Pelvic Organ Prolapse: What you should know

So here I am writing about another topic that’s not openly discussed…AGAIN, but that’s why I love my job. We get to talk about the underlying issues that the common folk are embarrassed to talk about, and we are here at Hey Babe to bury the stigma about prolapse once and for all!  

What is prolapse?

The medical definition of prolapse or aka, pelvic organ prolapse (POP) in this case, is when an organ slips out of place and for most women, this happens when the bladder, urethra, uterus, cervix, rectum, or vaginal wall protrude into the vaginal canal.  

It is estimated that 40% of women between the ages of 45 and 85 have POP, as well as two-thirds of women who have had children. With such a high occurrence, why am I still encountering so many patients who are not aware of this condition? Why aren’t we more proactive about prolapse? Ultimately, it’s a matter of awareness. By understanding the causes and implications of POP, we can definitely be more proactive. Let’s dive into some of the details.

POP happens when pelvic and abdominal connective tissue and ligaments are lax and don’t provide as much support to the pelvic organs, allowing them to sit lower into the pelvis.

Common risks include:

• vaginal childbirth
• excessive intra-abdominal pressure such as sneezing, coughing, laughing, or heavy weightlifting
• chronic constipation and/or straining for bowel movements
• aging and menopause
• hypermobility spectrum disorders
• obesity

Prolapse commonly presents as a sensation of heaviness in the pelvis, especially with prolonged walking and standing, and is typically worse at the end of the day. Other symptoms may include urinary or bowel incontinence, back pain, discomfort with sex. Sometimes women are asymptomatic, meaning they have no idea it is there. That is great…for now, but with another pregnancy or as connective tissue and muscle bulk decline with age, a prolapse can worsen and lead to any of the symptoms listed above.

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Where to begin:

If you think you have a prolapse, where should you begin? We highly recommend having an evaluation performed by a pelvic floor physical therapist. The exam typically is very similar to any orthopedic evaluation, observing how you walk and analyzing your posture, overall strength, balance, and flexibility. The only major difference is the pelvic exam in which the following are assessed: the strength of the pelvic floor, if you can relax and lengthen the pelvic floor muscles, muscle tension and trigger points, swelling, and nerve health. With lengthening of the pelvic floor, this allows the therapist to feel if a prolapse is present and then grade the severity. This is usually based on a 4-grade scale:

• Grade 1: organ extends halfway to the opening of the vagina  
• Grade 2: protrudes to the vaginal opening
• Grade 3: protrudes just outside of the vaginal opening
• Grade 4: the organ is completely outside of the vagina

Grades 1 and 2 can be treated with avoiding certain activities while strengthening the pelvic floor, core, and hip muscles and coordinating those muscles to provide more support to your pelvic organs.

Grade 3 POP will benefit from the same treatment of grades 1 and 2 but may also require internal support like a pessary. In some cases, grade 3 may require surgery but it is recommended you try physical therapy and pessaries first.

Grade 4 POP should be treated with all of the above. Some opt to use a long-term pessary instead of opting for surgery, however this type of prolapse can respond well to surgery if you go to pelvic floor physical therapy for “prehab” to prepare you for surgery and optimize your healing post-operatively.

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What to avoid:

While prolapse is treatable and can become asymptomatic with the right treatment, there is a possibility it can get worse with specific activities.

Avoid:

• Straining for bowel movements
• Pushing your pee instead of just relaxing to empty your bladder
• High impact activity (for now)
• Standing for long periods of time without breaks
• Holding your breath when picking up large or heavy objects

How can Pelvic Floor Physical Therapy help me with this?  

Here are some interventions that address a diagnosed prolapse or prevent prolapse from happening:

• Controlling pressure in the abdomen. This may not sound like much but it’s extremely important! Our diaphragm and pelvic floor should move up and down together naturally with our breath, but when this coordination is disrupted, large forces such as pushing in labor, heavy weightlifting, and straining with bowel movements can force an organ to displace.
• Managing constipation. Now that we know to avoid straining, there are many ways to get things moving. It may seem obvious but start tracking how much water and fiber consume daily because you may be surprised. You should take in at least half your body weight in ounces (converted from weight in pounds) and at least 21-25 grams of fiber for women and 30-38 grams of fiber for men. A Physical Therapist can show you how to perform pelvic floor relaxation techniques, abdominal massage to stimulate natural intestinal movement, breathing techniques, and proper mechanics involved in a bowel movement. And don’t forget our favorite tool, the Squatty Potty, which naturally relaxes the muscle that slings around your rectum.  
• Pelvic floor strengthening and coordination. The pelvic floor muscles require constant activation to support the bladder, uterus, cervix, vagina, and rectum just like our postural muscles in our core and back that allow us to sit upright for a long time. Even if the pelvic floor muscles are strong, it is common for these muscles to turn on and off at the wrong times. For example, the pelvic floor may shut off if these muscles don’t have the endurance to keep contracting throughout a long run. The levator ani can also be overactive to support the pelvis if the core and glutes are not doing their fair share, so when it’s time to sneeze, the LA are too fatigued to turn on.  ‍
• Looking at the body as a whole. Our pelvis plays a large part in how we transfer weight throughout our body, so it needs to be well supported by other much larger muscles too, such as the glutes, core, and all the muscles in our legs. Posture is another huge factor. With pregnancy, the weight of the fetus commonly pulls the pelvis forward, with the poor little bladder being smushed. To correct this takes both strengthening the core and glutes, as well consciously correcting your pelvic tilt throughout the day so it becomes a habit.  ‍
• Activity modification. We DESPISE telling you to avoid doing your favorite things, but sometimes we have to prioritize healing over some activities. It’s temporary, we swear. This applies after vaginal delivery, when there is significant swelling, and the pelvic floor tissue is still healing. Activities that typically worsen a POP are running, jumping, heavy lifting, prolonged walking and standing.  

What are other ways to supplement Physical Therapy?

• Topical Estrogen. The American College of Obstetricians and Gynecologists (ACOG) states there are no risks related to breast cancer and recurrence when vaginal estrogen is applied. Topical estrogen can be a real game changer by improving the health of vaginal and surrounding tissues, bringing more blood flow and increasing tolerance to pessaries (see below).
• Pessaries. A pessary is a vaginal insert that is composed of medical grade silicone. Pessaries are typically used in women with a Grade 3 or 4 prolapse and can be fitted by a skilled physician. Pessaries give women freedom to return to exercise and do the things they love without that aggravating heaviness in your pelvis.

And then there’s surgery…only if you must. These surgeries have high failure rates within 5 years (greater than 60%), meaning if you have a surgery there is a high likelihood you will need another within 5 years. This is why we highly recommend seeking conservative care first. There are two types of surgery, obliterative and reconstructive, both are very different. Here’s how:

Obliterative: This surgery narrows or closes off the vagina, in which sexual intercourse is no longer possible but this surgery has a high success rate.  

Reconstructive: This is the more commonly performed surgery that can be done through an incision in the vagina or abdomen. There are multiple approaches:

• Fixation or suspension: Ligaments from our own uterus or sacrum are used to reattach the uterus or vagina walls to the original position via a vagina incision.
• Colporraphy: Stitches are placed along the front or back of the vagina to repair a bladder or rectal prolapse.
• Sacrocolpopexy: This is where mesh, a synthetic material, is used to suspend the vaginal walls or small intestines to the vagina and sacrum. However, mesh can result in severe consequences such as erosion, infection, bowel or bladder perforations, and pain. Yikes!  
• Sacrohysteropexy: This surgery is indicated for uterine prolapse and suspends the uterus to the cervix and sacrum with mesh. This is indicated when a woman does not want a hysterectomy, a procedure where the uterus is removed.

If you opt for surgery or you have done everything else and surgery is your remaining option, remember to seek out pelvic floor physical therapy before and after surgery to optimize your outcomes and prevent surgery failure.

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That’s prolapse in a nutshell! Hopefully this information can directly help you or at least spread more awareness about ways to manage or prevent prolapse. Contact a Pelvic Floor Physical Therapist if you are seeking treatment for prolapse or want more information <3

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Sources:

Wang, B., Chen, Y., Zhu, X., Wang, T., Li, M., Huang, Y., Xue, L., Zhu, Q., Gao, X., & Wu, M. (2022, August 15). Global burden and trends of pelvic organ prolapse associated with aging women: An observational trend study from 1990 to 2019. Frontiers. https://www.frontiersin.org/articles/10.3389/fpubh.2022.975829/full

Vergeldt, T. F. M., Weemhoff, M., IntHout, J., & Kluivers, K. B. (2015, May 13). Risk factors for pelvic organ prolapse and its recurrence: A systematic review - international urogynecology journal. SpringerLink. https://link.springer.com/article/10.1007/s00192-015-2695-8

ACOG supports the use of estrogen for breast cancer survivors. ACOG. (n.d.). https://www.acog.org/news/news-releases/2016/02/acog-supports-the-use-of-estrogen-for-breast-cancer-survivors#:~:text=Although%20there%20is%20controversy%20related,use%20of%20topical%20vaginal%20estrogen

Surgery for pelvic organ prolapse. ACOG. (n.d.-b). https://www.acog.org/womens-health/faqs/surgery-for-pelvic-organ-prolapse#:~:text=In%20general%2C%20there%20are%20two,not%20possible%20after%20this%20procedure.

Jelovsek JE;Barber MD;Brubaker L;Norton P;Gantz M;Richter HE;Weidner A;Menefee S;Schaffer J;Pugh N;Meikle S; ; (n.d.). Effect of uterosacral ligament suspension vs sacrospinous ligament fixation with or without perioperative behavioral therapy for pelvic organ vaginal prolapse on surgical outcomes and prolapse symptoms at 5 years in the optimal randomized clinical trial. JAMA. https://pubmed.ncbi.nlm.nih.gov/29677302/

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