Do I have prolapse?
Pelvic organ prolapse is just starting to gain the attention it deserves in the birth and fitness worlds. With that comes a lot of well-intentioned information and, unfortunately, misinformation. While there is no one thing or even a list of things you can do to cause prolapse, or not do to avoid developing prolapse, there are many things you can do to lower your risk. There is even more you can do to ensure the symptoms of prolapse do not run your life.
Here’s what you need to know about prolapse - what it is and what you can do about it.
What is pelvic organ prolapse?
Pelvic Organ Prolapse, often referred to as POP or “prolapse” for short, is multifaceted. While increased maternal age, history of constipation or a connective tissue disorder, and a vaginal birth with use of forceps or vacuum are associated with developing POP, not all people who give birth with these predispositions develop POP. Additionally, current research suggests that most physical activity does not harm the pelvic floor. While we cannot say that any one thing will for sure cause POP, we can look at the risk factors and make educated choices about our bodies!
As detailed below, there are many types of prolapse. However, almost all people with symptomatic prolapse describe it as a feeling of heaviness or achiness at their pelvic floor. This feeling is often accompanied by a sensation of a tampon falling out. Sometimes there is a visible lump or bulge as well. These feelings often change throughout the day. The more time you spend standing or walking, the worse they become. If you lay down, they may even go away temporarily. It is not uncommon for these sensations to change with a full bladder or after a bowel movement. They may even fluctuate throughout your menstrual cycle or with the hormonal changes of pregnancy, postpartum, lactation, and menopause.
Types of Prolapse: Check out MyPelvicFloorMuscles or POPUPLift for some great visuals!
Cystocele: Bladder pushes the anterior vaginal wall towards the vaginal opening
Urethrocele: Urethra lowers toward the vaginal canal
Rectocele: Rectum pushes the posterior vaginal wall towards the vaginal opening
Uterine/Apical Prolapse: Uterus/cervix descend towards the vaginal opening
Rectal Prolapse: Rectum pushes towards or through the anus
Vaginal Vault Prolapse: Upper portion of the vagina drops down into the vaginal vault
Enterocele/Vaginal Hernia: Herniation of the peritoneal sac (location of the small intestine/sigmoid colon) between the vagina and the rectum
I think I have prolapse. What should I do?
Learn to Manage Pressure on Your Pelvic Floor. Learning to manage pressure throughout your abdomen and pelvic floor helps spread the load. This decreases the amount of force being sent straight down to your pelvic floor. Avoid constipation, straining to urinate, and bearing down on your pelvic floor around your home and in the gym. If you can continue to breathe as you are moving, you are likely managing pressure well, decreasing the need to be concerned about “am I making my POP worse?”
Work with a Pelvic Health Physical Therapist. There’s a subset of physical therapists with advanced training in the muscles of the pelvic floor and common changes and concerns of pregnant and postpartum people. These physical therapists can assess your pelvic floor muscles as well as your prolapse. Depending on exactly what is going on with your body, they may teach you how to lengthen or strengthen your pelvic floor muscles. There is a lot more to treating prolapse than just doing Kegels! Not only can they help you with managing pressure, they can help you with strategies to manage your symptoms throughout the day and help you work back up to activities like lifting and running if that’s your goal.
Talk to your Physician about a Pessary. If you have learned to manage pressure well and worked with a physical therapist to address the muscles and the way you move, and are still feeling pressure it is time to talk to you physician again. Sometimes our pelvic floor muscles need a little support to better do their job - a pessary can do just that! Pessaries are available to people of all ages with prolapse who continue to feel pressure at their pelvic floor and either decide surgery is not right for them or have medical concerns that make surgery too risky. If you live in the United States, a pessary is most often fit by a urogynecologist. However, your gynecologist, internist, or family medicine physician may also be able to help you.
Pessaries are medical devices, most often made of silicon, that vary in shape and size depending on your body and its needs. Your physician will take measurements to determine what size and style pessary to trial. The provider who is fitting you should ask you to get up, move around, see how it fits, and if it is a pessary you will be taking out and putting in on your own, that you know how to use it without pain. Sometimes it takes a few tries to find the right shape and size for you, so continue to communicate with your provider. They want to help you find the right fit! They may suggest different sizes and styles for different purposes depending on your specific goals. For the best results you may have more than one pessary. One day-to-day pessary and a running or lifting pessary for example. Just like you might not need glasses for every day, but rely on your readers for smaller fonts, pessaries can be used in the same way!
Surgical Options: Sometimes, a pelvic floor PT and a pessary are not enough and it is worth exploring a surgical option. I HIGHLY recommend working with a few different PTs and trying a few different pessary styles and sizes before deciding on surgery. You can always decide that a PT and a pessary aren’t enough for you; you cannot undo a surgery.
Types of Surgeries
Anterior or Posterior Colporrhaphy: The prolapsed portion of the anterior or posterior vaginal wall is reinforced with sutures, this is done with and without mesh.
Sacrohysteropexy for uterine prolapse: Mesh is attached to the cervix and secured to the sacrum, supporting the uterus.
Sacrocolpopexy: After a hysterectomy, mesh is attached to the vaginal wall and secured to the sacrum, lifting the vaginal vault.
Your Tissue vs. Mesh: A 2016 Cochrane Review determined that “current evidence does not support the use of mesh repair compared with native tissue repair.” Earlier this year the FDA ordered manufacturers of surgical mesh products intended for transvaginal repair of cystocele to stop selling and distributing their products. For MOST people, the potential risks of mesh outweigh the benefits.
Ask your surgeon about their training, experience, surgical approach and technique, and specific pre/post-operative instructions. Just like it is recommended to work with a few different physical therapists and try a few different pessary shapes and sizes if you aren’t getting the result you want, get more than one surgical consult!
A combination of pelvic floor physical therapy with or without the addition of a pessary, and surgery are the only evidence-based approaches to treating POP. There are some recommendations out there that do not have evidence to back their support of POP. Check out the two I’m most commonly asked about:
Hormone replacement therapy (HRT) can improve collagen content and the thickness of the vaginal wall. While this can make taking a pessary in and out more comfortable, it does not directly prevent or treat POP.
Hypopressives include using the core muscles to decrease internal pressure. While doing hypopressives can temporarily decrease symptoms, there is no evidence that they are any more effective than traditional pelvic floor muscle training (i.e. Kegels). This means that if you enjoy doing hypopressives, feel free to keep doing them! However, you can get just as much, if not more benefit from doing exercises that directly carry over into your daily life.
If you feel heaviness or pressure or see a bulge or lump, know that there is hope! It’s time to reach out to a pelvic floor physical therapist. Just like many pelvic floor issues, treating prolapse is not a one-size-fits-all. A strategy, modification, or treatment that works well for one person may not work well for another. While pressure management and physical therapy may work wonders for you, a pessary or surgery may help someone else get back to living their life. At the end of the day, you have a multitude of options for treatment. Finding the perfect combination takes time and the right providers, but you can start by optimizing nutrition to manage constipation and breathing to manage pressure and better connection with your pelvic floor!
Are you ready to start treating your prolapse? Schedule your free consultation or first appointment today.