By: Dr. Hyerim Kim, SPT (soon to be PT, DPT!)
What is pelvic organ prolapse?
Pelvic organ prolapse occurs when pelvic organs; bladder, uterus, rectum or intestines, descend into the vaginal wall.
Wait what?!!?
This sounds scarier than it is!
But honestly, it is very common and most of us don’t even know we have some prolapse
😉
Pelvic organ prolapse can occur due to ligament or muscular weakness, being overstretched from trauma or childbirth, menopause, and/or poor pressure management. Pelvic organ prolapse is also associated with sustained incidents of increased intraabdominal pressure such as heavy lifting, obesity, chronic cough and constipation (Iglesia 2017).
There are 4 main types of prolapse.
1. Bladder Prolapse or a Cystocele is a prolapsed bladder into the anterior vaginal wall. With this condition, the urethra usually prolapses as well which is called a Urethrocele. Symptoms of cystocele and urethrocele may include feeling of incomplete emptying along with stress urinary incontinence – leaking with exertion such as coughing, laughing, running, and jumping.
2. Uterine prolapse is a prolapsed uterus descending into the vaginal canal. Symptoms are feeling of heaviness or fullness, bulging in your vagina, low back pain, inability to completely empty your bladder and urinary incontinence.
3. Rectal Prolapse or Rectocele is the prolapse of the rectum into the posterior vaginal wall. The rectal wall pushes against the vaginal wall, creating a bulge. With rectocele, symptoms such as constipation, incomplete emptying, difficulty with bowel movements may be seen. Additionally, splinting may be required for a successful bowel movement. Splinting is when the perineal body or vaginal wall is supported with a patient’s thumb or fingers to minimize stretch and descent of tissues and organs with elimination of contents out of the rectum.
4. Prolapse of the intestines into the vaginal canal is called enterocele. This type of prolapse is more common with people who have had a hysterectomy.
Common Symptoms
Not everyone with prolapse will experience symptoms! Roughly 41-50% of women with pelvic organ prolapse, only 3% are symptomatic (Doshani 2007).
This is great news!!!
Some common symptoms reported with pelvic organ prolapse include pelvic pressure, low back pain, vaginal bulge (feeling heaviness or pressure like something is coming down or out), urinary and bowel dysfunction (recurrent urinary tract infections) or sexual dysfunction (painful intercourse).
Think of it like this….
You are over the age of 20. You have gray hair, wrinkles, degenerative disk disease, arthritis and prolapse. Welcome to the club, you are over the age of 20! They are all a normal part of the aging process and none of them mean your life is over! All can be managed and managed well to be asymptomatic!
There is hope, healing and health to be had by all!
Treatment
Treatment options vary and are dependent on the stages of prolapse and symptoms. Treatments can vary all the way from observation, pelvic floor physical therapy; pessary use and surgery (Raju 2021).
As mentioned above, poor pressure management from poor posture, increased intraabdominal pressure such as heavy lifting, chronic cough and constipation can lead to prolapse. One simple treatment to minimize prolapse is to retrain and develop proper pressure management. We can do this by activating our transverse abdominis, the deepest layer of the abdominal muscles that acts like an internal corset and/or stabilizing brace. Most activate their core incorrectly by pushing belly out and bearing down into the pelvic floor rather than activating their transverse abdominis. Some think they are activating their core by “sucking in,” which is also not the correct activation either.
To properly activate your transverse abdominis, lay on your back with your knees bent and place your hands on your lower belly, just inside your hip bones. Then, think about flattening your belly from one hip bone to the next, most of the time you just need to do about a 10-20% contraction to activate your transverse abdominis. Activating your transverse abdominis should feel like a corset, cinching things together, rather than sucking everything in or budging or bearing down and pushing your belly out. Your hands should sink into your lower belly, and your stomach should feel taught. Additionally, with heavy exertional activities or movements, always pair the lift with an exhale to minimize additional pressure into your pelvic floor. For example, when jumping, exhale when you land on the floor, for lifting weights, groceries or a baby exhale while activating your transverse abdominis on the way up.
Pelvic floor therapy is also a treatment option. It is standard of care to go to a pelvic floor therapist (physical therapist or occupational therapist) for the treatment of prolapse. Many times prolapse is a system problem, meaning that many other factors are in play that can be addressed to eliminate prolapse symptoms so that you can move your body without experiencing any pressure, fullness and/or leaking. Oftentimes there is tight scar tissue, tight fascia/muscles, or other decreased mobility outside of the pelvis that are contributing to the symptoms of prolapse. Oftentimes the low back, hips, rib cage, and inner thighs contribute significantly to prolapse and symptoms of prolapse. When you work with a pelvic floor therapist, like us, your therapist will uncover the root causes of your prolapse symptoms, be able to address them with manual therapy and get you back to living your life to the fullest! …And then you will also be able to avoid surgery like your Mom or Grandma.
Another treatment option is the use of a pessary, which is an internal vaginal device that acts like a tent or space holder in the vagina to hold organs in place when there has been increased laxity in the tissue from being stretched. This is very common to be used early postpartum during the healing journey. There are many types of pessaries, which we will save for another blog post another day 😉
Worst case scenario, you do all of the above treatment options first and if necessary you may be recommended to have surgery. It is very important to do pelvic floor therapy before doing surgery. Sometimes surgery can be prevented or postponed with pelvic rehab. Additionally most of the prolapse surgeries do not have very good success rates and often fail when the mechanics around prolapse were not addressed prior to surgery. In pelvic rehab you will be able to fix underlying issues that created the prolapse in the first place so that if surgery is a necessary option for your treatment, you will be set up for the best possible success.
Just because pelvic organ prolapse is common doesn’t mean it’s normal! If you are experiencing any of these symptoms feel free to reach out to us, at Reborn Pelvic Health & Wellness, to get all your questions answered and to get an individualized treatment plan.
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Cortesse A, Cardot V, Basset V, Le Normand L, Donon L. [Treatment of Urinary incontinence associated with genital prolapse: Clinical practrice guidelines]. Prog Urol. 2016 Jul;26 Suppl 1:S89-97.
Doshani A, Teo RE, Mayne CJ, Tincello DG. Uterine prolapse. BMJ. 2007 Oct 20;335(7624):819-23.
Karjalainen PK, Mattsson NK, Nieminen K, Tolppanen AM, Jalkanen JT. The relationship of defecation symptoms and posterior vaginal wall prolapse in women undergoing pelvic organ prolapse surgery. Am J Obstet Gynecol. 2019 Nov;221(5):480.e1-480.e10.
Haylen, B. T., de Ridder, D., Freeman, R. M., Swift, S. E., Berghmans, B., Lee, J., Monga, A., Petri, E., Rizk, D. E., Sand, P. K., & Schaer, G. N. (2010). An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. International urogynecology journal, 21(1), 5–26.
Iglesia CB, Smithling KR. Pelvic Organ Prolapse. Am Fam Physician. 2017 Aug 01;96(3):179-185.
Raju, R., & Linder, B. J. (2021). Evaluation and Management of Pelvic Organ Prolapse. Mayo Clinic proceedings, 96(12), 3122–3129.