Help & Support

"They spoke about prolapse like it was something that was so common, I couldn’t believe it. It shouldn’t be common, new mums shouldn’t have to deal with prolapse or pelvic floor dysfunction on top of a new baby and sleep deprivation"

What is Pelvic Organ Prolapse?

Pelvic organ prolapse (POP) is not uncommon although many women haven’t heard of the condition prior to experiencing it. Millions of women around the world will develop POP at some point in their lives. Statistically 50% of women who deliver a baby vaginally will have some degree of prolapse in their lifetimes, although many of those won’t notice it, or won’t be bothered by a small prolapse.

Prolapse is a hernia of pelvic organs through the opening in the pelvic floor muscle. It is harmless but can cause frustrating symptoms. Keeping it simple, it is when an organ (or organs) such as the bladder, uterus or bowel loses some of its support and moves downwards through the vagina.

Organs that may be affected by prolapse include:

  • Bladder
  • Uterus
  • Small bowel
  • Large bowel most commonly the rectum

What are the symptoms?

Many women with POP do not experience any symptoms. However, when women do have symptoms they can range from minor changes to completely life-altering consequences. The most common symptom is feeling or seeing a bulge or lump at the opening of the vagina. Sometimes it may cause difficulties with intercourse. Women may also feel a dragging sensation as if something is going to fall out of the vagina. There can also be a feeling of pressure due to the pelvic organs pressing against the walls of the vagina.

Additional symptoms can include some or all of the following:

  • Lower back ache
  • Faecal incontinence
  • Constipation or difficulty having a bowel movement
  • Pain or difficulty having sex
  • A sense that something is ‘falling out’ – this symptom is increased by standing, lifting, tiredness or at period time
  • Urinary incontinence
  • Difficulty passing urine

Diagnosing POP

If you are experiencing any of the above symptoms we suggest you speak to your doctor or make an appointment with a women’s health physiotherapist.  If you have visited or spoken with a doctor or midwife who has dismissed your concerns then find another health professional. Your women’s health physiotherapist or family doctor may suggest you see a gynaecologist or urogynaeologist which needs a referral from your GP. A urogynaecologist may conduct some of the following tests:

  • An internal exam
  • Urodynamic tests
  • A 3D/4D Ultrasound

Prolapse is assessed by describing the extent to which the bladder, uterus, small bowel or back passage move downwards. Sometimes doctors use staging, that is, they will talk about ‘Stage 1 prolapse’ and mention the organ involved. We have recently learned that a Stage 1 prolapse of the bladder or rectum is actually normal, but a Stage 1 prolapse of the uterus definitely is not.

However, what really matters is not the stage of prolapse, but rather the severity of the symptoms you are experiencing. Usually, a prolapse that is not noticed by the patient does not need to be treated, unless it causes problems with bladder or bowel emptying.

Treatments for POP

Pelvic floor physical therapy, especially pelvic floor muscle training, includes bracing and correcting the position for defecation. Recent research has shown that these strategies may make a significant difference in reducing prolapse symptoms. However, long term efficacy is not known.

Women’s health (Pelvic floor) physiotherapist

Your first appointment with a women’s health physio would ideally involve:

  • Education about normal and abnormal bladder and bowel function, regardless of your condition. This will ensure that you do not continue with bad habits which may lead to other problems in the future.
  • An internal muscle examination. This is routinely performed by specially trained physiotherapists to assess your muscle strength and teach you the correct action of the pelvic floor muscle. This is invaluable in giving you feedback about your pelvic floor muscles after childbirth. Not all Women’s health physiotherapists will perform an internal examination, so make sure you are referred to one who does, or a specialized pelvic floor physiotherapist.
  • You may be asked to keep a 1 to 2 day bladder diary.

An example summary of a treatment program may include:

  • Pelvic floor muscle training which includes learning the importance of relaxing the pelvic floor muscles as well as contracting them
  • Practising the knack and habit of bracing with all activities which increase intra-abdominal pressure, such as coughing and sneezing and also bigger tasks such as lifting your baby
  • Making positive changes to your diet to ensure a soft, easy to pass stool
  • Specific strategies to help if you have pelvic pain issues
  • A series of exercises to improve the strength of your pelvic floor muscles

Pessaries

A pessary is a silicon device that it inserted into the vagina and acts as a splint by holding the pelvic floor organs in place. They come in a variety of shapes and sizes and fitting one will be a case of trial and error. A pessary can take some time to adjust to, however, many women find these a useful alternative to surgery and that they can manage their day to day life well while using one.

There is a range of health practitioners qualified to fit pessaries.

Surgical Options

If the prolapse is significant and not responding to conservative measures, a urogynaecologist or gynaecologist will assess which surgical option will best suit your needs.

Surgery

Surgical approaches vary, depending on the type of prolapse, but can include:

  • Posterior prolapse surgery, in which the surgeon secures the connective tissue between the vagina and rectum.
  • Anterior prolapse surgery, in which the surgeon pushes the bladder back up into place and secures connective tissue between the bladder and vagina.
  • Uterine prolapse surgery, to remove the uterus (for women who don’t plan on having any, or any more, children).
  • Vaginal vault prolapse surgery, to correct prolapses of the top end of the vagina (the vault).
  • A series of exercises to improve the strength of your pelvic floor muscles
Implants

Implants may be used in prolapse repair. There has been some controversy in the use of synthetic mesh implant in prolapse repair. There are upsides and downsides of using a mesh implant. Only some women would benefit from mesh use and not all mesh implants are effective. Talk to a specialist or a Urogynecologist in regard to mesh use.

Urogynaecologist

You can get a referral from your GP to see a urogynaecologist. Urogynaecology is a sub-specialty of Gynaecology, and in some countries is also known as Female Pelvic Medicine and Reconstructive Surgery. In Australia and New Zealand it is a formal subspecialty of Obstetrics and Gynaecology which requires at least three years of additional training on top of specialist training. Such doctors have a ‘FRANZCOG’ and ‘CU’ after their name. A urogynaecologist manages clinical problems associated with dysfunction of the pelvic floor, bladder and bowel. However, there are also many general gynaecologists who are very experienced in this field.

Before making any decisions regarding surgery we suggest you seek a second opinion. Before considering any surgical procedure you may wish to try a pessary that can be fitted by either your doctor or a Women’s Health Physiotherapist (pessaries are not fitted by physiotherapists in New Zealand).