By the Doctors: Nico Naumann, Gynecologist; Valeria Gianfreda, Pelvic Floor Surgeon; Francesca Maccioni, Radiologist and Ultrasound Specialist; Christine Blondeel, Midwife and Specialist in Pelvic Floor Rehabilitation.
Dr. Nico Naumann, gynecologist, introduces a topic that concerns a great many women and that, even today, is often experienced in silence.
Increasingly frequently, after menopause — but sometimes even before — patients report a sensation of pelvic heaviness or the perception that “something is descending.” During examination, a genital prolapse may be identified, with possible weakening of the anterior vaginal wall and involvement of the bladder, or of the rectal compartment.
As Dr. Naumann emphasizes, symptoms may simultaneously affect multiple domains: urinary, intestinal, and sexual. For this reason, a comprehensive pelvic floor evaluation is essential today.
Prolapse is not a problem “of a single organ.” It is a condition requiring a multidisciplinary approach and a three-compartment evaluation, integrating gynecological, surgical, diagnostic, and rehabilitative expertise.
How common is prolapse and why does it occur?
Dr. Valeria Gianfreda, a pelvic floor surgeon, explains that pelvic organ prolapse is far more common than many people think. Estimates suggest it may affect 30% to 50% of women, and the true figures may be even higher: many patients do not talk about their symptoms out of embarrassment or because they consider them “inevitable” after pregnancy or with advancing age.
However, when prolapse starts to impact quality of life, effective diagnostic and treatment pathways are available.
Why it occurs: main risk factors
Prolapse is often the result of several factors that accumulate over time. The main risk factors include:
- Family history (mother, grandmother, or sisters with similar issues)
- Pregnancies and childbirth
- Hormonal changes during the perimenopausal period
- Significant weight fluctuations
- Chronic constipation and repeated straining during bowel movements
Warning signs not to ignore
Dr. Gianfreda reminds us that prolapse rarely presents with a single, isolated symptom. More often, it involves multiple compartments (bladder, vagina/uterus, rectum).
Urinary area
- Urinary incontinence
- Urinary urgency
- Sensation of incomplete emptying
- Frequent need to urinate
Genital area
- Sensation of vaginal heaviness
- Feeling of a “foreign body” in the vagina
- Pain or discomfort during intercourse
Rectal area
- Persistent constipation
- Ongoing bowel disturbances
- Anal pain
- Difficulty with bowel movements
👉 The right time to consult a specialist is when these symptoms start to affect daily activities, well-being, and quality of relationships.
Diagnosis: why dynamic examinations are needed
Dr. Francesca Maccioni, radiologist and ultrasound specialist, explains that when pelvic organ prolapse is discussed, it is often seen as a “bladder” or “bowel” problem. In reality, the pelvic floor is an integrated system: the organs influence one another, and symptoms can be mixed.
For this reason, the most appropriate diagnostic approach is often dynamic imaging: it does not simply capture the organs’ position, but observes their movement during function.
Dynamic examinations make it possible to assess:
- How the organs descend and at which phase
- How far they descend
- Which compartment is involved (anterior, middle, posterior)
- Whether the disorder is mechanical, functional, or both
This approach is essential to avoid partial diagnoses and to plan targeted therapy.
MR defecography
Magnetic resonance imaging with a defecographic study makes it possible to evaluate the bladder, uterus/vagina, and rectum during functional maneuvers.
It is particularly indicated in the presence of:
- Difficulty with bowel movements
- Sensation of incomplete emptying
- Mixed urinary, intestinal, and genital symptoms
Dynamic cysto-colpo-defecography
This is an alternative diagnostic method with the same goal: to functionally document organ descent and their reciprocal relationships.
As Dr. Maccioni explains, the choice between the two examinations depends on:
- Predominant symptoms
- Clinical indication
- Diagnostic work-up already completed
- Multidisciplinary specialist assessment
Complementary examinations
Depending on the clinical picture, the following may be added:
- transvaginal ultrasound
- Pap test
- Colonoscopy
- Urodynamic study
These are not alternatives to dynamic examinations, but pieces that complete the diagnostic puzzle.
When surgery is needed
Dr. Valeria Gianfreda explains that surgery is considered mainly for prolapse beyond stage II, when symptoms have a tangible impact on everyday life: walking, working, traveling, having sexual intercourse, and taking care of oneself.
A key point is uterine preservation whenever possible. A hysterectomy can alter pelvic anatomy and affect bladder and rectal function, in addition to having a significant emotional impact. For this reason, it is avoided unless strictly necessary.
Minimally invasive P.O.P.S. technique
The P.O.P.S. technique is a minimally invasive laparoscopic procedure for multi-organ prolapse. It involves:
- Three small abdominal incisions
- Placement of a V-shaped polypropylene mesh
- Support and repositioning of the bladder, uterus, and rectum in a single operation
- Average duration of about 120 minutes
- Hospital stay of about 3 days
- Generally rapid and gradual recovery
A benefit that many patients particularly value is preservation of the uterus, when clinically feasible.
Rehabilitation: the core of the therapeutic pathway
Dr. Christine Blondeel, a midwife specialized in pelvic floor rehabilitation, emphasizes that prolapse treatment is not the same for every woman. It follows a gradual and personalized pathway, as also recommended by the guidelines of the International Continence Society (ICS) and the International Urogynecological Association (IUGA).
Early prolapse (stages I–II): when rehabilitation can make a difference
In the early stages, in the absence of severe symptoms, first-line treatment is conservative.
A structured Pelvic Floor Muscle Training (PFMT) program can:
- Improve muscle tone and endurance
- Reduce the sensation of pelvic heaviness
- Improve quality of life
- Slow prolapse progression
The pathway begins with an assessment of proprioception and the ability to perform a voluntary contraction. If difficulties are identified, biofeedback or functional electrical stimulation may be used.
In parallel, work focuses on:
- Diaphragmatic breathing
- Posture
- Management of everyday pressures (coughing, constipation, lifting loads)
- Early intervention helps prevent worsening and, in some cases, may delay or avoid surgery.
Preoperative rehabilitation
When prolapse is advanced (stages III–IV) and surgery is indicated, preoperative rehabilitation significantly improves outcomes.
The program includes:
1️⃣ Pelvic floor strengthening
2️⃣Deep abdominal strengthening (hypopressive exercises, transversus abdominis activation)
3️⃣ Behavioral education, with attention to:
- A fiber-rich diet and adequate hydration
- Physiological posture for bowel movements
- Anticipatory perineal contraction before exertion
Patients who prepare the perineum before surgery often show better postoperative contraction and less loss of tone.
Postoperative rehabilitation
Surgery restores anatomy, but it does not automatically correct muscular dysfunction or abdomino-pelvic dynamics.
Dr. Blondeel notes that postoperative rehabilitation—generally started 6–8 weeks after surgery, as advised by the surgeon—aims to:
- Reactivate voluntary contraction
- Improve muscle endurance
- Correct paradoxical straining
- Coordinate breathing and the pelvic floor
One of the main factors behind recurrence is chronic increased intra-abdominal pressure (constipation, persistent cough, heavy lifting, breath-holding during effort). Pelvic floor education teaches exhalation–contraction coordination and non-straining bowel strategies, which are essential to maintain surgical results over time.
An integrated pathway for pelvic floor health
As Dr. Nico Naumann reiterates, prolapse should not be experienced as a condition to simply “put up with.” It is common, but today it can be managed with tailored strategies.
At Aventino Medical Group in Rome, the pathway is truly multidisciplinary:
- Three-compartment clinical evaluation
- Targeted dynamic diagnostics
- Minimally invasive surgical approach when necessary
- Personalized rehabilitation at each stage
The goal is not only to correct anatomy, but to restore quality of life, function, and well-being.
If you have persistent urinary, genital, or intestinal symptoms—such as a sensation of pelvic heaviness, incontinence, urgency, or difficulty with bowel movements—book a specialist evaluation to set up a comprehensive, personalized care pathway.
Pelvic floor health deserves attention, expertise, and an integrated approach.