Uterine prolapse: What are your treatment options?

If pelvic floor exercises or pessaries don't help enough, surgery is sometimes considered. Before deciding whether or not to have surgery, it's a good idea to find out about the pros and cons of the different options first. This decision aid can help here.

What are pelvic floor exercises?

Pelvic floor exercises – also called Kegel exercises or Kegels – strengthen the muscles in the lower part of the pelvis. These muscles help to support the womb (uterus) and the bladder. The exercises involve learning to move your pelvic floor muscles in a controlled way, to strengthen and stabilize them. Each session includes various exercises that last a few minutes and are repeated one to three times per day.

The exercises are particularly suitable for women who have light bladder weakness (stress incontinence) and feelings of pressure in their lower belly. It is best if a physical therapist (physiotherapist) shows you how to do the exercises. In Germany, a doctor can give you a prescription for physical therapy and then the costs are covered by your public health insurance. Once you have learned how to do the exercises, you can do them on your own at home.

There is a list of suitable physical therapists on the website of the German physiotherapy association (Deutscher Verband für Physiotherapie – in German).

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When you do pelvic floor exercises, you learn to activate your pelvic floor muscles in a controlled way. You will find more information and tips for daily life in the article "Pelvic floor exercises."

How effective are pelvic floor exercises?

Pelvic floor exercises can improve the symptoms in mild and moderate prolapse cases (stages 1 to 3) and sometimes also prevent the organs from slipping down further. The beneficial effects may already be noticeable after a few weeks. But these exercises don’t always help. Some women still have problems despite doing them. Pelvic floor exercises usually don't have any side effects when done properly. If they are carried out incorrectly, they can result in tension and pain.

To increase the chances of success, it’s important to do the exercises as instructed – and especially to do them regularly. This is easier if you make them part of your daily routine.

The exercises are more effective if the prolapsed organs are in the front part of the pelvis, where the bladder and urethra (urine tube) are found. If you have had prolapse surgery, pelvic floor exercises probably won’t help much more – at least not in the first few years after the operation. Studies in this area have found that pelvic floor exercises don’t make a difference in women who have already had prolapse surgery. But it’s not clear whether the exercises might prevent the organs from dropping down again in the long term.

What are pessaries and how do they work?

Vaginal pessaries for the treatment of prolapse are small cubes, rings or saucer-shaped devices made of rubber or silicone. They are inserted into the vagina and pushed up to the cervix (neck of the womb).

Although pessaries don’t treat the cause of the prolapse, they can keep the affected organs in their natural position. Experts also think that using a pessary might help to strengthen the pelvic floor muscles.

Pessaries are available in different shapes and sizes. People often have to try out a number of different pessaries before finding one that works. If possible, doctors usually prescribe pessaries that women can insert, remove and clean themselves every day. Other types of pessaries can stay in the vagina for 6 to 8 weeks but then have to be changed at the doctor's office.

The doctor checks the pessary regularly to look for signs of complications like damaged skin or infections. These check-ups take place every 4 to 12 weeks, depending on the situation.

Different types of pessaries

Saucer-shaped pessary

Ring pessary

Cube pessary

How effective are pessaries?

Well-fitting pessaries can support the pelvic organs in a way that reduces bladder and bowel problems or even makes them go away completely. They don’t fix prolapses. But women don’t always find a suitable pessary that is effective enough.

Pessaries are recommended if, for instance, a woman wishes to avoid or delay surgery. About half of all women who use a pessary get by with it so well that they use it for several years. Pessaries can also be a good idea if pelvic floor exercises don’t help enough on their own.

Do pessaries have disadvantages?

Because pessaries push against the lining of the vagina, they can irritate the mucous membranes there and even lead to pressure sores. These cause symptoms such as pain and bleeding. Vaginal infections may occur, too. A pessary can also disrupt bowel movements and make it harder to empty your bowel (poop). So it's a good idea to have regular check-ups where your doctor can check the pessary and examine your vagina.

Pessaries generally have no negative effects on your sex life – as long as they fit properly and women get by well with them. They can even have a positive effect by reducing prolapse-related problems such as pain during sex and feelings of pressure. But certain types of pessaries make it impossible to have vaginal sex (where the penis enters the vagina). Some pessaries can be removed before having sex, though.

To avoid side effects, it’s important that the pessary is well positioned and also changed and cleaned regularly. A lubricant gel can make it easier to insert the pessary. After menopause, women who use a pessary are advised to protect the lining of their vagina with a hormone cream – unless they have previously had cancer in a reproductive organ, or breast cancer.

Sources

• Barber MD. Pelvic organ prolapse. BMJ 2016; 354: i3853. [PubMed: 27439423]
• Bugge C, Adams EJ, Gopinath D et al. Pessaries (mechanical devices) for managing pelvic organ prolapse in women. Cochrane Database Syst Rev 2020; (11): CD004010. [PMC free article: PMC7173753] [PubMed: 23450548]
• Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG). Weiblicher Descensus genitalis, Diagnostik und Therapie (S2e-Leitlinie, in Überarbeitung). AWMF-Registernr.: 015-006. 2015.
• Espiño-Albela A, Castaño-García C, Díaz-Mohedo E et al. Effects of Pelvic-Floor Muscle Training in Patients with Pelvic Organ Prolapse Approached with Surgery vs. Conservative Treatment: A Systematic Review. J Pers Med 2022; 12(5). [PMC free article: PMC9142907] [PubMed: 35629228]
• Haya N, Feiner B, Baessler K et al. Perioperative interventions in pelvic organ prolapse surgery. Cochrane Database Syst Rev 2018; (8): CD013105. [PMC free article: PMC6513581] [PubMed: 30121957]
• Li C, Gong Y, Wang B. The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis. Int Urogynecol J 2016; 27(7): 981-992. [PubMed: 26407564]
• Sansone S, Sze C, Eidelberg A et al. Role of Pessaries in the Treatment of Pelvic Organ Prolapse: A Systematic Review and Meta-analysis. Obstet Gynecol 2022; 140(4): 613-622. [PubMed: 36075076]
• Taithongchai A, Johnson EE, Ismail SI et al. Oestrogen therapy for treating pelvic organ prolapse in postmenopausal women. Cochrane Database Syst Rev 2023; (7): CD014592. [PMC free article: PMC10335326] [PubMed: 37431855]
• Wharton L, Athey R, Jha S. Do vaginal pessaries used to treat pelvic organ prolapse impact on sexual function? A systematic review and meta-analysis. Int Urogynecol J 2022; 33(2): 221-233. [PubMed: 34982188]
• Wu YM, McInnes N, Leong Y. Pelvic Floor Muscle Training Versus Watchful Waiting and Pelvic Floor Disorders in Postpartum Women: A Systematic Review and Meta-analysis. Female Pelvic Med Reconstr Surg 2018; 24(2): 142-149. [PubMed: 29474288]

• IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

  Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

  Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.