What is prolapse and pelvic health?
Pelvic Organ Prolapse, more commonly known as Prolapse is more common than people think, it affects 50% of women over the age of 50 that have had a baby. That is not to say that you need to be over 50 for a prolapse to occur. The most common stages in a woman’s life when she will start to experience prolapse is either just after having a baby, where there is some heaviness in the perineal area that was not there prenatally, or during perimenopause or menopause, when the symptoms might be more obvious, with some tissue protruding to the opening of the vagina, or even below it.
What is prolapse?
The 3 main organs in our pelvis, from front to back, are the bladder, uterus (womb) and bowel. They are supported in this position by ligaments from above lifting them up and from the pelvic floor muscle below holding them up. When either or both of these structures are put under a lot of strain (such as after carrying a baby and then delivering the baby through the vagina; or during perimenopause when our ligaments and muscles are not quite as strong as they were before) one or a combination of these organs will essentially collapse down against the vaginal wall. So as in the above diagram, the top left is our “normal”. The top right is the bladder pressing back against the front wall of the vagina (cystocele); the bottom left is the rectum or back passage pressing forward onto the back wall of the vagina (rectocele) and the bottom right is the uterus descending down into the vaginal wall like a sock turning in on itself (uterocele).
Contributing factors to developing a prolapse
If you have given birth vaginally to one baby, you are 4 times more likely to develop prolapse, this increases to 8 times if you have had 2 or more vaginal deliveries. As we get older and our hormone levels reduce during perimenopause and menopause the development of, and degree of prolapse increases over time. A hysterectomy increases your likelihood of developing prolapse as the support from some of ligaments from above is lost.
Any activity that you do, where the pressure within the abdomen increases the force down on your pelvic floor and perineum, can increase the degree and development of prolapse.
– Having a slumped posture, also called thoracic kyphosis.
– Being constipated and straining to pass a bowel motion.
– Working in a job where you stand for prolonged periods of time or do an excessive amount of heavy lifting.
– Having a persistent cough.
– Drawing in your tummy all the time or holding your body too rigid. This stiffness hinders the pelvic floor muscle’s ability to absorb or soften the forces placed on it when we do exercise or carry out our daily tasks.
– *Doing higher impact exercise. This is not strictly true. It is not necessarily the activity but rather how it’s performed that is important. Previously the advice was to stop or reduce your higher impact or higher intensity exercise, however now research and clinical experience demonstrates that keeping active but modifying your technique or body position is the important factor.
How do I know if I have a prolapse?
There are some distinctive symptoms.
The main one being a feeling of “something coming down” or pressure or heaviness in your perineal area. There may also be some tissue protruding from your vagina and most people feel something “odd” as they are wiping following either a bowel motion or urinating.
These symptoms tend to worsen over the course of the day and by evening time. Urinary leakage can start to occur with activity or if present can worsen. Bowel symptoms of either leakage or difficulty passing a bowel motion can occur or worsen.
As per the NICE 2019 Guidelines for “The management of Urinary Incontinence and Pelvic Organ Prolapse in Women”, an assessment carried out by a specialist Pelvic Health Physiotherapist or Gynaecologist is recommended to assess the type and degree of prolapse. The degree of prolapse is graded based on a scale called the POP-Q system, which ranges from 1 – 4 with 4 being the most severe.
What can you do to treat prolapse?
It is really important to understand that we are not looking to “fix” or “cure” prolapse. Instead, think of it as a management programme that involves addressing some of the contributing factors that can be influenced by modifying our lifestyle and physical activity. It does not, nor should not involve avoiding physical activity or exercise.
Pelvic floor retraining:
As the pelvic floor muscles are often weakened or not working effectively, starting a programme involving pelvic floor retraining is important. This should be completed under the guidance of a specialist Pelvic Health Physiotherapist, as an internal assessment of your pelvic floor is recommended by the NICE guidelines. This allows each programme to be tailored to the individual’s specific lifestyle and activity demands. A minimum of 16 weeks retraining is recommended for those with a Grade 2 prolapse on POP-Q.
Lifestyle modifications – making some simple changes such as:
Improve your posture. Stand and sit tall. Imagine that there is a magnet on the crown of your head, lengthening you up towards the ceiling. If possible, avoid standing for too long. Walking and movement is much better than standing still as your muscles in your whole body are active, including to some degree your pelvic floor.
Don’t hold your tummy in all the time. Instead, let your tummy soften and relax.
If you are lifting something heavy, don’t hold your breath. Instead, as you lift breathe out, and if you know how to, try engage your pelvic floor muscles.
When you are going to the toilet, use a step under your feet and breathe rather than hold your breath when passing a bowel motion.
If you anticipate a cough, try engage your pelvic floor just before and during the cough and then allow your pelvic floor muscle to fully relax.
If you are experiencing perimenopause or menopause it is worthwhile contacting your GP or Menopause Specialist to discuss the use of topical or systemic oestrogen as the tissue atrophy (or thinning) that occurs during this stage of life can magnify the degree of prolapse.
Further treatments that can be used are pessaries. A pessary is a device that is placed into the vagina by your Gynaecologist or Pelvic Health Physiotherapist. This device essentially acts as scaffolding to support the walls of the vagina. A pessary should be considered as a non-surgical option for a woman that has a symptomatic prolapse.
Surgery is an option for those with a more severe degree of prolapse that is very symptomatic. Ideally a conservative approach to the management of prolapse should be the first line treatment (especially in the milder degree of prolapse). Pelvic floor retraining, modifications to physical activities, changes to lifestyle habits is often successful in alleviating symptoms for most women. Even if a woman requires surgery, I recommend those same lifestyle modifications and pelvic floor retraining as studies show that there is a high relapse rate (50%) for those that have had surgical repair with 30% of women that have had a relapse go on to have a repeat surgery within 2 years. If the contributing factors are addressed, the relapse rate can lower significantly.
PMC Physiotherapy Dunboyne recommendation
If you think you might have a pelvic organ prolapse or are experiencing symptoms, please contact us at email@example.com or on 01 825 3997 to book an appointment with our specialist Pelvic Health Physiotherapist Caitriona.
PMC Physiotherapy Clinic, Unit 36, Dunboyne Business Park, Dunboyne, Co Meath
01 8253 997