What does it mean to have a ‘Prolapse’?
“I was told I ‘probably had a Prolapse.’ I had to look it up on Google”
Rebecca sat on the toilet seat and positioned the hand mirror in between her legs. She gave birth 6 weeks ago and has had a feeling of pressure ‘down below’ when pushing her baby in the pram. She was sure she could feel something was there that shouldn’t be. She took a deep breath, leaned forward and peered down closely into the mirror.
“What the f*** is that!?”
In all honesty, when was the last time you looked at your vulva this closely? Can you remember ever looking inside your vagina in the past? How do you know if that flap was there before or not?
I speak to many women who are upset by the appearance of themselves after childbirth, but when questioned, it seems this could be the first and only time they have taken such a detailed look at themselves.
If you have scrutinised yourself before having children, of course things may look a little different now. The opening itself may be wider, or there may be parts of your internal anatomy which are a bit more prominent or visible, but this is to be expected. Particularly if you pushed out a head with a 13.5-inch circumference a short time ago.
But sometimes ‘bulges’ can be more obviously visible and uncomfortable, and these may protrude downwards or even outside of the vagina which can be disconcerting, particularly if you are unsure about ‘what’s going on down there’.
Pelvic Organ Prolapse [AKA POP] is thought to occur in around 1 in 3 women after childbirth. Not all women will have symptoms, but the condition has the potential to significantly affect a women’s body image, sexuality, confidence and quality of life.
Through experience of working with women with this condition, I have found that the simple mention of the word ‘Prolapse’ alone, has the potential to instil fear, and I have seen women cry at the mere suggestion of it without necessarily understanding what it means. As health professionals we are taught that communication is key, and our choice of words and the way we convey information can have a significant impact on our patient’s beliefs, outcomes and satisfaction. Despite this, ‘Prolapse’ is a diagnosis that is given by many health practitioners without a second thought, but one that is not always explained thoroughly. The result? A frenzied internet search and a woman who is left confused and freaked out about her ‘insides falling out.’
My aim for this blog is to provide women with more information about what it means to have a ‘Pelvic Organ Prolapse’. It will cover the questions that should be asked at your 6-week postnatal check that may help identify if you have one, the related symptoms of POP and what can be done treatment-wise.
First, some simple anatomy
The pelvic floor is a complex, layered sling of muscle which spans the base of your pelvis, sometimes referred to as your ‘undercarriage’. It is a supportive network of muscle, nerves and connective tissues, which connects the bones and helps to support the pelvic organs [the bladder, uterus and bowel] and their related openings [the urethra, vagina and rectum]. The pelvic floor plays an important role in sexual, bladder and bowel function and in keeping you continent.
Picture if you will, a tepee in a field [one of those big ones that you get at weddings]. It has a canvas roof, supported by strong ropes and several large disco balls are hanging down from the ceiling inside. 9 months of heavy rain, the roof starts to sag a little and the ground beneath it softens. Then, a heavy storm comes, bringing with it driving rain and strong winds, which batter the sides of the tepee. Some of the ropes start to fail and the roof starts to drop. The disco balls are still attached to the ceiling, but they too begin to descend downward as everything else is no longer held up firmly.
Not the perfect analogy granted, but you get the idea. The pelvic floor and its soft tissues are the guy ropes and the canvas holding the tepee up. The disco balls are the pelvic organs. If the sides of the tepee and its ropes weaken, they lose their supportive function and the balls will move downwards. It’s just simple physics.
9 months of growing a baby in the pelvis and the action of the hormones released during pregnancy, can begin to load and weaken the pelvic floor and its connective tissues. This combined with the downward pressure of pushing, overstretching, cuts and tears that may occur during vaginal delivery, often lead to further weakening of these structures resulting in their reduced ability to hold and support the pelvic organs above. The bladder may bulge down against the vaginal wall from the front [also known as a Cystocele], the bowel may do the same from the back [Rectocele], and the uterus may slip down the vagina from above [Uterine]. It is possible for a woman to have more than one type of POP at the same time.
There are also a few other types of prolapse which affect the bowel and sometimes parts of the rectum may prolapse outside of the back passage.
“I have a bulge that sticks out sometimes and I can feel it when I wash myself. I can poke it back up inside but I’m not sure if that’s what I’m supposed to do” [Liz]
There are varying degrees of POP and a woman’s symptoms may range from none to mild to severe. In some instances, a bulge may protrude to the edge or even outside of the vagina and the woman may be able to ‘relocate’ it by pushing it back inside herself.
The size of a woman’s Prolapse will not always correlate with the symptoms she experiences from it, or with the degree of impact it has on her quality of life.
The causes of Pelvic Organ Prolapse
There are several known risk factors for the development of POP. Activities or events which cause repeated or prolonged downward pressure or straining into the pelvic floor have the potential to contribute to or worsen the development of a POP. There are some questions which can be asked to help determine your level of risk in relation to this.
- What type of birth did you have?
Having a caesarean section isn’t always protective when it comes to POP, but we know that vaginal delivery carries a greater risk due to the prolonged pushing downward, and the delivery itself may cause trauma and overstretching to the pelvic floor. Hypermobility syndromes, genetics, a high infant birth weight, instrumental deliveries [such as forceps or vacuum] and a high body mass index of the mother may also be influencing factors for developing POP after vaginal delivery.
- Are you constipated?
Constipation is very common during pregnancy and after birth, but repeated downward straining, particularly over a long period can be very detrimental to the pelvic floor. Vomiting bugs and chronic coughs may have a similar effect and so it is important to mention these problems if present, to your GP or health provider. Looking after your bowel health is paramount during pregnancy and in the postnatal period to prevent constipation and unnecessary pressure on your recovering pelvic floor.
Here are some useful tips on how to keep your bowel healthy;
- Keep your dietary fibre intake up [lots of fruits and veggies, ideally with every meal]. I always recommend having a breakfast smoothie using a nutribullet and homemade soups are amazing as you can chuck a whole load of different veggies in and they keep you hydrated too!
- Keep hydrated – aim for at least 1.5 litres of water every day [more if you’re breastfeeding]
- Avoid straining and breath-holding as much as possible when you’re on the toilet. Using a step under your feet and leaning forward can help position things to make life easier.
- How often do you lift your baby?
The average mum will lift her baby 20-30 times in a day. And that’s not considering everything else you find yourself lugging about. Car seats, toddlers, how many bags? Each lift you make places a downwards force into your pelvic floor and it’s possible that you’ll hold your breath as you lift, which increases pressure further.
Of course, it’s impossible to stop lifting all together, but little changes may help to offer some protection to your pelvic floor as it recovers.
- Don’t carry your baby in the car seat
A car seat will weigh approximately 20 pounds and babies only grow and get heavier. That’s a lot of weight to be dragging around [even if you do try to counterbalance yourself with bags on the opposite shoulder, by swinging the seat out to the side on every step or walking like a right angle], not to mention the chronic bruises you develop on your hip from the repeated banging against you. So, to get around this problem, leave the seat in the car and try to take your baby to the car seat. Then transfer him or her from the car seat to the buggy. Yes, it may add a few extra minutes to your life, but your pelvic floor will thank you.
- Keep your baby close to your body as you lift
Snug your baby into you as you pick them up and lower them down. This helps to reduce the load through the pelvic floor. It also helps to hold them directly in front of you rather than supporting them on your hip or to one side. Many women favour balancing their baby on their hip as they grow, but this not only leads to abnormal pressures through the pelvis but can lead to asymmetrical postures and back pain.
- Don’t hold your breath
We all do this without even noticing it, but holding your breath as you lift, increases the pressure in your abdomen which can push down into the pelvic floor. Try to get into the habit of breathing in through your nose as you lower or bend and breathing out through your mouth as you pick up and lift. This helps to manage pressure, but also encourages engagement of the pelvic floor which can offer some added protection.
- Don’t use shoulder bags
How much stuff do you pack into your gazillion bags? Changes of clothes, nappies, bottles, wipes, muslin cloths, toys and the list goes on and on. The weight of your bag is significant, and so carrying it on one side can have a drastic effect on your posture which can lead to back and pelvic problems, as well as increased pressure into your pelvic floor. Carrying a bag on both shoulders can help spread the load more effectively. Better still, use a buggy with a storage area for your bags [or get someone else to carry them for you].
- Have you started exercising?
Many women want to return to exercise quickly after having their baby [couch to 5k anyone?]. But the types of exercise that you commence can have a significant effect on your recovering pelvic floor. ‘High impact’ exercise such as running and jumping [which involve both feet being off the floor at the same time], can result in large loads being transferred into your weakened pelvic floor and this can lead to problems. It is very important to give yourself at least 3 months of recovery before returning to this type of exercise and even better, ensure that your pelvic floor and pelvic health are in good working order before you start by having a thorough check by a Women’s Health Physio. This is recommended regardless of whether you are experiencing symptoms or not.
A Women’s Health Physiotherapist will be able to examine your pelvic floor thoroughly and will be able to determine if is strong enough to cope with heavier loads. If you are having other symptoms such as pressure, dragging or aching in your perineum or urinary incontinence, it is even more important to have a proper check before you start or resume higher impact activities such as running, as the reality is that there is a potential for things to get worse if they are not properly managed and addressed.
The symptoms of POP
The following list of questions are commonly used as screening tools to help determine if a POP may be present;
- Are you experiencing heaviness, pressure, bulging, aching, or a feeling of something ‘coming down’ inside or around your vagina and perineum and does this get worse with upright positions and activities like standing, walking and running, or around your period?
The symptoms experienced from a POP can vary widely and do not always correlate with the degree of its severity. You may feel pressure, dragging or aching in your perineum, or an element of pain or discomfort in your back, pelvis or abdominal region. These symptoms may get worse with gravitational forces, as the day goes on, with activity or being on your feet. You may also find that the symptoms feel worse around the time of your period. This can be due to fluctuations in hormones particularly oestrogen, which affect the supportive function of the pelvic floor.
- Does anything protrude outside your vagina and can you push it back inside?
- Do you always empty completely when you pass urine or stool?
- Is the flow normal when you pass urine and stool?
- Are you experiencing any leakage of urine or stool?
- Do you get recurrent urinary tract infections?
- Do you ever have to get into awkward positions or use your fingers to help you pass urine or stool?
- Do you find it hard to get clean after passing stool?
- Do you feel a strong sense of urgency to pass urine or stool and are you going more frequently?
Bladder and bowel symptoms are common with POP. You may be experiencing a feeling of urgency to go to the toilet or find you’re going more frequently. You may be leaking at times either from your bladder or bowel, the flow of urine or stool may be disrupted and different to normal and you may feel as though you don’t always empty your bladder or bowel completely. Some women report having to get into certain positions or use their fingers to relocate the prolapse, support the rectum or vaginal wall from the inside or apply manual pressure on the perineum to help them pass urine or stool [also referred to as splinting].
- Are you having pain or problems having sex, particularly on penetration?
Sex can also be uncomfortable in certain positions and the sensation may not feel the same as before. You may also feel that there is something ‘getting in the way’ during intercourse.
You can have sex if you have a POP and it will not make it worse.However, using a lubricant may make things easier and more comfortable.
Many women who have children don’t have symptoms of POP until later life, with many noticing their onset around their peri and post-menopausal years. This may be due to gradual changes in hormone levels which can affect the functionality of the pelvic floor and its related connective tissues.
The diagnosis and treatment of POP
The prevalence of Pelvic Organ Prolapse after childbirth is high, but some women will not develop problems until later life, at which point, surgery is sometimes required. This questions whether there is a need for all postnatal women to be offered a standard physical examination postnatally, to screen for the condition and be provided with strategies and advice to prevent its potential onset or worsening of symptoms.
Asking the questions is of course, important. But ultimately, POP is diagnosed by a physical examination. This is nothing like a smear test, and is normally undertaken by your GP, Gynaecologist or Women’s Health Physiotherapist. A gentle [normally pain-free], internal vaginal assessment should be carried out, whereby the clinician will feel the vaginal wall, sometimes in different positions, to see which areas are affected and how the pelvic floor is functioning. Once diagnosed, an appropriate treatment and management plan that is specific to you, should be provided.
“Do Women’s Health Physio’s even exist in this country?”
A somewhat depressing, but very real question, that I was asked only a few weeks ago whilst on a Pilates training course.
The reality is as follows;
- Women’s Health Physiotherapists do in fact, exist [both in this country and abroad].
- We know our stuff when it comes to bladder, bowel and pelvic floor problems [and that includes POP].
- We should be the first-line of referral for most cases of women with POP [as recommended by the National Institute of Clinical Excellence].
- You can be referred to a Women’s Health Physiotherapist through your GP, you can self-refer in some parts of the country or you can seek help privately.
“I was told to get a ‘Kegel cone’. I thought to myself ‘I hope it comes with instructions’” [Annie]
We know from extensive research that pelvic floor exercises can have excellent outcomes on the degree of POP and its symptoms. Strengthening the pelvic floor through exercise and activation, thickens the muscle tissue which improves the structural support offered to the pelvic organs. You may have already been told;
“You just need to get on and do your Kegels”
But I feel that this very general advice is just not good enough.
Although some women can contract their pelvic floor by a simple verbal cue, evidence has shown that women with POP find it more difficult to activate these muscles correctly and so it is advised they receive individualised, supervised training to improve their pelvic floor function. Further to this, in my experience, women rarely seem to receive adequate verbal instructions or cues about how to engage their pelvic floor muscles at their postnatal check, rather they are just told to ‘do their exercises’.
“I was told to do my Pelvic Floor exercises, but I wasn’t sure how” [Georgina]
Some women are unable to contract their pelvic floor at all and others may not do so optimally. Research has shown that not all women activate their pelvic floor in the same way and some women use substitution strategies [like bracing their tummy or bottom muscles or holding their breath], which may result in more downward pressure into the pelvic floor, which is counterproductive, particularly when a woman has a POP.
So, do you know how to activate your pelvic floor?
Imagine you are in a queue and suddenly you get the feeling to pass wind. Without squeezing your bottom cheek muscles or bracing your tummy, gently close off the muscles around the opening of your back passage as though you’re holding wind. Then imagine you are drawing these muscles upwards and forwards as though you need to hold urine.
There are several visualisations which may help you to engage your pelvic floor correctly.
- Imagine you are picking up a marble with the muscles around your back passage, then lift the marble forwards and up towards your tummy button. Your spine and pelvis should not move as you do this – keep the muscle activation internal.
- Visualise a jellyfish swimming.
- Close the curtains and draw them up
You should feel the muscles squeeze and lift. You should be able to keep breathing at the same time. You should not feel a sense of bearing down.
The aim is to be able to contract your pelvic floor and hold for up to 10 seconds, then fully relax, aiming to reach 10 repetitions or until the muscles get tired. You should also try to practise some short squeezes or ‘quick flicks’ aiming for 10 times initially, then until the muscles get tired.
You should try to practise these exercises 3 times a day. You may find practising them lying down is a good place to start, however when you’re ready and able, you can try them in different positions such as sitting and standing.
If you have problems with activating or if you’re just unsure about what you’re doing – see a Women’s Health Physio who will ensure you’re on the right track.
Is simply ‘Squeezing the pelvic floor’ enough?
For any exercise or strength-training program to be effective, a muscle must be loaded appropriately, and a specific individualised program must be prescribed according to the individual’s capabilities. To achieve optimal function of the pelvic floor, strength, speed, endurance and co-ordination must be trained and because of this, it is important to determine how strong a woman’s pelvic floor is in the first place, what it’s endurance and quick-firing ability is like and how it is functioning overall, in-order-to prescribe exercise suitably for the individual woman. There are many ‘quick fixes’ advertised out there to get your pelvic floor functioning. But its more likely that what you need is supervised Women’s Health Physiotherapy and pelvic floor training.
Should you be avoiding certain things when you have a POP?
“I was told lots of ‘can’ts’. I can’t lift, I can’t carry my baby, I can’t exercise. I’m a PE teacher, does this mean I can’t work?” [Steph]
I hear comments like this frequently. It’s easy to tell someone not to do something and at times this advice may have its place with certain types of activity, or in the short-term. But advice like this is not a helpful, long-term solution and requires backing up with the ‘Whys’, the ‘How-long-for’s’, and the ‘What-can-you-do-about-its’. It is more important to educate a woman HOW to bend, HOW to lift and HOW to exercise, to make sure she is protecting her pelvic floor as she is doing these repetitive, everyday activities that are difficult to avoid. Avoidance of activity is not therapeutic, it has the potential to generate a level of fear and much of the time, is not even possible.
Women have goals and may want to continue with or return to certain activities like running or other forms of exercise. Telling a woman to stop the things she enjoys, particularly without an explanation or a plan, is negative and will only affect her quality of life further. It is important to re-educate the pelvic floor in a task-specific way, to enable it to respond to load and activity, according to the woman’s individual requirements and aims. Goal-setting is therefore very important both from a pelvic floor rehab point of view, but also from a motivational [and mental well-being] perspective.
It’s not all about the Pelvic Floor
Women’s Health Physiotherapists can assist with pelvic floor training and recovery, but they can also help provide information about lifestyle modifications, movement techniques, constipation prevention and management, and toileting techniques to help manage, improve and prevent further worsening of POP.
Weight loss management is something that may need to be discussed as excess weight leads to more pressure into the pelvic floor. Furthermore, the other muscles surrounding the pelvic floor may also require rehabilitation. If a woman is generally weak and if the muscles around the pelvic floor are of low tone, this may contribute to the issue. By strengthening the muscles around the pelvic floor including the leg muscles, bottom muscles and tummy, this will help to improve fascial integrity and strength. Keeping active with low impact exercise is beneficial and will help from a psychological perspective to improve body confidence, as-well as upholding the benefits for general health. Examples of low impact exercise include swimming, biking, cross-training, Pilates and walking.
A note about Pilates…
Pilates has a very good reputation for being an excellent form of exercise in the postnatal period. HOWEVER please note that not all classes are the same, and not all instructors will be trained in postnatal conditions. Exercises which involve both legs being in the air at the same time and lifting the head into a ‘crunch’ position will not always be suitable for a woman who has a POP. If you feel a sense of bearing down, increased pressure or worsening of symptoms during or after a Pilates class, chances are it may not be suitable for you.
What if Physio doesn’t work?
Research evidence recommends that Physiotherapy and Pelvic floor rehab should be carried out for a minimum period of 3 months. My experience working with women with varying degrees of POP [from mild to severe], has shown that the vast majority improve symptomatically with pelvic floor rehab. However, in some cases, women will require further help and onward referral for further management or opinion is appropriate.
Pessaries are useful medical devices which many women find beneficial. These are commonly ring-shaped and are inserted into the vagina to help provide support to the vaginal walls and pelvic organs. They can be left in place for several months and are periodically checked and replaced. Pelvic floor rehab may be continued with pessary usage.
“Can’t I just have surgery to sort it out?” [Emma]
Of course, surgery is sometime the solution for Pelvic Organ Prolapse, however this is always a last resort. Pelvic floor training and other treatment options such as pessaries must be carried out initially, and surgery will only ever be performed if these other treatment options fail to provide improvement, or if they are considered to be inappropriate. It is important to remember that surgery is not always a ‘quick fix’ and that the results are not always long-lasting.
So, to summarise!
- POP is a very common condition, particularly after childbirth and it doesn’t have to be scary.
- Women with POP can continue with life as normal. They can continue to have sex, and can function normally, however in some cases must learn to adapt and manage their lifestyle and health to prevent worsening of their condition.
- Education is very important in the management of POP and much can be done to improve and prevent symptoms.
- There are many symptoms associated with POP but some women won’t have any symptoms at all.
- Women may develop symptoms from POP later in life.
- Your symptoms from a POP and the POP itself can improve!
- Pelvic floor training through Physiotherapy can be very useful in treating POP and has been shown to be effective in improving the severity of the condition and its symptoms.
- Some women don’t know how to activate their pelvic floor and may not be doing it correctly or in the most suitable way for them, so an internal exam is always recommended. An individualised exercise program should be prescribed and progressed over time.
- Onward referral may be required but Physiotherapy is the first-line treatment for this condition in most cases.
- Just being told ‘to do Kegels’ is not adequate advice or treatment for this condition. A woman must be taught exercises properly, advised about lifestyle, movement, exercise modifications and preventative strategies to help improve and manage this condition in the most effective way possible.
- If you are concerned or feel you may have a POP – You are not alone. Getting some help from a Specialist Women’s Health Physiotherapist is a good call to action!