Prolapse is Confusing
Prolapse is Confusing

Prolapse is Confusing

If you've been diagnosed with, or ever suspected that you have, pelvic organ prolapse, I'm certain it brings up a million questions for you. Will my bladder eventually fall out of my vagina? Will having sex make it worse? Do I need surgery? What about having more kids, returning to exercise and running, etc etc??

By, Stephanie Dillon, PT, DPT, WCS

These are all FANTASTIC questions that typically don't get explained very well by the person who diagnoses you with prolapse, or by doing your own internet research. And, most of these difficulties originate with the fact that prolapse is not just one diagnosis. There are so many different organs that can prolapse, and so many different grades of prolapse, that it can be incredibly confusing. So today, let's start with the basics: what is prolapse, and how do we diagnose and grade it?

What is Prolapse? 

The definition of prolapse is when "an organ or organs in the pelvic cavity shift downward out of their normal position." (Palm 2017)  

What are the types of Prolapse?

Vaginal prolapse can occur from the bladder (cystocele), the rectum (rectocele), the uterus/cervix (apical or uterine prolapse), the small intestines (enterocele), or the vaginal vault (vaginal vault prolapse only happens in individuals who have had a total hysterectomy). 

It's also important to note that similar to a hernia, the “bulge” created by a prolapse is the organ pushing the vaginal wall downwards or outwards. As a result, the tissue you are actually seeing or feeling is the vaginal wall, not the organ itself. So no, your bladder or bowel will not just fall out one day! The only exception to this is cervical/uterine prolapse, where you will actually feel or see the cervix if it gets low enough. But, I promise that still won’t fall out one day either!

You can also have prolapse outside of the vaginal canal—the urethra can descend from its original position towards the vulva (urethrocele), or the lining of the rectum can prolapse outside of the anus (rectal prolapse). {NOTE: this is why language is important; many people will talk about a "rectal prolapse" when they really mean a rectocele. Rectal prolapse external to the anus requires surgical correction—no amount of pelvic floor exercises will help.}

WHEW that's a lot. So, before you freak out and worry about just exactly how many of your organs will eventually fall out of your vagina (haha), let's talk about grading and statistics!

How do we grade prolapse?

This is super important. Not all prolapses are created equal! There is a VERY big difference between minor prolapses (the bladder just slightly bulging into the vagina) vs major prolapses (the cervix or uterus being external to the vagina). There are a few different grading scales out there, but here are the most common grades:

  1. Prolapse is less than halfway to the opening of the vagina

  2. Prolapse is more than halfway to, or AT the opening of the vagina

  3. Prolapse is EXTERNAL TO the opening of the vagina

  4. Maximal descent of the entire organ outside of the vagina

The good news is that prolapse is a pretty slowly-progressing condition. So no, you won't go from a grade 1 to a grade 3 overnight. And, grade 4's are pretty rare, especially in higher-income countries. Typically it takes years for prolapse to worsen, if it does worsen at all.  In upcoming posts we'll talk about what does and doesn't cause prolapse, and if you do have prolapse what you can do to help it get better (or at least not get worse).

Who can diagnose me with prolapse?

This is also an excellent question with a very nuanced answer. Your gynecologist (GYN) of course can do so, but the prolapse specialists are truly urogynecologists (urogyns) or in some cases colorectal surgeons, particularly for rectoceles. A pelvic floor PT can also diagnose you with prolapse, but we can't say with certainty which organ is prolapsing—we typically talk more about which wall of the vaginal canal is bulging. A pelvic floor PT also typically can do a more detailed assessment than your GYN, as we also can assess people in standing positions. Sometimes prolapses are tricky to see when you are laying flat on your back, so a standing examination can be very useful!

If someone is concerned about their prolapse diagnosis, I do typically recommend they seek a consult with a urogynecologist. This usually occurs when they have been told they don't have a prolapse when they think they do, or have been blindsided with a diagnosis of higher-degree or multiple-organ prolapse when they were unaware. A urogyn can do a much more detailed assessment of prolapse than a GYN can, and they are also the experts at fitting pessaries or performing corrective surgeries. More on this in upcoming posts! But if you are curious, you can look up a urogyn close to you or a colorectal surgeon (for rectoceles or rectal prolapse).  

I will say also that typically fancy imaging studies are not needed to diagnose prolapse. They can be used in certain cases, for example if you have constipation and a rectocele, there is a special test that can be done to see how much of your rectum is falling into the vagina when you are bearing down to pass stool. But, this is definitely the exception rather than the rule.  Usually the examination done in the office is all that is needed.

What else should I know about Pelvic Organ Prolapse?

I will cover a LOT more in upcoming posts as I referenced at the start of this article. But in the meantime if you are curious for more information, you can check out the following websites. And of course, you can always complete our Prolapse Longer Fix! You have to be a member to play the videos, but even non-members can see what videos are there.

Voices for Pelvic Floor Dysfunction

Association for Pelvic Organ Prolapse Support

International Urogynecological Association patient information leaflets

American Urogynecological Association patient fact sheets


Palm, S. (2017). Pelvic Organ Prolapse: The Silent Epidemic (3rd ed.). POP Publishing and Distribution.

Photo by Liza Summer: