Pelvic pressure and prolapse symptoms

Pelvic pressure and prolapse symptoms are sensations of heaviness, dragging, fullness or a vaginal bulge, often with urinary, bowel and sexual symptoms, that are usually worse on standing and at the end of the day and relieved by lying down. The commonest cause is pelvic organ prolapse, in which the bladder, uterus, vaginal vault or rectum descends into or through the vagina.

The main clinical point is to stage the prolapse, identify associated bladder and bowel dysfunction, exclude pelvic masses and cancer, and choose between pelvic floor therapy, a pessary and surgery by symptoms and fitness.

Clinical relevance. Prolapse affects a large share of parous women, may cause retention, hydronephrosis, sexual dysfunction and ulceration, and is a leading reason for gynaecological surgery. Pressure symptoms without prolapse can reflect a pelvic mass, pelvic floor hypertonia or bowel disease.

Anatomy. Support comes from the levator ani muscles (pubococcygeus, puborectalis, iliococcygeus), endopelvic fascia, uterosacral and cardinal ligaments, and the perineal body. Levator avulsion, nerve injury and connective tissue weakness lead to loss of support.

Mechanisms. Obstetric injury, ageing and oestrogen deficiency, raised intra abdominal pressure (chronic cough, constipation, heavy lifting, obesity), connective tissue disease, previous hysterectomy or pelvic surgery and genetic factors.

Classification. By compartment:

• Anterior (cystocele, urethrocele).
• Posterior (rectocele, enterocele, perineal descent).
• Apical (uterine, cervical, vault prolapse).

By stage using the pelvic organ prolapse quantification system:

• Stage 0: no prolapse.
• Stage I: leading edge more than 1 cm proximal to the hymen.
• Stage II: leading edge from 1 cm proximal to 1 cm distal to the hymen.
• Stage III: leading edge more than 1 cm distal to the hymen but less than 2 cm short of total vaginal length.
• Stage IV: complete eversion.

Key distinctions. A bulge that is felt or visible is prolapse until proved otherwise. Pressure without a visible bulge on straining suggests a pelvic mass, hypertonic pelvic floor or bowel cause. Obstructed defaecation with a need to splint suggests rectocele. Incomplete bladder emptying with a large cystocele raises concern for hydronephrosis.

History

• Vaginal bulge, heaviness, dragging, sensation of sitting on a ball, lower back ache; onset, progression, daily variation, effect on activity, work and sex.
• Urinary: stress and urgency incontinence, frequency, nocturia, hesitancy, slow stream, incomplete emptying, need to reduce the prolapse to void, recurrent infection, haematuria.
• Bowel: constipation, straining, incomplete evacuation, splinting or digital evacuation, faecal incontinence, rectal bleeding, rectal mucosa protruding at the anus.
• Sexual: dyspareunia, embarrassment, avoidance, vaginal dryness.
• Bleeding, discharge, ulceration (decubitus ulcer).
• Risk factors: parity, vaginal delivery, forceps, birth weight over 4 kg, prolonged second stage, perineal tears, age, menopause, obesity, chronic cough, constipation, heavy lifting, smoking, family history, connective tissue disorder (Ehlers Danlos, Marfan), previous hysterectomy, pelvic radiotherapy.
• Medical and surgical: previous prolapse or incontinence surgery, mesh, fistula, spinal disease, neuromuscular disease, diabetes.
• Goals: desire for sexual function, future pregnancy, preference for surgery or conservative care, and frailty.

Examination

• BMI, blood pressure, abdomen for masses, distended bladder.
• Stand and lie down, and ask the woman to strain and cough. Use a half speculum (Sims or Cusco) to assess each compartment separately.
• Stage the prolapse with the pelvic organ prolapse quantification system (points Aa, Ba, C, D, Bp, Ap, genital hiatus, perineal body and total vaginal length) or a simple grading of descent relative to the hymen.
• Cervix and vault, atrophy, ulceration, and discharge.
• Bimanual examination for uterine size, adnexal mass; rectovaginal examination for rectocele, enterocele and sphincter tone.
• Cough stress test with the prolapse reduced (occult stress incontinence).
• Pelvic floor muscles: voluntary contraction strength (Oxford scale 0 to 5), levator avulsion, tenderness and hypertonia.
• Neurological examination: sacral sensation, anal reflex, bulbocavernosus reflex.
• Inspection of the anus for prolapsed rectum or haemorrhoids.

Red flags

• Postmenopausal bleeding, intermenstrual bleeding or bloodstained discharge (cancer).
• Pelvic mass, ascites or early satiety.
• Acute urinary retention or inability to reduce the prolapse to void.
• Flank pain, fever, rising creatinine or hydronephrosis.
• Necrotic, ulcerated or bleeding prolapse, or incarceration.
• Full thickness rectal prolapse with ischaemia.
• New neurological deficit, saddle numbness or bilateral leg weakness (cauda equina).
• Faecal incontinence with new neurological features.
• Weight loss, rectal bleeding or change in bowel habit.

Special groups. Pregnancy and postpartum: pressure symptoms from the gravid uterus and pelvic girdle pain; postpartum prolapse is common and often improves. Older women: frailty and cognitive impairment affect pessary self care and surgical risk. Women with connective tissue disease: recurrent prolapse. Women with spinal cord disease: bladder and bowel dysfunction.

Organised by cause of pressure and bulge. Each cause is common unless marked serious or uncommon.

Pelvic organ prolapse

• Cystocele and urethrocele (anterior wall).
• Uterine and cervical prolapse (procidentia in stage IV), cervical elongation.
• Vaginal vault prolapse after hysterectomy.
• Rectocele, enterocele, sigmoidocele, perineal descent.
• Combined prolapse with stress urinary incontinence.

Gynaecological masses and conditions

• Uterine fibroids, adenomyosis with bulky uterus.
• Ovarian cyst or tumour, pelvic abscess.
• Retroverted gravid uterus, fixed retroversion with endometriosis.
• Prolapsed fibroid, polyp or inverted uterus.
• Pelvic congestion syndrome.
• Pelvic floor hypertonia and pelvic floor myalgia.
• Serious: pelvic malignancy (ovarian, endometrial, cervical, vaginal, colorectal).

Urological

• Urinary retention and bladder distension.
• Urethral diverticulum, urethral caruncle, urethral prolapse.
• Interstitial cystitis (bladder pain syndrome).
• Recurrent urinary tract infection, bladder stone, bladder tumour.
• Serious: bladder cancer, hydronephrosis from ureteric kinking.

Gastrointestinal and anorectal

• Constipation and faecal loading.
• Full thickness rectal prolapse and internal rectal intussusception.
• Haemorrhoids, anorectal abscess.
• Irritable bowel syndrome, inflammatory bowel disease.
• Serious: colorectal cancer, presacral tumours.
• Levator ani syndrome and proctalgia.

Musculoskeletal, neurological and other

• Perineal hernia, obturator or sciatic hernia.
• Pelvic girdle pain, coccydynia, lumbar spine disease.
• Cauda equina syndrome, pudendal neuropathy.
• Pregnancy related pelvic pressure.
• Anxiety and somatic symptom disorder.

Special groups. Older women: advanced prolapse, atrophy and retention. Young women: pelvic congestion, endometriosis and pelvic floor hypertonia. Postpartum women: levator avulsion and transient prolapse.

Stepwise reasoning

1. Examine standing and lying to stage the prolapse and identify which compartments are involved.
2. Exclude a pelvic mass, cancer and urinary retention.
3. Assess bladder and bowel function, pelvic floor strength and sexual function with symptom questionnaires if available.
4. Image and investigate only when needed for diagnosis or surgery.
5. Match treatment to symptoms, stage and patient goals.

First line tests

• Urine dipstick, microscopy and culture.
• Post void residual by bladder scan or catheter (over 100 mL is abnormal; over 30% of voided volume suggests incomplete emptying; repeat once).
• Pregnancy test in women of reproductive age.
• Urea, creatinine and electrolytes for severe prolapse or retention; HbA1c if diabetes is suspected.
• Cervical screening if due.

Targeted tests

• Renal ultrasound for stage III or IV prolapse, retention or flank pain (hydronephrosis).
• Pelvic ultrasound (transvaginal, transabdominal or translabial) for masses and uterine size; translabial or transperineal ultrasound for levator avulsion and hiatal area (over 25 cm2 indicates ballooning).
• Urodynamics for mixed incontinence, voiding dysfunction, neurological disease, previous incontinence surgery, or occult stress incontinence before surgery (the cough stress test with prolapse reduction identifies those at risk of post operative stress incontinence).
• Endometrial sampling or hysteroscopy for abnormal bleeding.
• Defaecography or MRI defaecography for complex posterior compartment symptoms or suspected enterocele with obstructed defaecation.
• Colonoscopy for rectal bleeding, change in bowel habit or anaemia.
• Cystoscopy for haematuria, recurrent infection or suspected fistula.
• MRI pelvis for pelvic masses or combined pelvic floor disorders.
• Vaginal swabs to exclude infection before pessary use.
• Frailty and cognition assessment and anaesthetic review before surgery.

Limitations. Symptoms correlate poorly with stage. Examination in the clinic may underestimate prolapse unless the woman strains standing. Residual urine measurements vary. Urodynamics changes management in selected women only. Imaging adds little in uncomplicated prolapse.

Immediate steps. Relieve acute retention with a catheter, reduce an incarcerated prolapse (lubricant, gentle pressure, analgesia, supine head down position), treat ulcers and infection, and refer suspected cancer within 2 weeks. Explain that prolapse is benign, not dangerous in itself, and that treatment aims to relieve symptoms.

Asymptomatic or mild prolapse. No treatment other than risk factor control. Review if symptoms develop.

General measures. Weight loss when BMI is over 30. Treat constipation (macrogol 3350 with electrolytes 1 to 3 sachets daily dissolved in water, adjusted to stool consistency; or ispaghula husk 3.5 g one sachet once or twice daily with a full glass of water). Treat chronic cough. Stop smoking. Avoid heavy lifting and straining. Review diuretics and drugs that cause constipation.

Pelvic floor muscle training. Supervised by a physiotherapist for at least 16 weeks: 8 to 12 slow contractions held for 6 to 8 seconds, three times daily, with fast contractions. Biofeedback may help. It reduces symptoms in stage I to II prolapse; improvement in stage is limited.

Vaginal oestrogen. For atrophy, erosion or before pessary use: oestradiol 10 microgram vaginal tablet nightly for 2 weeks, then twice weekly (maximum one tablet daily). Contraindicated with undiagnosed vaginal bleeding, active venous thromboembolism and active liver disease; review at 3 months.

Alternative: oestriol 0.5 mg vaginal pessary nightly for 3 weeks, then twice weekly, or oestriol 0.1% cream 0.5 g daily for 2 to 3 weeks, then twice weekly.

Pessary

• Ring pessary with support (sizes 50 to 100 mm) is first line for stage II to IV prolapse; Gellhorn or cube pessaries for severe prolapse or short vaginal length; shelf or donut for large defects.
• Fit with the largest size that stays comfortably in place and allows voiding and walking.
• Offer self care (remove and clean every week or two) or clinic change every 3 to 6 months.
• Complications: discharge, odour, vaginal erosion, bleeding, expulsion, urinary retention, new stress incontinence, and (when neglected) fistula or impaction.
• Treat bacterial vaginosis or infection before use. Vaginal oestrogen reduces erosion.
• Contraindications include pelvic infection and non adherence to follow up.

Surgery. Offered after conservative options, or earlier for symptomatic stage III to IV prolapse. Choice depends on compartment, age, sexual activity, uterus preservation, previous surgery and fitness.

• Anterior and posterior colporrhaphy for cystocele and rectocele.
• Vaginal hysterectomy with uterosacral or sacrospinous ligament fixation of the vault.
• Sacrocolpopexy (laparoscopic or robotic) with mesh for vault or uterine prolapse in younger or sexually active women; sacrohysteropexy for uterine preservation.
• Uterine preserving procedures (sacrospinous hysteropexy, Manchester repair) for women who wish to retain the uterus.
• Colpocleisis (vaginal closure) for frail older women who do not wish to be sexually active, with high success and low morbidity.
• Mid urethral sling for stress incontinence, either at the time or staged, after urodynamics.
• Vaginal mesh kits for primary repair are not used in most women because of erosion risk and pain.
• Pre operative: vaginal oestrogen for 4 to 6 weeks in postmenopausal women, treat urinary infection, and give antibiotic prophylaxis (cefazolin 1 to 2 g intravenously at induction) and venous thromboembolism prophylaxis.
• Counsel about recurrence (approximately one in five over several years), de novo stress incontinence, voiding difficulty, dyspareunia, bowel dysfunction, mesh complications and anaesthetic risk.

Associated bladder symptoms

• Overactive bladder: bladder training.
• Mirabegron 25 mg orally once daily, increased to 50 mg after 4 to 8 weeks (maximum 50 mg daily; maximum 25 mg when eGFR is 15 to 29 mL/min/1.73 m2; avoid with severe uncontrolled hypertension of 180/110 mmHg or more; monitor blood pressure).
• Alternative: oxybutynin 2.5 mg orally twice daily, increased to 5 mg two to three times daily (maximum 5 mg four times daily). Use caution in older adults, glaucoma, dementia and urinary retention; avoid in women with raised post void residual.
• Stress incontinence: pelvic floor training, and surgery after urodynamics.
• Recurrent urinary tract infection: vaginal oestrogen (oestradiol 10 microgram vaginal tablet nightly for 2 weeks, then twice weekly) and prophylaxis directed by culture.
• Retention: clean intermittent self catheterisation or catheter until prolapse treatment.

Associated bowel symptoms. Treat constipation with macrogol 3350 with electrolytes 1 to 3 sachets daily, with biofeedback, correct splinting, posture and timing; surgery for symptomatic rectocele only after optimisation of bowel function.

Special groups. Pregnancy: avoid pessaries unless symptomatic, use pelvic floor exercises, rest and a support belt; vaginal delivery is usually possible. Postpartum: pelvic floor physiotherapy and review at 6 to 12 weeks. Older adults: choose a pessary or colpocleisis if surgical risk is high. Connective tissue disease: surgical repair has a higher failure rate.

Monitoring. Review at 3 months after starting treatment, then every 6 to 12 months. Review pessary fit at 2 weeks and then every 6 to 12 months or at each change. Record symptom scores, post void residual and residual urine after surgery.

Referral and escalation. Refer urgently within 2 weeks for suspected cancer. Refer to gynaecology or urogynaecology for stage II or higher symptomatic prolapse, failed conservative therapy, recurrent prolapse, complications of mesh, mixed incontinence, retention, fistula or abnormal bleeding. Refer to colorectal surgery for full thickness rectal prolapse and to urology for haematuria and hydronephrosis. Refer to physiotherapy for pelvic floor muscle training.

Admission criteria. Acute retention not relieved, incarcerated or strangulated prolapse, ulcerated prolapse with sepsis, acute kidney injury with hydronephrosis, bleeding, and surgical admission for repair.

Discharge and follow up. Outpatient. Provide written pessary care instructions, a contact for problems, and a review date.

Safety netting. Return for inability to pass urine, fever, offensive discharge, vaginal bleeding, severe pain, expulsion of the pessary with symptoms, flank pain, or a prolapse that cannot be reduced.