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  • Olivia Clark & Jenni Davies

Pelvic Organ Prolapse (POP)

What is a prolapse?

You may have heard this term before, know someone who has had a prolapse, or may be concerned that you have a prolapse. This blog will explain what a prolapse is and what you can do about it.


Let’s start with the basics:

A pelvic organ prolapse (POP) is the downward movement of one or more of the pelvic organs (the bladder, uterus or bowel) into the vagina.


Why?

The bladder, bowel and uterus are held in place, within the pelvis, by non-stretch connective tissues (fascia and ligaments). Think of it like the ropes attaching a boat to the dock.

The pelvic floor muscles (PFM) sit underneath the organs and help support them – like the water.


If the ‘ropes’ are lengthened the organs (boat) will sit in a lower position than normal. This can occur due to a number of factors:

· Lack of support from a weak pelvic floor

· Chronic straining when emptying your bowel

· Repeated heavy lifting/carrying

· Pregnancy

· Giving birth vaginally (increased risk with a forceps delivery)

· Family history of prolapse


The PFM, when working well, they can compensate for the prolapse and hold the organs (boat) in a better position thus decreasing symptoms.


How common is it?

It actually a lot more common that you think. In Australia approximately half of women over the age of 50 will have some signs or symptoms of pelvic organ prolapse.


Symptoms of POP:

· Vaginal heaviness or a sensation of something ‘falling out’

· Dragging sensation through lower abdomen or lower back

· Visible or palpable ‘bulge’ or ‘lump’ in vagina

· Issues with emptying your bladder/bowel

· Incontinence/urinary leakage

· Recurrent urinary tract infections

· Inability to hold in tampons

· Pain/discomfort, or a sensation of something blocking intercourse


Types of prolapse:

  1. Bladder prolapse (cystocele) and/or urethral prolapse (urethrocele) is caused by the softening of the connective tissue that supports the front vaginal wall. This causes the bladder/urethra to fall backwards into the vagina

  2. Uterine prolapse is caused by the softening of the connective tissue holding up the uterus and causes the downwards descent of the uterus into the vagina

  3. Bowel prolapse (rectocele) is caused by the softening of the connective tissue of the back vaginal wall. This causes the bowel to fall forwards into the vagina.

There are some other less common types of prolapse such as an enterocele (small intestine prolapse into the vagina), a vault prolapse (descent of the top of the vagina after hysterectomy) and a rectal prolapse where there is a bulging externally through the anus.


Stages of prolapse:

Prolapses vary significantly in severity from a very mild prolapse where there is barely any movement of the organ through to a severe prolapse where the whole organ is outside the body. Thankfully the latter are rare. When you are diagnosed, the prolapse will be staged using the following criteria:


Stage 1 = descent of the organ to less than 1cm inside the entrance to the vagina

Stage 2 = descent of the organ to between 1cm inside and 1cm outside the entrance to the vagina

Stage 3 = descent of the organ more than 1cm outside the vagina

Stage 4 = procidentia = the whole organ is outside the entrance to the vagina


Diagnosis:

As Pelvic Health Physios, it is part of our job to assess your pelvic health and diagnose a prolapse if present. Alternatively, you may have been diagnosed by your GP or by a Specialist. You may have also self-diagnosed using Dr Google. In this latter instance, it is always best to get your suspicions confirmed by a Medical Practitioner or Pelvic Health Physio.


Of note, when researching prolapses online, Dr Google has some very scary information. It is often very frightening to read this information with it's extreme guidance for activity limitation as it usually focuses on the most extreme types of prolapse and doesn't take into account individual circumstance. At Beaches Pelvic Physio we feel VERY STRONGLY that this information is misguided and misleading. A prolapse is not a life sentence. It is like have a dicky back or shoulder, you learn how to manage it and life continues on.


We cannot stress this point enough.


As for every other thing in life, there is not a “one size fits all” diagnosis or solution. You are an individual with a multitude of unique factors that need to be taken into consideration. With regards to POP, information on the internet tends to be very conservative and negative in outlook. At Beaches Pelvic Physio we fundamentally disagree with this approach. We specialise in detailed assessments and diagnoses, so that we can formulate a recovery plan based on your individual needs and goals, with the sole aim to minimise your symptoms and maximise your activity.


The reality of POP though, is that there is a significant difference in severity of symptoms and rehabilitation outcomes dependent upon a multitude of factors, including:

· The severity of the prolapse

· The level of activity desired (day to day function is very different from Cross Fit heavy lifting)

· Your hormone status (early post-natal when tissues are still recovering, breastfeeding, post-menopausal etc)

· Your pelvic floor muscle function

· Other health factors such as a history of breast or gynaecological cancer


Our aim is to achieve the best result possible. If the ‘best result’ is not good enough i.e. you’re still symptomatic and/or can’t get back to the level of activity desired, this is when we start to consider surgery.


How do Pelvic Health Physio's treat pelvic organ prolapse?

There are 2 main approaches to treating a prolapse:

1. Physiotherapy (conservative) management (including vaginal pessary fitting)

2. Surgical management


Physiotherapy/Conservative Management:


There are many different aspects to Physiotherapy (conservative) management of a POP. Not all of these may be applicable to you.


1. Activity modifications and progressions:

It is a rare occasion when we tell you to stop an activity altogether. However, we often assist you in adjusting your exercise/activity to a level that is symptom-free and appropriate for your body. As the other aspects of management improve (see below), we then assist you in gradually increasing your levels of exercise/activity back towards normal, monitoring symptoms along the way. In this way we build your tolerance gradually and work out whether there will be any long-term limitations or not.

2. Symptom-relieving positions:

Gravity pulls the organs downwards (hence why your symptoms will typically be worse after long periods on your feet, or later in the day). To relieve these symptoms, you can try the following positions:

· Horizontal rest: either lying on your back, stomach or side with a pillow under your hips

· Downward dog

· Child’s pose with your hips in the air (kneeling, keeping your hips high whilst resting your upper body/head on the floor)

· Stretching/leaning forwards onto the kitchen bench or back of a chair


3. Bowel and constipation management:

· Avoid heavy straining or bearing down when passing a bowel motion as this can exacerbate symptoms and worsen the prolapse

· Aim for a stool type 3-4 on the Bristol stool chart - this can be passed easily without straining

· If your stools are too firm then ensure you are getting enough fluid and fibre into your diet (e.g. leafy greens or oats)

· If fluid and dietary changes are not enough, you may need an over-the-counter supplement such as Metamucil or Movicol

· Magnesium Citrate (safe when breastfeeding) helps relieve constipation. Magnesium Glycinate is a stronger form of magnesium if the Magnesium Citrate is ineffective (check with the Pharmacist if you are breastfeeding)

· Toilet stools are used to bring you into a more functional ‘squatting’ position. This has been shown to flatten out the kink in your bowel and makes passing your bowel motion easier (for more information please see the blog on healthy bowel management)

· If you have a rectocele, you may find that putting direct upwards pressure on the perineum (area between the vagina and anus) or on the back wall of the vagina, whilst emptying your bowel, enables you to empty more fully and more easily. If the latter is helpful but hard to do, there is a ‘tool’ called a Femeze (stocked in our clinic) that makes it easier to apply this pressure

. Empty your bowel before exercising to decrease the discomfort and symptoms from the prolapse


4. Lifestyle modifications:

Similar to the activity modifications, we will discuss your lifestyle factors with you to help identify symptom-provocative activities, then look for ways we can alter them to decrease their impact.


5. Pelvic floor muscle retraining:

Performing a regular and progressive pelvic floor muscle retraining program can help reduce prolapse symptoms and prevent recurrence of symptoms in the future. Our programmes are individually tailored to your needs and address strength, speed, endurance and the functional coordination of the pelvic floor muscles.


6. Deep core retraining and intra-abdominal pressure management:

The pelvic floor muscles (PFM), together with the deep abdominal and back muscles, and diaphragm, are an integral part of the true deep core.


The deep core muscles should work as a coordinated unit to assist in body movement and control the intra-abdominal pressure (IAP). IAP refers to the pressure created internally in the abdomen. This pressure increases with activities like coughing, sneezing, lifting, carrying - basically any activity that requires you to brace your abdominals.

What should happen automatically, is that the deep core pre-empts the onset of an IAP increase, thus maintaining the pressure within the walls of the deep core. If one component of the deep core is not working well, for example the pelvic floor, then the IAP increases but the pressure escapes through the point of least resistance – in this case downwards. This loads the supporting tissues of the pelvic organs which, over time, can create or worsen a POP.


This is demonstrated so beautifully by our little chook in the photograph. At rest there is a balance of pressure from all sides but when squeezed around the middle (like abdominal bracing which increases the IAP) without any support underneath (pelvic floor muscle contraction), the result is a downward bulging - a crude version of a prolapse.


For this reason, the following top tips should be followed:

o Avoid straining/bearing down with heavy lifting - use pelvic floor muscles when lifting or carrying, this will help support your pelvic organs

o If you’re having to do heavy lifting, consider breaking the lifts into smaller loads e.g. groceries, washing

o With young children, when possible, minimise lifting them. Instead get them to climb up to you or you go down to them

o Avoid kids sitting/resting on your lower stomach - have kids sit on your thighs instead of lower stomach

o Consider how you are wearing your baby carrier. As soon as the baby is big enough, drop the belt down onto your pelvis so that the pressure goes through your pelvis, hips and legs rather than your abdomen. Once you have done the belt up, physically lift your abdominal wall up behind the belt so it rests onto the belt rather than the belt pushing down on it

o When lifting, you may need to adapt your technique. For some people bending from the waist will be more provocative of symptoms, for others doing a deep squat will be more provocative. Either way, use your PFM at the same time

o Avoid sitting for long periods with a tight waist band, this creates a subtle increase in IAP that overtime, can be very provocative of symptoms


7. Vaginal Pessaries:

Vaginal pessaries are silicone devices that sit inside the vagina to provide internal support for the pelvic organs. Think of them like fancy tampons, used in the same way that an ankle or knee brace would be used externally to support a joint. They are an excellent alternative to surgery when the above management techniques are not sufficient to manage your symptoms.


There are many different types of pessaries, each with different indications for use. Your Pelvic Health Physiotherapist will advise you on which type is ideal for your POP.


It should be noted that pessary fitting is an ‘artistic science’. There is a degree of trial and error when finding the right one for you. We aim to get the right one first time, but this is not always possible. They are also not for everyone. However, when they work, they are brilliant and can be absolute ‘game changers’ in terms of your activity tolerance.


Surgical Management:


Unfortunately, surgery has a failure rate of approximately 30% within 5 years of the operation (dependent on which operation you have). For this reason, we encourage you to go through a conservative management programme first. If this fails to achieve the desired results, firstly no harm has been done, and secondly, any improvements you’ve made will only help to protect any future surgery.


Whether you proceed to surgery after a ‘failed’ conservative programme, is up to you. For some women, the symptoms are tolerable enough to continue living life as is. For others, the symptoms are impacting too much on their lives and surgery is a good option. Either way, it is your choice.


For any women reading this blog who do a lot of heavy lifting (whether in the garden, at work, in daily life, or as part of an exercise programme), please remember that if you do proceed to surgery, you will likely be given a long-term lifting limit that may well impact your normal activities. We strongly advise you to consider this in your decision-making process if you are considering surgery.



If you would like more information on any of the above, or if prolapse symptoms are bothering you or stopping you from doing your normal activity, don’t suffer in silence – please contact us using on 02 8954 5579 or 0435 150 136 or via email: hello@beachespelvic.physio





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