Hey doctor, what is protruding from my vulva?

By Dr. Nathalie Leroux

Everything you want to know about genital prolapse.

What is a prolapse?

A prolapse is the descent of an organ through the vaginal mucosa in women. Uterine prolapse is the descent of the uterus. The bladder is located behind the anterior wall of the vagina. The downward protrusion of the bladder is called a cystocele. In contrast, the rectum (bowel) is located behind the posterior vaginal mucosa, and its descent is called a rectocele. Enterocele is the prolapse of the small intestines.

Do all prolapses need to be treated?

Only symptomatic prolapses should be managed. The goal of the treatment is to improve the quality of life. Patients are invited to consult with a specialist if a prolapse has been found during a routine examination, where the medical professional will assess the patient’s condition. Still, suppose a woman reported no complaint before the examination. In that case, the approach is reassuring the patient that no treatment is necessary.

What are the symptoms associated with prolapse?

A good proportion of patients are asymptomatic. One of the first impressions is the sensation of pelvic heaviness. A typical description is feeling like you’re wearing a misplaced tampon. Some patients may discover a vaginal mass at the entrance to the vagina during vulvar cleansing in the shower. The mass or lump is perceived with the fingers but may otherwise not be felt. It is possible to feel discomfort during intimate relationships but not always. Urinary symptoms may accompany genital prolapses, such as difficulty initiating urination, stress incontinence or incomplete urinary emptying. Similarly, the stool may be more difficult to evacuate in the case of a rectocele.

What are the elements to consider in the choice of treatments?

As mentioned previously, the prolapse must be inconvenient for the patient, and the patient wishes to correct the situation. Health professionals must also take the medical condition of the patient into account. Specific health problems (severe heart or lung diseases) may contraindicate the surgical approach. Doctors should always keep in mind that the indication for surgery is to improve the quality of life. It is in no way compulsory to have surgery, as in the case of cancer. For patients for whom surgery is not a safe option, there are other possibilities to reduce the extent of symptoms.

The desire for pregnancy is an essential element in the choice of our therapeutic options. Any surgery should be considered once the desire for fertility is over.

Could this vaginal mass be cancerous?

This is a legitimate fear. The fear of cancer is a frequent reason for consultation in patients who discover a lump at the entrance to the vulva. Women must indeed investigate a vaginal mass, and some may be cancerous. Once a health professional has made this evaluation, rest assured that the genital prolapse is not cancerous. It can even be left alone, depending on the symptomatology.

What are the risk factors for genital prolapse?

Pregnancy and childbirth are risk factors contributing to the development of pelvic organ prolapse (POP). Vaginal childbirth can cause direct damage to the pelvic floor muscles and connective tissue attachments in the pelvis. In addition, trauma to nerve fibres by tissue stretching during childbirth contributes to pelvic floor dysfunction. A cesarean section could be a short-term protective factor compared to vaginal delivery. This protective effect dissipates with subsequent pregnancies or deliveries, decreases with age and disappears entirely in older women.

Body mass index (BMI) is a significant risk factor related to the prevalence of POP. Excess abdominal weight creates excessive intra-abdominal pressure on the pelvic floor compared to women with a healthy weight. Compared to non-obese women, obese women are three times more likely to have urinary incontinence. Encouraging weight loss should be the first treatment option.

A positive family history is possible for POPs. There are hereditary factors in the quality of connective tissues.

Obstructive lung disease in women over 60 significantly increases the risk of POPs.

Can my prolapse affect my sexual relations? 

Although the partner can perceive the POP, know that the penetration allows a reduction of this; that is to say, it will be pushed back inside. This is usually painless and should not interfere with satisfying sex. For some patients, however, as the tissues are relaxed, sensations during intercourse may be diminished. One of the goals of the treatment will be to restore tone to your pelvic floor muscles.

What can I do to reduce the symptoms associated with my prolapse?

The exercises, known as Kegel, are voluntary activation and contraction of the pelvic floor muscles. They can help limit the progression of POP and reduce pelvic pressure/heaviness.

Practical pelvic muscle training can improve and sometimes wholly treat patients with mild to moderate POP. It may be difficult for a patient to contract these muscles in isolation. Some patients contract the abdominal muscles instead. Others will make the opposite effort, a Valsalva (the effect of pushing). In this case, the symptomatology could even worsen following the treatment. It is estimated in some studies that up to 80% of women fail to reproduce adequate contraction of the pelvic floor muscles. Although some women can execute this contraction, muscle recruitment is slow, and the force of contraction is weak.

A physiotherapist specializing in perineal rehabilitation can help you train the muscles in this region, which are sometimes difficult to activate. You may be offered treatment with a vaginal probe. This will allow you to see the importance of the contraction that you develop during your exercise session and will let you have better results. Several physiotherapy sessions may be necessary to obtain satisfactory results.

What is the Emsella chair?

It is a platform (chair) with high-intensity focused magnetic resonance technology. You are seated in the chair, fully clothed, and the magnetic resonance will cause your pelvic floor muscles to contract. The contraction is supramaximal, with sustained duration. The force of muscular contraction developed during a session is much higher than what we can achieve individually. It is also possible to maintain this muscle contraction for longer than we can do voluntarily—all without pain. A 65% improvement in symptoms is reported in treated patients with a satisfactory rate of 90%. Appreciable results are possible after six sessions (2 sessions/week).

What is a pessary?

A pessary is a silicone prosthesis inserted into the vagina to support organs in pelvic floor prolapse. There are several types and sizes of pessaries. The success of the pessary varies depending on the degree of prolapse and several other factors. Not all women are good candidates for the use of a pessary. This one requires cleaning (removal), which you will be taught. If the patient cannot take care of her pessaries herself, the maintenance can be treated by a CLSC nurse.

How do I know if I am a good candidate for surgery?

Your health specialist will be able to advise you on your symptoms, the severity of your prolapse, your age and your general state of health. No one surgery is suitable for everyone. Each case is individual, and the approach depends on several factors.

Are surgeries effective in treating pelvic floor prolapse?

There are several types of surgeries to treat POP. Some are more effective than others, and your doctor can explain the nuances of each. The success rate is reported in the literature at 70% more or less long term. The recurrence is due to several individual factors but also to the quality of the connective tissues, which are weaker than the average by the nature of the pathology (POP).

Do I have to consult a urogynecologist?

Urogynecology is a subspecialty undertaken following specialized training in obstetrics-gynecology or urology. Their expertise is pelvic floor surgery and, therefore, the complete management of pelvic floor prolapse and urinary incontinence. Some gynecologists in general practice also have the necessary skills to offer you the same kind of intervention. Others will prefer to refer to subspecialists straight away. It’s all about having your healthcare professional put you at ease and being comfortable discussing the treatment options available to you.

In summary, there is nothing to do if your prolapse does not bother you, and several alternatives exist if it ruins your life!