Many women describe the same picture: a feeling that "something is coming down" in the vagina, less sensation during sex and drops of urine when they cough or laugh. Urinary incontinence and vaginal laxity often appear together because they share a common root: weakening of the muscles, ligaments and fascia that hold the pelvic organs in place.
It is not a cosmetic issue, nor something you have to put up with after childbirth or menopause. It is a common, well-studied condition with many treatment options: from exercises and pessaries to modern surgical procedures. In large population studies, about one in eight to one in five women will need surgery for prolapse or incontinence at some point in her life. Most, however, improve without surgery when treatment starts early.
Below you will find, in plain language, how the vagina is supported, why it becomes lax, what symptoms it causes, how it is assessed and which treatments are used today, according to international guidelines.
How the vagina, bladder and uterus are supported
Picture the base of the pelvis as a hammock of muscle that closes the pelvis from below. Three openings pass through it: the urethra at the front, the vagina in the middle and the anus at the back. The bladder, uterus and rectum rest on top of it.
The pelvic floor muscles
The main muscle is called the levator ani. At rest it keeps a steady tone, holds the vaginal opening almost closed and supports the organs from below. When you cough, sneeze or lift something heavy, it contracts reflexively within fractions of a second and "locks" the urethra. If the muscle has been injured or weakened, the contraction is delayed or not strong enough.
Ligaments and fascia: the three levels of support
The muscles do not work alone. The vagina is attached to the walls of the pelvis by connective tissue, at three levels:
- Upper level: the uterosacral and cardinal ligaments hold the cervix and the top of the vagina high, toward the sacrum.
- Middle level: the fascia attaches the sides of the vagina to the pelvis. The front wall acts as a shelf for the bladder and the back wall as a barrier in front of the rectum.
- Lower level: the lowest part of the vagina joins the perineum, the muscles around the opening and the tissues around the urethra.
Damage at each level produces a different picture. That is why two women with "laxity" can have completely different symptoms and need different treatment.
Why the vagina becomes lax: causes and risk factors
The vagina is supported by the pelvic floor muscles, the fascia and the ligaments. When this system weakens, the vaginal wall loses its support and neighboring organs begin to bulge into it. The most common reasons are:
- vaginal births, especially with a large baby, a prolonged second stage of labor or the use of forceps,
- the drop in estrogen at menopause, which thins the tissues,
- chronically increased pressure in the abdomen from obesity, chronic cough, constipation or frequent heavy lifting,
- inherited predisposition and connective tissue disorders,
- previous pelvic surgery.
Usually more than one factor is involved. Childbirth may cause the initial damage, but symptoms often appear years later, when age and falling hormone levels reduce the tissue's reserves.
Types of laxity: which wall gives way
- Cystocele: the front wall gives way and the bladder bulges into the vagina. It is the most common type and the one most closely linked to urination problems.
- Rectocele: the back wall gives way and the rectum forms a "pocket". It often comes with difficulty emptying the bowel or the need to press on the perineum to finish.
- Uterine prolapse: the cervix and uterus descend toward the vaginal opening because the upper-level ligaments have become lax.
- Vaginal vault prolapse: after a hysterectomy, the top of the vagina can gradually descend.
- Laxity of the vaginal opening and perineum: the vaginal opening widens, usually after tears during childbirth. It causes a feeling of "air" or reduced sensation during sex, without always involving organ prolapse.
Two or more types often occur together. Proper repair requires identifying all of them before any treatment, so that one wall is not repaired only for the weakness of another to show up later.
Symptoms of vaginal laxity
Mild laxity often causes no symptoms and is found by chance during an examination. When there are symptoms, the most common are:
- a feeling of heaviness, pressure or a "ball" in the vagina that gets worse as the day goes on and eases when you lie down,
- a bulge you can see or feel at the vaginal opening, for example in the shower,
- leaking urine when you cough, sneeze, run or jump,
- a strong urge to urinate, frequent urination or waking up at night to urinate,
- a weak stream, a feeling that the bladder has not emptied, or needing to change position to urinate,
- difficulty emptying the bowel,
- a feeling that the vagina is "loose", reduced sensation or the sound of air during sex, a tampon that does not stay in place.
When you should be examined soon
Some signs should not wait: bleeding or a sore on the bulging wall, inability to urinate, fever with pain when urinating or in the lower back, recurrent urinary tract infections and any bleeding after menopause. Also, any new bulge in the vagina needs to be examined to confirm that it is prolapse and not something else, such as a cyst in the vaginal wall.
How vaginal laxity is linked to urine leakage
The urethra is supported by the front vaginal wall like a hammock. When this support weakens, the urethra moves downward when you cough or sneeze and does not close well enough. This is how stress urinary incontinence develops.
The opposite can also happen. A large cystocele can "kink" the urethra and hide incontinence. The woman has difficulty emptying her bladder but does not leak urine. After the prolapse is corrected, the incontinence may be unmasked. That is why, before surgery, urination is tested with the prolapse reduced. For the types and treatment of urine leakage in general, see the guide to urinary incontinence.
Stress or urge incontinence: why the distinction matters
Leaking urine when you cough or exercise is mainly due to a problem with mechanical support. Leakage that comes with a sudden, uncontrollable urge before you can reach the toilet is related to an overactive bladder and is not corrected by support surgery. Many women have a mixed picture. The distinction determines treatment: a midurethral sling helps with the first type, while the second is treated with bladder training, adjusting fluid intake and, when needed, medication.
Prolapse grades and what the examination involves
Prolapse is usually classified in stages from 0 to 4, based on how far the vaginal wall descends in relation to the vaginal opening when straining:
- Stage 1: mild laxity, more than 1 cm inside the opening.
- Stage 2: the wall reaches close to the vaginal opening.
- Stage 3: the wall bulges outside the opening.
- Stage 4: complete prolapse.
The examination is done lying down and, when needed, standing, with coughing and straining. It is often complemented by a urine culture, measurement of the urine left in the bladder after urination and a bladder diary. Urodynamic testing is needed mainly when surgery is planned or the symptoms are mixed.
How to prepare for your appointment
- for two or three days, record how much you drink, how many times you urinate and when you leak,
- note which activities trigger the symptoms and how much they limit you,
- bring a list of your medications, because some, such as diuretics, affect urination,
- mention your deliveries, any pelvic surgery and whether you are considering another pregnancy,
- ask whether you should come with a full bladder, as a cough test is often done.
Non-surgical treatment of vaginal laxity
- Specialized pelvic floor physical therapy: a supervised program of at least three months. It improves symptoms in the early stages and reduces urine leakage.
- Vaginal pessary: a silicone ring that supports the organs. It suits women who want to avoid or postpone surgery and needs regular check-ups.
- Local estrogen: improves tissue quality after menopause and tolerance of the pessary.
- Lifestyle changes: weight loss, treating constipation and chronic cough, proper technique when lifting.
For laser or radiofrequency treatments promoted as vaginal "tightening", the evidence for prolapse and incontinence is still limited. The FDA has issued a warning about them, so they should not replace diagnosis and evidence-based treatments.
Doing pelvic floor exercises correctly
Kegel exercises only work when done correctly. Many women tighten their abdomen, buttocks or thighs, or even push down, which has the opposite effect. The correct contraction feels like holding in gas and urine at the same time, with a sense of lifting inward and upward.
- Slow contractions: hold for up to 10 seconds, relax for the same time, 8 to 10 repetitions.
- Fast contractions: 10 short, strong contractions right afterward.
- Frequency: three times a day, for at least three months, before judging the result.
- Contract before effort: tighten your pelvic floor just before you cough, sneeze or lift something.
Do not stop the flow of urine as a routine exercise, because it can disrupt bladder emptying. If you are not sure you are contracting correctly, a check with a vaginal exam or biofeedback by a specialized physical therapist makes a big difference.
Living with a pessary day to day
The pessary is fitted in the office and tried for size, like a shoe. When it fits correctly, you cannot feel it, it does not fall out when you walk or cough, and it allows normal urination. Some women learn to remove and clean it themselves. Others prefer to have it changed or cleaned in the office every few months.
Slightly increased vaginal discharge is expected. Bleeding, foul-smelling discharge or pain need to be checked, because they may mean irritation or a small ulcer in the vaginal wall. Some types of pessary allow sexual intercourse, while others are removed beforehand.
Local estrogen: which women it helps
This is a very low-dose cream, vaginal tablet or ring that acts mainly on the vagina and urethra, with minimal absorption into the blood. On its own it does not correct prolapse. However, it reduces dryness, irritation, recurrent urinary tract infections and urgency in women after menopause, and it is often given for a few weeks before surgery. In women with a history of breast cancer, the decision is made individually, in consultation with the oncologist.
Surgical treatment: options in modern practice
Surgery is recommended when symptoms affect daily life and non-surgical treatments have not worked or do not suit you. The choice of technique depends on which part has become lax, whether there is also urine leakage, age and general health, sexual activity and the wish for a future pregnancy.
Repair using the woman's own tissues
This is the main operation for cystocele and rectocele. It is done through the vagina, with no abdominal incisions. The surgeon identifies the weakened fascia, stitches it to form a firm support again and removes only the excess wall, so that the vagina does not become narrow. When the opening has also become lax, perineoplasty repairs the perineum.
If the top of the vagina has also descended, its support is restored in the same operation with stitches to strong pelvic ligaments, such as the sacrospinous or uterosacral ligaments. When there is also uterine prolapse, vaginal hysterectomy or preserving the uterus by suspending it is discussed. Front wall repair has a higher chance of recurrence than other areas, but recurrence is often mild and does not always cause symptoms. Proper support of the vaginal vault appears to reduce this risk.
Midurethral sling for stress incontinence
A thin polypropylene tape is placed through a small incision in the vagina, under the middle of the urethra, and passes either behind the pubic bone or through the obturator foramina of the pelvis, toward the groin. It is not pulled tight. It acts as a point of resistance when pressure in the abdomen rises suddenly. The procedure is short and often allows discharge the same or the next day.
It is one of the most studied procedures in urogynecology. Like any method, it has possible complications: difficulty urinating, new urgency, groin pain, more often with the obturator approach, and rarely exposure of the tape in the vagina. In the United Kingdom, the 2018 restrictions also covered tapes, which are now offered after detailed counseling and always alongside the alternatives:
- Burch colposuspension, open or laparoscopic,
- a sling made from the patient's own fascia (autologous sling),
- bulking agent injections around the urethra, which are less demanding but give a less durable result.
When prolapse and stress incontinence occur together, the repair can be done in the same operation or in two stages. The decision is based on the examination with the prolapse reduced and on your own preferences.
Sacrocolpopexy for vaginal vault prolapse
When the top of the vagina or the uterus has descended significantly, mainly in younger, sexually active women or after a recurrence, the vaginal vault can be suspended to the sacrum with a mesh tape, through the abdomen. This operation is different from mesh placed through the vagina and remains an established procedure. However, it takes longer and has its own possible complications, which are discussed in detail before the decision.
Colpocleisis
In older women with advanced prolapse who no longer wish to have sexual intercourse and are at higher risk from a major operation, the vagina can be partially closed. It is a short operation with a very low chance of recurrence, but it is irreversible. That is why it requires a mature, informed decision.
The current facts about mesh for prolapse and incontinence
Views on synthetic mesh have changed significantly over the last decade, and you should know this before making any decision:
- Transvaginal mesh for prolapse: in 2019 the US FDA ordered manufacturers to stop selling mesh for transvaginal repair of anterior wall prolapse, while strict restrictions have applied in the United Kingdom since 2018. Today it is used only in selected cases, mainly for recurrence, and after detailed counseling.
- Midurethral slings for stress incontinence: remain an evidence-based option, with long-term data, once non-surgical treatments have been tried first.
- Abdominal sacrocolpopexy with mesh: is considered an established procedure for vaginal vault prolapse and is usually performed by laparoscopy.
- Repair using the patient's own tissues: remains the most common first choice for anterior and posterior wall prolapse.
What to expect before and after surgery
Preparation
- a urine test for infection and, when needed, urodynamic testing,
- an anesthesia assessment, usually for spinal or general anesthesia,
- local estrogen for a few weeks in women after menopause, when appropriate,
- managing constipation and stopping smoking, because smoking delays healing and keeps a cough going.
The first days
After vaginal repair, a urinary catheter and vaginal gauze may stay in place for a few hours. Before discharge, we check that the bladder empties properly. If not, the catheter stays in for a few days or you learn to empty your bladder with a thin catheter, usually temporarily. Mild pain, controlled with simple painkillers, and pink or brownish discharge for a few weeks while the stitches dissolve are expected.
Returning to activities
- Walking: from the first day, gradually more.
- Light office work: usually after two to four weeks.
- Driving: when you can brake hard without pain.
- Heavy lifting, strenuous exercise, sexual intercourse: after about six weeks and the postoperative check-up.
Contact your gynecologist right away if you have a fever, heavy bleeding, increasing pain, foul-smelling discharge or cannot urinate.
How to protect the result
No operation changes the quality of connective tissue. Long-term success also depends on daily habits: continuing pelvic floor exercises, a healthy weight, soft bowel movements without heavy straining, treating chronic cough and using proper technique when lifting, with bent knees and a tightened pelvic floor. Regular check-ups help detect a possible recurrence early.
For a personalized assessment of your symptoms, book an appointment with Dr. Panagiotis Polyzos at his office in Athens or Volos.
Frequently Asked Questions
What is vaginal laxity?
It is the weakening of the pelvic floor muscles and ligaments, so that the bladder, uterus or rectum bulges into the vagina (prolapse). It often occurs together with urinary incontinence.
What symptoms does it cause?
A feeling of heaviness or a "ball" in the vagina, difficulty urinating or emptying the bowel, urine leakage and discomfort during sex. Symptoms get worse with standing and at the end of the day.
Can it be treated without surgery?
In the early stages, pelvic floor exercises, weight loss, a vaginal pessary and local estrogen after menopause help. For non-surgical treatments of incontinence, see the guide to urinary incontinence in women.
Is mesh safe?
Midurethral slings for stress incontinence are an established treatment. The use of transvaginal mesh for prolapse has been restricted internationally and is now chosen for specific indications, after detailed counseling on benefits and possible complications.
How long does recovery take after surgery?
After vaginal repair, the hospital stay is usually one to two days, while a midurethral sling for stress incontinence often allows discharge the same or the next day. Heavy lifting, strenuous exercise and sexual intercourse are avoided for about six weeks.
Can I have surgery if I want another child?
It is usually recommended to complete your family first, because a new pregnancy and delivery can undo the result. In the meantime, non-surgical measures are used.
Does every cystocele need surgery?
No. A small cystocele without symptoms is simply monitored. Treatment, non-surgical or surgical, is recommended when there are symptoms that affect daily life, such as a feeling of heaviness, difficulty urinating or urine leakage.
Does vaginal laxity affect your sex life?
It can cause reduced sensation, embarrassment or discomfort during sex, and some women also leak urine during sexual activity. Pelvic floor physical therapy and, when needed, surgical repair often improve these symptoms. It is worth discussing this openly with your gynecologist.
When should pelvic floor exercises start after childbirth?
Gentle contractions can usually start in the first days after a vaginal birth, if there is no pain. A structured program, ideally guided by a physical therapist, helps prevent laxity and urine leakage in the following months.
