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Dr Margaret answers e-mailers' embarrassing problems in this biweekly problem page. Genitourinary prolapse Dear
Dr Margaret Where exactly is this bulge? It is not quite clear from your description. It sounds as if it could be the wall of the vagina bulging forwards towards the opening of the vagina. This is called ‘prolapse’. (The correct medical term is ‘genitourinary prolapse’.) It occurs when the muscles and ligaments that support the vagina and uterus have lost some of their strength. This allows the bladder (at the front) or the rectum (back passage) to flop onto the vagina, causing a bulge. In your case it sounds as if it is the rectum pressing onto the back wall. When you push on it you are pushing the rectum, so it is not surprising that faeces come out. Prolapse is a very common condition, especially in women past the menopause who have had children. In fact, gynaecological surgeons spend about 20% of their time dealing with prolapse. It is not a dangerous condition, but it can cause some annoying symptoms. You may experience a dragging feeling in the vagina or backache, or may have difficulty keeping tampons in. Prolapse can also cause problems during sex – such as discomfort, passing wind from the vagina, leakage of urine and a loss of sensation. If it is at the front (i.e. weakness of support for the bladder), it can cause stress incontinence of urine and a tendency to urinary infections. If it is mainly at the back, it can cause constipation or a feeling that you have not emptied your bowels properly. If the bulge is very large, it can protrude through the opening of the vagina, and become sore from rubbing on underwear. Symptoms from prolapse are usually worst at the end of the day, and after standing for a long time. There is no need to put up with these problems, because there are treatments for prolapse. First of all, your doctor will need to examine you to check that the bulge you describe is actually a prolapse, and to estimate its severity. (Anyone with a lump should see their doctor for a check.) This will involve having a speculum inserted into the vagina (like having a smear), and possibly a rectal examination. There are a some things you can do to help yourself. Are you fat? If so, lose some weight. This will reduce strain on the pelvic muscles and ligaments that support the vagina. Do you have a chronic cough, such as a smoker’s cough? Each time you cough, the pelvic floor is strained, so this is another reason to stop smoking. If you are at or past the menopause, you might consider asking your doctor for HRT; some people think this helps the pelvic floor (but I have not been able to find any research that confirms this). If the prolapse is not severe, you should definitely do pelvic floor exercises to strengthen the supporting muscles. The other main treatments for prolapse are pessaries and surgery. Pessaries are made from plastic or latex rubber. They are placed in the vagina to give support where it is needed, and there are many different shapes. Some are like rings or doughnuts, others are saddle-shaped and there is a type that looks like a mushroom. After being fitted, if it is satisfactory, the pessary is usually left in place for 9–12 months – it is not something that you take in and out by yourself. Some types are unobtrusive, but others (especially the substantial types used for severe prolapse) get in the way during intercourse, so this is something to discuss with the doctor if a pessary is suggested. Pessaries used to be the standard treatment, but now surgery is recommended if prolapse is causing troublesome symptoms and there are various different types of operation. By the age of 80, 1 in 9 women will have had a surgical operation for prolapse. After surgery you have to avoid heavy lifting, and not have intercourse for 6–8 weeks. Any
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