What causes vaginal prolapse?

Causes of Vaginal Prolapse

Vaginal prolapse results from weakening or damage to the pelvic floor support structures, with vaginal childbirth being the most significant modifiable risk factor, followed by advancing age, obesity, and chronic increases in intra-abdominal pressure. 1

Primary Causative Mechanisms

Obstetric Trauma

• Vaginal childbirth causes direct mechanical injury or denervation damage to the pelvic floor musculature, increasing stress on fascial support structures and leading to progressive weakening of pelvic floor integrity 1
• The levator ani muscle complex sustains damage during vaginal delivery, compromising the primary support mechanism for pelvic organs 1
• Increasing parity progressively elevates risk, with weighted prevalence rates ranging from 1.4% to 4.5% depending on number of vaginal deliveries 1
• Prior vaginal reconstructive surgery or episiotomy correlates with muscle defects visible on imaging studies 2

Age-Related Degeneration

• Advanced age contributes to progressive deterioration of pelvic floor support structures through tissue weakening and loss of mechanical strength 1
• Aging evokes tissue denervation and devascularization, anatomic alterations, and increased collagen degradation, all predisposing to prolapse development 3
• Approximately 25-33% of postmenopausal women are affected by pelvic organ prolapse 1

Hormonal Factors

• Menopause compromises tissue integrity and elasticity through estrogen deficiency, affecting connective tissue composition and metabolism 1
• Reduction in protein content and estrogens occurs in uterosacral ligaments, vagina, and parametrium of women with prolapse 3
• Hormonal changes lead to irregular tissue metabolism and biomechanical abnormalities in connective tissue 3

Secondary Contributing Factors

Chronic Mechanical Stress

• Obesity increases chronic intra-abdominal pressure on pelvic structures, creating sustained downward force on support mechanisms 1
• Chronic straining from activities that repeatedly elevate intra-abdominal pressure (constipation, chronic cough, heavy lifting) contributes to prolapse development 1, 4
• Occupational factors including jobs requiring heavy lifting or prolonged standing accelerate support structure failure 1
• Chronic respiratory conditions create repetitive increases in intra-abdominal pressure 1

Anatomical and Structural Defects

• Levator ani muscle dysfunction represents the key pathophysiological mechanism, as damage to this muscle complex compromises primary pelvic floor support 1
• Support defects involve excessive descent of organs through the pelvic floor hiatus 1
• Muscle defects correlate directly with prolapse symptoms and can be quantified on MRI imaging 2
• Patients with prolapse demonstrate larger pelvic floor hiatal areas compared to unaffected women 2

Surgical History

• Hysterectomy predisposes to vaginal vault prolapse through disruption of apical support structures 4, 5
• Preexisting pelvic floor defects prior to hysterectomy represent the single most important risk factor for subsequent vault prolapse 5

Multifactorial Pathophysiology

The development of clinically significant prolapse operates through a "multiple-hit" process in which genetically susceptible women experience cumulative life events (childbirth, aging, mechanical stress) that ultimately overwhelm pelvic support capacity 6

• Prolapse encompasses disruption, stretching, or dysfunction of the levator ani complex, connective-tissue attachments of the vagina, or both 4
• The pathophysiology involves both muscular and fascial components, with secondary findings including displaced lateral and apical vaginal walls 2
• Multiple compartments may be affected simultaneously (anterior, apical, posterior) 1

Clinical Significance

• The lifetime risk of requiring surgery for prolapse or urinary incontinence by age 80 is approximately 11% 1
• Prolapse primarily causes morbidity affecting quality of life rather than mortality, with impact on urinary, defecatory, and sexual function 1, 6
• Many women with anatomic prolapse remain asymptomatic and do not require treatment 4, 7

Important Clinical Pitfall

While genetic susceptibility and connective tissue abnormalities contribute to prolapse risk, the modifiable risk factors (obesity, chronic straining, occupational exposures) should be addressed in prevention strategies, though no definitively effective prevention protocol has been established 4, 3