Pelvic organ prolapse sounds scary. Your bladder falling out? Yes, that sounds terrifying! Seeing a bulge of tissue in your vagina? Also, horrifying.
The good news is – prolapse is extremely common, with up to 50% of women having prolapse of some degree. I’d argue more than that because many women aren’t even aware they have one.
To reduce fear, the first thing we need to do is learn what exactly prolapse is. Prolapse is not a sinister diagnosis, although I really understand that being told your organs are falling into your vagina isn’t the greatest news. But it’s not inherently bad and there are many ways we can continue to live life without it bothering us.
Pelvic organ prolapse occurs when there is a weakness or a disruption in the tissues that help to hold up our bladder, rectum and uterus. Prolapse occurs most commonly after a vaginal delivery. The risk increases with more complicated deliveries with vacuum assist deliveries, forceps or prolonged pushing, especially with pushing greater than 2 hours. This is because if there is any tear or trauma to the fascia above the vagina and organs, or any tear or trauma to the pelvic floor muscles – these structures lose support, and they begin to drop. I like to explain it as spraining an ankle – if you tear a ligament in your ankle, you will always have increased mobility in that foot/ankle. The chances of a recurring ankle sprain are high because tearing that ligament gives the ankle less stability. We can strengthen the muscles around that foot and ankle to help the stability, as well as up the chain to have strong hips to further support the foot. The same thing can happen around the vagina – if the supporting ligaments or muscles or torn, the organs will have more mobility which is why they fall into the vagina. We can manage prolapse by strengthening around it – including the pelvic floor, abdominals and hips. Improving and managing the way we move, managing the way we lift heavy things and managing constipation can all help reduce worsening of prolapse and resolving symptoms.
Vaginal childbirth is one risk factor for prolapse, but you do not have to have had children in order to develop a prolapse. It can also occur from:
1. Straining for bowel movements
2. Straining for lifting (poor pressure management)
3. Chronic coughing or sickness
A prolapse is usually diagnosed by a urogynecologist who may administer a POP-Q test for an accurate diagnosis. Options for treatment are usually pelvic floor physical therapy, pessary, or surgery. As a pelvic floor therapist, I will always recommend pelvic floor physical therapy as part of your treatment team – even if a pessary or surgery is needed for long term management. Research-wise, the recurrence rate for prolapse post-operative is high. This is due to a number of reasons, but I find clinically that is because of underlying dysfunction such as straining for bowel movements or excessive pressure onto the weakened tissues has not been addressed. Sometimes surgery is necessary if fascia and tissues are damaged to the point that supportive structures can no longer do their job of holding organs up – surgery can be life altering at improving quality of life, BUT we have to make sure constipation is managed and pelvic floor muscles are strong for lifelong support.
So, how does pelvic floor physical therapy help?
A common question I get with treating prolapse is – will my bladder go back to where it was? The answer is no. The bladder (or rectum, uterus, etc.) will not go back to its original pre-prolapsed state with pelvic floor PT. Research shows if prolapse is Grade 1-2, it may change positions slightly. But remember what I said at the beginning – grade of prolapse does not correlate to symptoms. Meaning that someone could have a grade 1 prolapse (slight descent/disruption) with a lot of bothersome symptoms like heaviness, pressure and back pain. Someone could have a grade 2/3 with the bladder sitting at the opening of the vagina without any symptoms at all. In pelvic floor physical therapy, our goal is resolving the symptoms of heaviness, pressure, back pain, cramping, difficulty emptying bladder/bowels and correcting lifting patterns, breathing patterns and managing pressure. The pelvic floor muscles can be a cause for the symptoms of pain and pressure, not necessarily the prolapse. If the muscles are being strained by the prolapse and trying to give support, that can increase bothersome symptoms. The longer that a more severe prolapse is stretching the vaginal opening and pelvic floor, the weaker the muscles could get which can overtime worsen a prolapse. In these cases, a pessary can be helpful to provide support to the organs so that the muscles can try to strengthen and thus give more support to the organs.
In pelvic floor physical therapy at Break Free, our assessments are thorough of the following:
1. Internal vaginal exam feeling for pelvic floor muscle tone, strength and coordination
2. Internal vaginal exam in standing position to assess for prolapse change while bearing down and moving into positions like squatting and lifting
3. Abdominal assessment for tone, strength, diastasis (separation), coordination with pelvic floor muscles
4. Breathing assessment for rib mobility, diaphragm movement and coordination with pelvic floor muscles
5. Spine assessment for mobility and postural strength
6. Lower body assessment for hip and foot strength, mobility and balance
7. Nervous system assessment for dysregulation, pain/symptom tolerance, activity tolerance, head/neck pain, clenching patterns
*8. Depending on your area, some pelvic floor physical therapists are trained to measure and fit patients for pessaries!* Even if your therapist is not trained to fit one, they can educate you on if a pessary may be a good option and refer you to an ob/gyn or urogynecologist to be fitted.
We hope this information is helpful if you are struggling with bothersome symptoms or just learned you have a prolapse. You do have options and prolapse is extremely common. Education is our best tool to empower you in managing you prolapse and finding the best treatment option and team for you. Pelvic floor physical therapy will be one of your best assets for relief!
