Spend anytime in an IC support group and you will inevitably find a handful of women who have struggled with a pelvic organ prolapse (POP), with some requiring surgical repair. Prolapse occurs when muscles and/or ligaments are damaged and weakened, resulting in the vagina, bladder, uterus and/or rectum falling downwards. Prolapse can occur at any age, sometimes after pregnancy, childbirth, previous pelvic surgeries, straining or lifting heavy weights. A family history of prolapse or other connective tissue conditions could also play role. Of course, menopause is also a common cause as muscles weaken with age.

Given the small, confined space of the pelvis, this  downward movement can directly affect the bladder, uterus and rectum which could be pushed to the side, fall downwards or bend in such a way that urination, defecation and intimacy becomes difficult. A cystocele occurs when the bladder falls out of position. A rectocele occurs when the rectum falls, while a uterine prolapse involves the uterus falling forwards. An enterocele occurs when  a portion of small bowel bulges out of position.

How is it diagnosed?

POP can be diagnosed with a pelvic examination. It’s important to note that some patients feel a prolapse when they stand, but as soon as they down on the examination table, the prolapse slides back into the pelvis which can make the diagnosis more challenging. If you feel something at the entrance to your vagina, please tell your physician. They usually perform pelvic floor strength tests as well as bladder function tests.  Imaging, such as an MRI or ultrasound can also be used.

How is treated?

Treatment depends upon the severity of the prolapse. A mild presentation may need no treatment if a patient has no symptoms. However, if the symptoms get worse, physical therapy may be suggested. The goal of therapy is to strengthen the muscles of the pelvic floor to hold the organs in place.

A pessary is a non surgical treatment that can support the organs. Placed in the vagina, they come in a variety of shapes and sizes. Usually, your gynecologist will try a variety of devices to find one which is the most effective and comfortable. Patients are also taught how to take them out at night to clean them. Some devices may stay in place for a few months before your doctor will remove them for cleaning purposes. Pessaries can be challenging over time with.

Surgery is the ultimate therapy for a prolapse which can correct a prolapse and place the organs back in their proper position. If a patient is beyond childbearing age, a hysterectomy may be suggested. But, sometimes, the hysterectomy can cause its own complication, a vaginal vault prolapse that may require repair.

Surgeries usually involve a mesh product which has been quite controversial in the past with some meshes associated with severe side effects. It’s vital that you discuss any proposed mesh surgery with your doctor, with a thoughtful discussion of risks vs benefits, potential side effects and if the mesh they are suggesting has good research results.  Ideally, the surgeon will use a patients own tissue to repair the prolapse, without requiring a mesh. This depends not only on the surgeons experience level but the severity of prolapse repaired.

There is hope. A new study of 277 women with POP has given us encouraging information.(1) 64% of these women had symptoms of urinary urgency, incontinence and/or moderate to severe night time urination. Some also struggled with an underactive bladder, fecal incontinence and difficulty having bowel movements. However, after surgical repair, a significant reduction of their symptoms were cured. Urinary symptoms improved 65 to 85% of patients with substantial and significant improvements in pain.

What are the symptoms of a prolapse?

Mild prolapse may have no symptoms at the time but if it progresses, it can cause:

  • pelvic pressure, heaviness or pain
  • lower back pain
  • feeling a bulge to tissue at the opening of the vagina, usually worse when standing
  • urinary frequency or difficult emptying the bladder.
  • bowel changes
  • pain with intimacy

One  common sign of a prolapse is needing to put pressure on the perineum and/or in the vagina to help empty the bowels. Straining to urinate, a weak stream or intense frequency are also quite common.

Two IC patient experiences

We frequently encounter women diagnosed with IC who have a history of pelvic organ prolapse as well as surgical repair. Here are two patient experiences worth consideration if you are struggling with a prolapse and/or are not sure what course of treatment you could to take.

Shirley*

Shirley had a severe prolapse and severe Hunner’s lesions.(2,3) Because she was unable to urinate, they performed surgery and found that her uterosacral ligament, which normally holds the vagina in place, had broken. Known as posterior fornix syndrome, this had caused her uterus to twist backwards. The surgeons repaired the ligament, restoring the correct positioning for all. That’s when something even more amazing occurred. Her Hunner’s lesions healed completely. Her case study was published in a medical journal and supports the theory that, for some patients, lesions may occur because nerves have become very inflamed, such as when they are stretched out of position by a prolapse. Had she not had her prolapse repaired, she would likely be in severe pain today.

Mary*

Mary was diagnosed with a prolapse in her early 70’s. Her doctors recommended surgical repair but she was very reluctant to have surgery. She came to regret that decision over the years as her prolapse and urinary symptoms worsened over time, eventually resulting in great discomfort and stress When she stood, her bladder was hanging out of her vagina. It was awful. Thankfully, she was able to use a pessary, a device inserted into the vagina, to hold organs in place but as she aged, that became difficult.  The last time we spoke, she was in her late 80’s. She said that her greatest regret was not having her prolapse repaired when she was younger and healthier. She has since passed away.

Conclusion

A diagnosis of interstitial cystitis suggests, at first, that a patient may have a bladder disease. Yet, for many of us, bladder therapies (i.e. oral meds and instillations) simply don’t work. That’s when we must ask more questions. Could something have been missed? This cements the importance of a proper physical examination, including a pelvic floor assessment during your diagnostic workup. As the authors of the study state “The coexistence of bothersome pain, bladder, and bowel symptoms is common in women with POP. Therefore, POP should always be ruled out as a differential diagnosis before classifying the symptoms as interstitial cystitis/bladder pain syndrome.” Furthermore, patients should be advised that if physical therapy cannot help, the use of pessaries and/or surgical repair are viable options with a good success rates at reducing symptoms.

References

  1. Schmidbauer L, et al. Coexistence of Pelvic Pain, Bladder, and Bowel Symptoms in Women with Pelvic Organ Prolapse: The Effect of Transvaginal Surgery. Int Urogynecol J. 2025 Nov 8.
  2. Osborne J. Hunner’s lesion patient unexpectedly “cured” with a ligament repair. IC Network. June 3, 2021
  3. Scheffler K, Hakenberg O, Petros P. Cure of Interstitial Cystitis and Non-Ulcerating Hunner’s Ulcer by Cardinal/Uterosacral Ligament Repair. Url Int. 2021 May 21;1-4