both of which remain in use with a different evidence base.
If you already have transvaginal mesh in place and have no symptoms, the FDA has not recommended routine removal. If you do have symptoms, they should be evaluated.

We will tell you exactly what material, if any, a proposed repair uses, and why.

Getting evaluated

The visit involves a discussion of your symptoms and how they affect daily life, a pelvic examination performed both lying down and often standing or straining so the prolapse can be seen at its full extent, and an assessment of bladder and bowel function. Additional testing, such as a post-void residual measurement or urodynamic studies, is added when the urinary picture is unclear.

You do not need to have "waited long enough" to be seen. If something feels wrong, that is reason enough. Book an appointment or find our Chicago location. You can also read about Dr. Alshahrour's background and training.

Medical disclaimer

This page is for general education and does not constitute medical advice, diagnosis or treatment, and it does not create a physician-patient relationship. Treatment decisions depend on examination findings and your individual circumstances. Regulatory guidance and surgical practice change over time. Discuss your symptoms and options with our office or your own physician. In a medical emergency, call 911 or go to the nearest emergency department.