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Managing Pelvic Organ Prolapse

Did you know that up to 70% of women suffer from pelvic organ prolapse (POP) but only 25% are symptomatic? While POP is usually non-life-threatening, it can significantly affect your comfort and quality of life. The good news is that we can manage this!

WHAT IS PELVIC ORGAN PROLAPSE (POP)?

Prolapse occurs when one or more pelvic organs descend into the front or back walls of the vagina, the uterus, or the top of the vagina. This happens due to the stretching and weakening of the pelvic floor or after gynaecological surgeries.

WHAT ARE THE SYMPTOMS OF POP?

While these differ with the type and severity of the prolapse, the most common is experiencing heaviness and seeing a bulge in the vagina.

Any changes to your anterior vaginal wall (front) will lead to changes in bladder function, whereas changes to the posterior vaginal wall (back) will affect your bowel function.

Other symptoms also include:

  • Straining, incontinence, and urgency of the bladder or bowels
  • Frequent urination
  • UTIs and urinary retention
  • Needing to apply pressure on the perineum to open the bowels
  • Difficulty inserting tampons
  • Pain during sex or feeling that something is in the way
  • Backache or abdominal discomfort

In severe cases, women can experience obstruction of the ureters, which can lead to kidney impairment.

Please note, however, that these symptoms are independent of prolapse and can be caused by other factors.

WHAT ARE THE RISK FACTORS OF POP?

Obstetric risk factors

  • Pregnancy
  • Childbirth
    • Baby weighs more than four kilograms
    • Forceps or vacuum-assisted delivery
  • Short (less than 30 minutes) or long (more than 90 minutes) second-stage labours

NON-OBSTETRIC RISK FACTORS

  • Genetics
  • Hypermobile conditions such as Ehlers-Danlos syndrome
  • Ageing and menopause
  • Conditions that cause excessive strain on the pelvic floor
    • Obesity
    • Chronic cough
    • Chronic constipation
    • Heavy lifting

HOW DO I ASSESS FOR POP?

The best way to determine the type and grade of POP is to perform a pelvic floor examination. Your therapist will ask you to strain and cough while lying down then again while standing up.

HOW CAN PHYSIOTHERAPY HELP?

While symptoms can worsen, they can also remain unchanged over time. That is why some women do not address their prolapse until they experience more discomfort. This is where physiotherapy can help.

CONSERVATIVE MANAGEMENT

  • Minimising strain. Modifying activities and learning the right way to open your bladder and bowels. Medical management can also be used to address chronic respiratory conditions.
  • Pelvic floor exercises. We have emerging literature that proves how pelvic floor muscle training can help with POP. With proper guidance from your physiotherapist, you can improve the strength, endurance, and coordination of your pelvic floor muscles. If you have very weak pelvic floor muscles, I might suggest biofeedback or electrical stimulation to help you rehabilitate. It may take four to six months of consistent training with regular follow-up sessions to keep you on track.
  • Weight loss. This has been shown to prevent the worsening of prolapse symptoms in overweight and obese women.
  • Pessary management. A pessary is typically made from vinyl, silicone, or latex and works by inserting it into the vagina. These removable devices support the walls of your vagina and/or uterus and help to minimise your symptoms. They can also be a great option for long-term prolapse management in some individuals.

Vaginal estrogen. For 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.

NON-CONSERVATIVE MANAGEMENT OR SURGERY

There are two main types of surgeries offered: native tissue repair and synthetic mesh repair.

  • There is a 20% lifetime risk of surgery in women by 80 years of age for prolapse. (Wu, 2014)
  • Prolapse will reoccur in 58% of women after surgery. A third of these women will undergo at least one more revision. (Whiteside, 2004; Olsen, 1997)
  • Severe complications can occur after mesh implant surgery. (Bo, 2015) That is why it is now banned in some countries.
  • Rates of postoperative pain may be high. (Paul, 2013).

When conservative management fails, surgery may be your next option. 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.

That is why it is recommended that you see a physiotherapist before and after your operation to optimise your surgical outcomes.

CAN I EXERCISE EVEN IF I AM EXPERIENCING PROLAPSE?

Yes! Exercise is necessary to keep the pelvic floor muscles engaged, improve bone and cardiovascular health, and help with psychological well-being. Strength training and weightlifting can be considered but should be done right! Low-impact exercise is a great place to start, with a gradual increase in impact under the guidance of your physiotherapist.

As physiotherapists, we stress that personalised guidance is important. Working with your physiotherapist can help assess your level of support, identify the right kind of exercise for you, and help you reach your goals.

Feel free to look through our website, where you can learn about other women’s health conditions we treat. This is a safe space where we can discuss how we can help you with physiotherapy.

Note: While I am a physiotherapist, I am not your personal physiotherapist. The contents of this website are for informational purposes only and are not intended to serve as personal medical advice.

References:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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
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