Pelvic Organ Prolapse occurs when one or more of the pelvic organs (the uterus, bladder or bowel) descends into the vagina. This happens when the pelvic floor muscles, fascia and ligaments that suspend these organs stretch and weaken. It may also occur post-hysterectomy or after other gynaecological surgeries too.
Whilst pelvic organ prolapse is usually not life-threatening, it can significantly affect your quality of life, and typically enjoyable activities may become unpleasant. The good news is that managing pelvic organ prolapse is possible, and you can feel better.
Up to 70% of women will suffer from POP but only 25% will be symptomatic. The good news is that you can lead a normal life with the right advice and management.
WHAT IS A PROLAPSE?
Prolapse can occur in the front wall of the vagina (cystocele), back wall of the vagina (rectocele), uterus (uterine) or top of the vagina (vault). You can have prolapse of more than one organ at the same time.
WHAT ARE THE SYMPTOMS OF PROLAPSE?
Depending on the type and severity, symptoms may differ. The commonest symptoms though are the feeling of vaginal heaviness, pressure, dragging or you see/feel a bulge/bubble in the vagina.
Broadly speaking, if you have anterior wall changes you may experience changes to your bladder function and if the changes predominantly affect the posterior wall then you’ll notice changes to your bowel function.
Symptoms may include:
- incomplete emptying of bladder or bowels and needing to strain
- frequent urination
- bladder or bowel urgency
- urinary retention (unable to urinate when the bladder is full) and/or UTIs
- needing to apply pressure on the perineum to open bowels
- difficulty inserting tampons
- pain during sex, or feeling something is in the way
- backache or abdominal discomfort
In severe cases of prolapse obstruction of the ureters may lead to kidney impairment.
Please note that these symptoms are also independent of prolapse i.e. can occur because of other reasons.
WHAT ARE THE RISK FACTORS OF PELVIC ORGAN PROLAPSE?
Obstetric risk factors
- baby weighs more than 4kgs
- forceps/vacuum-assisted birth
- short (<30 mins) or long (>90 mins) 2nd stage labours
Non-obstetric risk factors
- Being hypermobile (gymnasts, ballerinas or being diagnosed with a hypermobile condition such as Ehlers-Danlos syndrome)
- Ageing and Menopause
- Conditions that cause excessive strain on the pelvic floor like
- chronic cough
- chronic constipation
- heavy lifting
HOW TO ASSESS FOR PELVIC ORGAN PROLAPSE?
The best way to determine the type and grade of POP is to perform a pelvic floor examination.
Typically, you will be asked to strain and cough whilst laying on your back and in standing. Prolapse behaves differently depending on your position. A laying down assessment allows me to measure whereas, standing up gives a much more functional picture. Make sure your therapist does both.
HOW CAN PHYSIOTHERAPY HELP?
There are 3 ways to manage your symptoms:
1/ Do nothing
Symptoms may worsen or remain unchanged over time. Perhaps when more bothersome, consider an assessment?
2/ Conservative management (this is where physiotherapy fits in)
Minimise straining- It may mean learning the right way to open your bladder and bowels if you strain to do so. Learn about activity modifications and consider medical management of chronic respiratory conditions that make you cough a lot.
Pelvic floor exercises- We have emerging literature to support the role of pelvic floor muscle training under the guidance of a Women’s Health Physiotherapist that focuses not only on the strength and endurance of the pelvic floor muscles but also on improving muscle bulk and co-ordination. If you have very weak muscles, I might suggest a course of biofeedback or electrical stimulation to help you rehabilitate. Unfortunately, there are no quick fixes here and typically it takes 4-6 months of consistent pelvic floor muscle training with regular follow-up to keep you on track
>>> (a bit like going to the gym- if you want guns, you are not going to keep lifting 5kg, you will up the weight as you improve!)
Weight loss- It has been shown to prevent worsening of prolapse symptoms in overweight and obese women.
Pessary Management- This is a removable device that is inserted into your vagina to support the walls of your vagina and/or uterus. Pessaries are made from materials such as vinyl, silicone or latex. This can help to minimise your symptoms and may be a great option for long term management in the right person.
Vaginal Estrogen- In postnatal mums or menopausal ladies, a course of vaginal estrogen may be indicated to improve vaginal mucosal health. Both Pessary and vaginal estrogen management need to be considered in conjunction with your Urogynecologist.
3/ Non-conservative management- surgery (physiotherapy helps here too)
I won’t detail too much here except to say there are 2 main types of surgeries offered: native tissue repair and synthetic mesh repairs.
Let’s lay down some facts…
- There is a 20% lifetime risk of surgery in women by 80 years of age for prolapse (Wu 2014)
- In 58% of women prolapse reoccurs post-surgery & 1/3 undergo at least 1 more revision (Whiteside 2004 and Olsen 1997)
- Severe complications can occur after mesh implant surgery (Bo 2015)- it is now banned in some countries.
- Rates of postoperative pain may be high (Paul 2013).
There are instances where conservative management fails, and surgery may be the option for you. Please do consider though that if you have not managed modifiable risk factors such as straining, continuing to strain post-operatively will likely have an adverse impact. It is recommended that you do see a Women’s Health Physiotherapist pre and post-operatively to optimise your surgical outcomes.
CAN I EXERCISE WITH PROLAPSE?
YES! Many women are anxious about exercising with prolapse, especially if they notice their symptoms during these activities. Low impact, HIIT, strength training, even weightlifting can all be considered if you have a prolapse but pelvic floor muscle strength and connective tissue support must meet the demand of the exercise.
All women should be given the opportunity to exercise given its widely reported benefits on psychological well being, bone and cardiovascular health. Pelvic floor muscles need impact too in order to keep challenged and stay supportive. But this needs to be done right!
Low impact exercise is a great place to start, with a gradual introduction and increase in impact under the guidance of your Women’s Health Physio. I stress there is no recipe here, hence guidance is important.
If you feel any heaviness, dragging or vaginal discomfort when exercising, it is a good indication that perhaps technique may need to be modified and if that doesn’t work then maybe its not the right kind of exercise for you at this point in time.
Working with your Women’s Health Physiotherapist can help assess your level of support, identify the right kind of exercise for you, and progress you to your goals.
If you believe you may be suffering from POP, please do call/WhatsApp on 9780 7274 or get in touch over email to discuss your options for managing pelvic organ prolapse. You are not alone, help is available.
You can also visit our website to learn about other women’s conditions we treat through physiotherapy and how we can help you.
Bo, K., Hilde, G., Tennfjord, M. K., Jensen, J. S., Siafarikas, F., & Engh, M. E. (2013). Randomized controlled trial of pelvic floor muscle training to prevent and treat pelvic organ prolapse in postpartum primiparous women. Neurourology and Urodynamics, 32 (6), 806-807.
Bo, K., Hilde, G., Staer-Jensen, J., Siafarikas, F., Tennfjord, M. K., & Engh, M. E. (2015). Postpartum pelvic floor muscle training and pelvic organ prolapse — a randomized trial of primiparous women. American Journal of Obstetrics and Gynecology 2015 Jan;212(1):38.e31-28.e37.
Braekken, I. H., Majida, M., Engh, M. E., & Bo, K. (2010). Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. American Journal of Obstetrics and Gynecology 2010 Aug;203(2):170.e171-170.e177.
Olsen, A. L., Smith, V. J., Bergstrom, J. O., Colling, J. C., & Clark, A. L. (1997). Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol, 89(4), 501-506.
Pauls, R. N., Crisp, C. C., Novicki, K., Fellner, A. N., & Kleeman, S. D. (2013). Impact of physical therapy on quality of life and function after vaginal reconstructive surgery. Female Pelvic Med Reconstr Surg, 19(5), 271-277.
Wu, J. M. M. D. M. P. H., Matthews, C. A. M. D., Conover, M. M. B. S., Pate, V. M. S., & Jonsson Funk, M. P. (2014). Lifetime Risk of Stress Urinary Incontinence or Pelvic Organ Prolapse Surgery. Obstetrics & Gynecology, 123(6), 1201-1206.
Whiteside, J. L., Weber, A. M., Meyn, L. A., & Walters, M. D. (2004). Risk factors for prolapse recurrence after vaginal repair. Am J Obstet Gynecol, 191(5), 1533-1538. doi:10.1016/j.ajog.2004.06.109