Vaginal prolapse occurs when the muscles and connective tissues supporting the pelvic organs weaken, allowing one or more organs to drop down and press into or through the vaginal wall. About 40% of women will experience some degree of pelvic organ prolapse in their lifetime, though many won’t have noticeable symptoms. The condition ranges from mild, where tissues shift slightly but cause no problems, to severe, where organs visibly bulge beyond the vaginal opening.
How Prolapse Happens
Your pelvic floor is a group of muscles, ligaments, and connective tissue that sits like a hammock at the base of your pelvis, holding the bladder, uterus, and rectum in place. When this support system weakens or stretches, organs can shift downward from their normal position. The vaginal walls are the path of least resistance, so the descending organs push against them, creating a bulge that can sometimes be felt or seen.
Researchers describe the causes using a useful framework: predisposing factors you’re born with (like genetics and how your body produces collagen), inciting factors that cause damage (like vaginal childbirth), promoting factors that worsen things over time (like obesity or heavy physical labor), and decompensating factors that tip you over a threshold (like aging and menopause). Childbirth is the most commonly studied trigger, but the condition is genuinely multifactorial. Some women develop prolapse without ever giving birth, while others deliver multiple children and never experience it.
Types of Vaginal Prolapse
Prolapse is categorized by which part of the vaginal wall is affected and which organ is involved:
- Anterior wall prolapse (cystocele): The bladder drops down and presses into the front wall of the vagina. This is the most common type.
- Posterior wall prolapse (rectocele): The rectum pushes forward into the back wall of the vagina.
- Apical prolapse: The top of the vagina (or the uterus, if still present) descends. When the uterus drops, it’s called uterine prolapse. After a hysterectomy, the top of the vaginal canal itself can collapse inward, known as vaginal vault prolapse.
- Enterocele: The small intestine pushes down into the upper part of the vagina, typically at the back.
It’s common to have more than one type at the same time, since the overall weakening of pelvic support can affect multiple areas.
What It Feels Like
Mild prolapse often causes no symptoms at all. A study in the Gambia found that 46% of women had some degree of prolapse on examination, but only 12.5% reported symptoms. Many women discover they have prolapse during a routine pelvic exam.
When symptoms do appear, the most recognizable one is feeling or seeing a bulge of tissue at or beyond the vaginal opening. Other common signs include pelvic pressure or heaviness that worsens throughout the day or after standing for long periods, lower back pain, and difficulty keeping a tampon in place.
Urinary symptoms are particularly common with anterior prolapse: needing to urinate more frequently, feeling urgency, having a weak stream, or being unable to fully empty the bladder. Posterior prolapse tends to cause bowel-related issues, including difficulty completing a bowel movement. Some women find they need to press against the vaginal wall with a finger to support the bulge in order to pass stool, a technique called splinting. Pain during sex is another frequently reported symptom across all types.
How Severity Is Measured
Doctors grade prolapse on a five-stage scale based on how far the tissue has descended relative to the vaginal opening (the hymen):
- Stage 0: No prolapse.
- Stage 1: The lowest point of the prolapse is still more than 1 cm above the vaginal opening.
- Stage 2: The prolapse reaches within 1 cm of the vaginal opening, either above or below it.
- Stage 3: The prolapse extends more than 1 cm beyond the opening, but the vagina hasn’t fully turned inside out.
- Stage 4: The vagina is essentially completely everted.
Staging helps guide treatment decisions, but symptoms don’t always match the stage. Some women with stage 2 prolapse have significant discomfort, while others with stage 3 manage well with conservative treatment.
Pelvic Floor Exercises
Pelvic floor muscle training, commonly known as Kegel exercises, is typically the first approach for mild to moderate prolapse. Research consistently shows that a structured exercise program improves prolapse-related symptoms and quality of life, with significant symptom improvement documented at 6, 12, and even 24 months of training.
The evidence on whether exercises can actually reverse the anatomical stage of prolapse is mixed. Some studies found measurable improvement in the position of the prolapse, particularly for anterior wall descent, while others found no significant change. What’s more consistent is that women feel better and report less bother from their symptoms, even when the prolapse itself doesn’t move much on examination. Pelvic floor exercises have not been shown to improve sexual function related to prolapse, and adding them around the time of surgery doesn’t appear to improve surgical outcomes.
Working with a pelvic floor physical therapist, rather than doing exercises on your own, generally produces better results because many women unknowingly perform Kegels incorrectly.
Pessaries
A pessary is a removable silicone or plastic device inserted into the vagina to physically support the prolapsed organs. It works like an internal brace, holding everything in a more normal position. Pessaries come in many shapes and sizes. Support-style pessaries (like rings) work for milder prolapse, while space-filling types (like the Gellhorn or donut) are better suited for more advanced cases.
A healthcare provider fits the pessary during an office visit, trying different sizes until one sits comfortably without falling out. Some women learn to remove and reinsert the pessary themselves for cleaning, while others return to their provider periodically for maintenance. Pessaries are inexpensive, generally safe, and well-tolerated, making them a good option for women who want to avoid surgery or who aren’t good surgical candidates.
Surgical Options
Surgery is typically considered when symptoms significantly affect daily life and conservative treatments haven’t provided enough relief. About 11% of American women undergo surgery for prolapse or urinary incontinence by age 79, and roughly 29% of those women need a repeat procedure.
The two main surgical approaches are native tissue repair and mesh-based repair. Native tissue repair uses your own tissues and sutures to reconstruct the pelvic floor support. Mesh-based repair, called sacrocolpopexy, involves attaching a synthetic mesh to the top of the vagina and anchoring it to the tailbone area to provide structural support. This procedure is done through the abdomen, either with open surgery or minimally invasive laparoscopic or robotic techniques.
An important distinction: in 2019, the FDA ordered manufacturers to stop selling mesh designed for transvaginal placement (inserted through the vagina) to treat prolapse, concluding that the risks outweighed the benefits. Transabdominal mesh (sacrocolpopexy) remains available and has lower complication rates. The most commonly reported mesh complication is erosion through the vaginal wall, occurring in about 4% of abdominal mesh cases within two years. Other possible complications include pain, infection, scar tissue formation, and pain during sex.
Compared to traditional surgery without mesh, abdominal sacrocolpopexy results in fewer anatomical recurrences, though it hasn’t been shown to reduce the rate of repeat surgeries overall.
Recovery After Surgery
Post-surgical recovery varies depending on the approach used. Most surgeons recommend some activity restrictions, though practices vary widely. About 60% of gynecologic surgeons recommend lifting restrictions for at least six weeks after minimally invasive surgery, with many setting the limit at around 10 pounds.
Recent research is challenging the traditional approach of strict restrictions, however. A multicenter study that randomly assigned women to either liberal or restricted activity after prolapse repair found that at three months, women who resumed activities freely (including running, lifting, and strenuous exercise) had similar anatomic outcomes and were equally satisfied. They actually reported fewer prolapse and urinary symptoms than those who restricted their activity. A separate trial confirmed these findings, concluding it was reasonable to encourage patients to resume physical activity after prolapse surgery. This suggests that while some caution in the early days makes sense, prolonged restrictions may not be necessary for most women.
Who Is Most at Risk
Prolapse prevalence rises sharply with age. Women in their 60s have the highest incidence in the U.S., and the rate of women seeking medical consultation peaks between ages 70 and 79. Prevalence among women over 40 is estimated at 41% to 50%, though most of these cases are mild and asymptomatic.
Vaginal childbirth is the strongest modifiable risk factor, with risk increasing alongside the number of deliveries. Obesity adds ongoing strain to the pelvic floor and is one of the few risk factors you can address directly. Menopause plays a role because declining estrogen weakens pelvic connective tissues. Previous hysterectomy also increases risk, since removing the uterus can change the structural dynamics of the pelvic floor. Chronic heavy lifting or physically demanding work contributes to prolapse over time by repeatedly increasing pressure on the pelvic floor. Genetics matter too: some women are born with weaker connective tissue, which predisposes them to prolapse regardless of other factors.