What is Pelvic Organ Prolapse?
A prolapse is a hernia of pelvic organs through the opening in the pelvic floor muscle. A prolapse in itself is not harmful to physical health if left untreated, however the frustrating symptoms can impact the enjoyment of daily life and adversely impact mental health. Put simply, 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:
- Small bowel
- Large bowel, most commonly the rectum.
Symptoms of Pelvic Organ Prolapse
Some women with Pelvic Organ Prolapse do not experience any symptoms. When women do have symptoms they can range from minor changes to completely life-altering consequences and can include some or all of the following:
- Feeling or seeing a bulge or lump at the opening of the vagina
- Feeling a ‘dragging’ sensation, as if something is going to fall out of the vagina
- Feeling of pressure due to the pelvic organs pressing against the walls of the vagina
- Difficulty, discomfort or pain with intercourse
- Lower back ache
- Faecal incontinence
- Constipation or difficulty having a bowel movement
- Pain or difficulty having sex
- Urinary incontinence
- Difficulty passing urine.
Is Pelvic Organ Prolapse ‘normal’?
In order to discuss “normal”, we have to consider how common some degree of descent is: research looking purely at anatomy (and not other POP symptoms) identifies >50% of women to have some degree of pelvic organ descent, in clinical terms POP of stages of 1 or higher on a POP-Q scale.1,2
So, what is “normal”?
Language matters, some women may have a more significant prolapse than others and yet they don’t feel bothered by their symptoms. Whereas other women could have what is described as a stage 1 prolapse and feel completely overwhelmed by their symptoms. One woman’s “normal” will be different from another’s.
Regardless of whether your pelvic presentation is considered “normal” or “common” you are still entitled to receive support and care directed at addressing your concerns!
If you are experiencing any of the above symptoms we suggest you speak to your doctor or make an appointment with a physiotherapist specialising in pelvic health. If you have visited or spoken with a doctor or midwife who has dismissed your symptoms, you should find another health professional who takes your concerns seriously. Your GP can refer you to a gynaecologist or urogynaeologist for specialist diagnosis or treatment.
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. Often, health professionals will rate prolapse on a scale of one to four, with one referring to indicating relatively minor changes in the body and four indicating relatively major changes. For example, 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.4
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, and does not have an impact on emptying the bladder or bowel, does not need to be treated.
Women’s health/(Pelvic floor) physiotherapist
Pelvic floor physical therapy includes gentle exercise of the pelvic floor muscles, developing the habit of ‘bracing’ when carrying out strenuous activities, and correcting your position for bowel movements. Recent research has shown that these strategies may make a significant difference in reducing prolapse symptoms.5,6 However, long term effectiveness is not known.7
Your first appointment with a women’s health physio would ideally involve the following:
- Education about normal and abnormal bladder and bowel function, regardless of your condition. This will ensure that you address any ‘bad habits’ which may lead to a worsening of your condition, or other problems in the future. It should include advice on making positive changes to your diet to ensure a soft, easy to pass stool. It may also include instructions on how to keep a bladder diary over one or two days to help in developing an accurate treatment plan.
- An internal muscle examination to assess your muscle strength and teach you the correct action of the pelvic floor muscle. This is different to the standard internal examination carried out by your GP or gynaecologist. A specialised pelvic floor physiotherapist may carry out the exam using a gloved hand and/or an internal ultrasound wand. This is invaluable in giving you feedback about your pelvic floor muscles after childbirth, and identifying areas of muscle tightness, tenderness or pain, as well as muscle strength and endurance.8,9
- A pelvic floor muscle treatment program setting out a series of exercises to improve the strength of your pelvic floor muscles. This may include learning the importance of relaxing the pelvic floor muscles as well as contracting them. A treatment program should also emphasise the important of bracing during all activities which increase intra-abdominal pressure, such as coughing and sneezing and also bigger tasks such as lifting your baby. Other strategies may be included to help with any pelvic pain issues.
A pessary is a silicon device that it inserted into the vagina. It acts as a splint by holding the pelvic floor organs in place. They come in a variety of shapes and sizes, so finding the right one for you can require patience. Wearing a pessary can take some time to get used to, however, they can be a useful alternative to surgery as many women find they can manage their symptoms well while using one. A pessary can be fitted by your doctor or women’s health physiotherapist (although pessaries cannot be fitted by physiotherapists in New Zealand).10
If the prolapse is significant and not responding to conservative measures like physiotherapy or pessaries, 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 sub-specialty 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. A urogynaecologist or gynaecologist will assess which surgical option will best suit your needs.
Surgical approaches 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), and/or
- Vaginal vault prolapse surgery, to correct prolapses of the top end of the vagina (the vault).
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. Now, after a number of years, problems have been reported with certain types of mesh products, including erosion of the mesh into the vagina, and chronic pain. Talk to a specialist or a urogynecologist in regard to mesh use, and seek a second opinion if in doubt.
For many of us, exercise is a way of maintaining our identity and routine after having a baby. It can also be crucial to managing our mental health. However, it is vital to learn how to exercise effectively in the postpartum period and beyond. Prior to commencing exercise, it is important to seek the advice of a health professional such as a women’s health physiotherapist in order to prevent further injury to the pelvic floor.
Unfortunately, the fitness industry as a whole doesn’t recognise the risk that postpartum women face. As Robin Kerr, women’s health physiotherapist says, ‘If you’ve had a baby and feel like you’ve played a game with the All Blacks then consider managing your pelvic floor like you would a sporting injury’.
If you have been diagnosed with pelvic floor dysfunction or POP, then learning to exercise effectively will become a part of your motherhood journey. It isn’t about what you can’t do; it’s about how you can safely continue to do the exercise you enjoy doing. It is important that you seek out a personal trainer who works collaboratively with a women’s health/pelvic floor physiotherapist and has a proven track record for safe pelvic floor training. Even if you have worked with a personal trainer before or during pregnancy, it is crucial that your personal trainer asks the right questions before you commence exercise again.
For more information visit Pelvic Floor First.
Sexual dysfunction is another common, yet taboo subject. Women with prolapse are often extra self-conscious about the changes their bodies have gone through during pregnancy and childbirth. They may be concerned that intercourse could worsen their prolapse (which is not true) and therefore avoid intimacy, in turn placing extra pressure on relationships.
The pelvic floor muscle, which lies behind the vagina, determines vaginal tone and pressure. If the pelvic floor muscle has been overstretched or torn in childbirth (which is common) 6, vaginal tone is reduced, and both partners may notice this during sex. In addition, vaginal laxity can be an early symptom of prolapse. Pelvic floor muscle exercises can help, but if it is a major problem you may want to see a pelvic floor physio, gynaecologist or urogynaecologist.
If there is ongoing scar tissue discomfort or pain following childbirth, or if you have had a significant tear or gynaeacological repair surgery (such as an episiotomy), it is crucial that you seek help. Simple effective education can help women with this (often embarrassing) topic. The following list provides some tips to improve sexual dysfunction, but it is also important to talk to your GP, gynaecologist or physio to get help for specific problems.
Tips for improved sexual function:
- Talk about issues with your partner
- Take more time for arousal
- Concentrate on relaxing your inner thighs, buttocks and lower tummy
- Use a lubricant
- Use non-latex condoms
- Use local oestrogen pessaries or cream
- Don’t forget ‘outercourse’.
Seek professional help early–finding someone you trust and feel able to talk to about this topic can often be the first step to getting help. In our experience a good women’s health physiotherapist can often be the starting point. However, further help from a couples counsellor or sex therapist may be useful.
If you have had gynaecological repair surgery, check with your surgeon as to when you can have intercourse. Due to pain and discomfort after major surgery, there is often a reluctance (from both partners) to resume intercourse. It can take up to 8 weeks for the pain to disappear. If there is ongoing chronic pain you should see a specialist.
Some of this information is taken with consent from Sue Croft Physiotherapists ‘Pelvic Floor Essentials’ book.