What is Pelvic Organ Prolapse?
First and foremost, let me reassure you—that you are not alone, there are treatment options, and healing is possible. Pelvic organ prolapse, is a frequently overlooked yet widespread condition. It involves the displacement of organs such as the bladder, urethra, uterus, rectum, and small intestines from their normal positions into the vagina or through the anus. Surprisingly, it’s a rather common occurrence, with studies suggesting that up to 50% of people with female anatomy might experience prolapse at some point in their life. Misconceptions around pelvic organ prolapse are widespread, thus gaining a better understanding of your condition can empower you to explore and discover suitable treatment methods for improved comfort and well-being.
What Are the Symptoms of Pelvic Organ Prolapse?
Pelvic organ prolapse can exhibit a broad range in both presentation and severity, with many people with female anatomy being asymptomatic. Yes, you read that right. It is possible to have pelvic organ prolapse without experiencing any symptoms at all!
For individuals who do experience symptoms some of the most common include:
- Pelvic heaviness or pressure “down there”
- The feeling of something bulging or dropping out of you
- Seeing tissue coming out of your vagina or anus
- Feeling tissue rubbing on your clothes
- Stress incontinence
- Post-micturition dribbling
- Needing to splint vaginally to complete a bowel movement.
What Are the Different Types of Pelvic Organ Prolapse?
Understanding the diagnostic criteria can help you make sense of your symptoms and figure out what the best course of action is when it comes to treatment. A trained healthcare professional is required to accurately assess the type and grade of prolapse. Diagnosis is based on identifying the descended organ and the extent of its displacement. Typically categorized as grades 1-4, with grades 1-2 indicating organs that have descended above the introitus and grades 3-4 representing those below it. Let’s dive into the different types of prolapse one might experience:
- 1. Apical Prolapse: Involves the descent of organs from the top of the vagina, including the uterus/cervix (procidentia), small intestines (enterocele), and the vaginal apex (vaginal vault prolapse)
- 2. Anterior Prolapse: Occurs when organs descend from the front of the vagina, such as the bladder (cystocele) or urethra (urethrocele)
- 3. Posterior Prolapse: Characterized by the descent of organs from the back of the vagina, particularly the rectum (rectocele)
- 4. Rectal Prolapse: Specifically pertains to the descent or “telescoping” of rectal tissue through the anal sphincter
What Causes Pelvic Organ Prolapse?
Your organs reside within the pelvic cavity and depend on the support of various structures, including fascia, ligaments, and muscles, to maintain their position. When these supportive tissues are compromised, it can result in pelvic organ prolapse. It’s crucial to understand that organs don’t just fall out of your body as if one day you’ll look down and find your bladder lying on the floor. The organs still have support, but it may not be as strong. Imagine these supportive tissues as a hammock cradling pieces of fruit, representing your organs. If the hammock becomes less taut, the fruit starts to sag, but it doesn’t fall to the ground.
Tissue compromise can occur as a result of excessive downward pressure, leading to an undesirable amount of tissue stretch or even injury. Not only does that compromise the passive and active support structures, but it can also lead to increased tissue tension which can consequently pull down on the organs, worsening symptoms. One common source of this pulling force is scar tissue formation after an episiotomy during the postpartum period. The scar tissue tends to become stiff and less pliable, contributing to the downward pull on the organs.
Factors contributing to increased downward pressure include childbirth, pregnancy, chronic straining from constipation, postural abnormalities, increased body weight, heavy lifting, and a chronic cough. Additionally, estrogen deficiency and connective tissue abnormalities can lead to inherent laxity, reducing initial organ support and increasing the risk of prolapse. As you can see, the cause of pelvic organ prolapse is likely multifactorial.
What Are The Treatment Options?
Pelvic Floor Physical Therapy
Pelvic floor physical therapy is the first line of treatment for pelvic organ prolapse and can be highly effective in helping to alleviate your symptoms. It is particularly beneficial for those with milder-grade prolapses. However, it has not been shown to guarantee a reduction in the grade of prolapse or the amount of prolapse descent. This is an important concept to understand as many people come to physical therapy with the expectation that their prolapse will reduce in grade and hold a false belief that to be symptom-free they must reduce their prolapse grade to zero. Let me reassure you that this is not true and that it is possible to experience an improvement in symptoms even without changes in prolapse grade. Remember – many people with pelvic organ prolapse are asymptomatic and don’t even realize they have it! Therefore, while a reduction in prolapse grade can sometimes occur, the focus in physical therapy is on reducing prolapse symptoms, not the grade.
Pelvic floor PTs employ various techniques to alleviate prolapse symptoms, including manual techniques and targeted exercises to enhance pelvic floor function. Additionally, they focus on improving posture, movement mechanics, mobility, strength, coordination, pressure management, and helping patients make positive behavior changes. Often people with female anatomy avoid exercise when they are diagnosed with prolapse out of fear that they will make symptoms worse. However, exercising is generally safe with prolapse, provided that you consult with a pelvic floor PT before returning to your regular workout routine, especially if you are experiencing symptoms. If symptoms persist during exercise, seeking guidance from a pelvic floor PT is advisable to ensure the appropriate exercise prescription and proper performance technique. Pelvic floor PTs excel in crafting personalized exercise programs that can effectively alleviate prolapse symptoms without causing further harm.
Some examples of exercises that your pelvic floor PT might do with you are as follows (Note: always consult with a healthcare provider before attempting any of the below exercises):
360-degree breathing
Individuals who have difficulty achieving a 360-degree breath may experience an onset of tightness in the back pelvic floor muscles, changes in posture, poor pressure management, and other musculoskeletal imbalances that can result in exacerbation of prolapse symptoms. Practicing 360-degree breathing offers a more balanced breath throughout the entire torso and proves to be an effective way to alleviate symptoms.
How to Perform:
- Find a comfortable sitting position.
- Wrap your hands around your torso.
- Inhale for a count of 4 seconds.
- Focus on breathing into your fingertips, the webspace in between your index finger and thumb, and your thumb so that you feel expansion 360 degrees around your entire torso. Imagine a balloon filling up evenly on all sides.
- Exhale for a count of 6-7 seconds.
- Repeat 10 times.
“Ha” Breathing
The job of our intercostal muscles is to elevate and depress the rib cage while we breathe. However, many people with female anatomy who have prolapse present with a decrease in intercostal recruitment, resulting in difficulty achieving full exhalation and descent of the rib cage. As a result, the upper abdominals turn on more as an alternative strategy to bring their rib cage down. Gripping in the upper abdominal muscles can increase pressure down on the pelvic floor which can worsen prolapse. “Ha” breathing can be an effective approach to re-engage the intercostal muscles, reducing excessive dependence on the upper abdominals and alleviating strain on the pelvic floor.
How to Perform:
- Find a comfortable sitting position.
- Round forward through your lower back allowing your belly to relax.
- Wrap hands around your rib cage.
- Take a big 360-degree inhale breath and slowly exhale making a “ha” sound keeping the abdominals relaxed. Assist your rib cage by pressing your ribs down with your hands on the exhale.
- Holding the position of your front ribs with your hands, inhale again to get more back-body expansion.
- Repeat the slow, relaxed exhale, trying to bring the ribs closer together with your hands with each exhale 10 times.
Supine March
Often patients with prolapse struggle to keep their core engaged while breathing. Instead they may breathhold and bear down onto their pelvic floor, which can make prolapse worse. Core exercises with a focus on maintaining a steady breath is a great way to improve intra-abdominal pressure management.
How to Perform:
- Lay comfortably on your back.
- Take a 360-degree breath in and a full exhale out dropping the sternum/rib cage and zip up from your pubic bone to activate your abdominal wall.
- Continue with gentle nasal breathing while maintaining abdominal activation.
- Slowly march one leg up to tabletop, march it back down, and switch sides while keeping your trunk still.
- Perform 3 sets of 10.
Lunges
People with female anatomy with hip weakness may find it more difficult to complete everyday tasks which can increase pressure and worsen prolapse symptoms. Lower body strength training proves to be an excellent approach for enhancing your body’s ability to handle forces and provide support to your organs. Lunges are a great way to challenge your hips and start rebuilding strength!
How to Perform:
- Come into a split stance position, with a neutral pelvis, and hips square forward.
- Bend both knees sitting down and back as if you were sitting in a chair behind you.
- Hinge your trunk forward to help sit your weight back.
- Press the ball of your big toe, ball of pinky toe, and heel into the ground.
- Wait until you feel your glutes and hamstrings turn on.
- Drive through your legs to stand back up.
- Repeat 3 sets of 8-12 reps.
Supported Bridge Pose
If you are currently feeling a lot of symptoms and are seeking an exercise that provides temporary relief, this is the exercise for you. Inverted positions leverage gravity to assist in reducing prolapse to its normal position.
How to Perform:
- Lay on your back with knees bent.
- Bridge up and place a yoga block or pillows under your hips so that your hips are higher than your heart.
- Take deep calming breaths.
- Stay in this position for as long as you like or until symptoms improve.
Pessary Support for Pelvic Organ Prolapse
A vaginal pessary is a removable silicon device inserted into the vagina to provide support for prolapsed organs. It serves as an effective conservative option for managing symptoms and is appropriate for temporary or long-term use. Various types of pessaries exist, some examples include rings, gellhorns, and donuts. Consult with a medical provider trained in pessary fittings to determine the most suitable pessary type, duration of wear, and proper care based on your individual needs.
In contrast to a widespread misconception, using a vaginal pessary does not cause pelvic floor weakness. Wearing a vaginal pessary can make it easier to contract your pelvic floor muscles, as they won’t be constantly stretched by the weight of the organs. Additionally, by reducing stretch on the tissues, pessary wear allows the tissues to shorten, leading to a reduction in the levator hiatus, the opening in the pelvic floor where prolapse occurs. Properly positioning the organs through pessary use can facilitate better overall pelvic floor function and reduce prolapse symptoms.
Pelvic Organ Prolapse Surgery
Physical Therapy and pessaries are the first lines of treatment, but if either of these fails and you have a higher-grade prolapse surgery is an option. It is important to note that the recurrence rate for prolapse surgery is between 30-70% within 4 years, hence why less invasive options such as pelvic floor PT and or pessaries are typically recommended first.
There are two primary types of pelvic organ prolapse surgeries: obliterative and reconstructive. Obliterative surgery offers organ support by narrowing or completely closing the vagina. However, this procedure renders sexual intercourse impossible thereafter. Reconstructive surgery employs your tissues, mesh, or sutures to reposition the organs to their natural state—this remains the more common choice. Many different types of reconstructive surgeries exist, and the most suitable option depends on your prolapse type, risk tolerance, and personal goals.
I Still Feel Anxious!
Addressing your anxieties, fears, and concerns about pelvic organ prolapse is a crucial step in your healing journey. When left unattended, these concerns can intensify the impact of your symptoms. Common worries that people with female anatomy often express upon being diagnosed with pelvic organ prolapse include the fear of exacerbating the condition, concerns about the potential for improvement, worries about the need for surgery, and the emotional distress of not being informed about the possibility of this happening.
It’s important to understand that pelvic organ prolapse doesn’t mean you can never lift heavy, run, jump, squat, or have sex again. Many people with female anatomy with pelvic floor organ prolapse lead active lives, especially those that are mothers – arguably one of the most physically demanding roles.
Various factors may contribute to your symptoms, and seeking assessment from a trained healthcare professional, such as a pelvic floor PT, is a crucial initial step in identifying the underlying causes and determining the most effective treatment plan. Pelvic organ prolapse is a treatable condition, and with the right guidance, you can improve and reclaim your life.
REFERNCES:
Clinic, Toronto Pessary. “Home.” Toronto Pessary Clinic, torontopessaryclinic.com/pessary-removal-and-cleaning/. Accessed 11 Jan. 2024.
Hagen, Suzanne et al. “Individualized pelvic floor muscle training in women with pelvic organ
prolapse (POPPY): a multicentre randomized controlled trial.” Lancet (London, England) vol. 383,9919 (2014): 796-806. doi:10.1016/S0140-6736(13)61977-7
“Pelvic Organ Prolapse Causes, Symptoms, and Treatments -.” APOPS, www.pelvicorganprolapsesupport.org/pelvic-organ-prolapse-help-and-hope. Accessed 11 Jan. 2024.
“Pessary.” Pessary Patient Instructions – Brigham and Women’s Hospital, www.brighamandwomens.org/obgyn/urogynecology/forms-and-education-materials/pessary-instructions. Accessed 11 Jan. 2024.
“Surgery for Pelvic Organ Prolapse.” ACOG, www.acog.org/womens-health/faqs/surgery-for-pelvic-organ-prolapse. Accessed 11 Jan. 2024.
“Understanding Pelvic Organ Prolapse.” ACOG, www.acog.org/womens-health/videos/understanding-pelvic-organ-prolapse. Accessed 18 Jan. 2024.
