Prolapse

The pelvic floor has 5 different functions.

1. Supportive
2. Sphincteric
3. Stabilization
4. Sexual 
5. Sump-pump (for lymph flow)

When we don’t have any issues, we don’t realize how much responsibility our pelvic floor muscles have in our everyday functions, such as going to the bathroom, having sexual intercourse, and supporting our pelvic organs all... day... long. When we do experience some kind of pelvic floor dysfunction, it can be absolutely debilitating. Symptoms may include urinary incontinence, constipation, difficulty initiating urinary stream, feelings of unfinished emptying of bladder or bowel, pain with sexual intercourse, or pain in pelvic region, abdomen, lower back, and hip. Another big symptom is a feeling that something is bulging out of the vagina, or prolapse. Prolapse is defined as the descent of one or more of the pelvic organs (cervix/uterus, vaginal vault, bladder, rectum or intestine). Unfortunately, prolapse is more common than we think. One Swedish study found 31% of women aged 20-59 experienced prolapse of the reproductive organs and in another study reported 41% of women aged 50-79 experienced prolapse (Jundt, 2015). 

There are many different kinds of prolapse; one is uterine prolapse where the uterus is low and descending down towards the vagina. Other kinds are when other organs are pushing against the vaginal wall in different directions. For example, one common type of prolapse is a cystocele. This is when the bladder is pushing against the anterior vaginal wall. It is common to experience post-void dribble or feelings of incomplete bladder emptying with a cystocele. Another type of prolapse is rectocele, where the rectum is pushing against the posterior vaginal wall. This can make it very difficult to defecate or sometimes feel like you’re sitting on a golf ball.  Other common symptoms include bleeding, discharge, and low back pain. Prolapse symptoms fall under the “supportive” function of the pelvic floor muscles. The pelvic floor muscles and pelvic fascia are responsible for supporting all of your pelvic organs. There are several reasons why some people may experience this lack of support.

1. Childbirth 
2. Intra-abdominal pressure: 
1. Poor toileting mechanics/chronic straining or constipation
2. Chronic weightlifting with poor breathing mechanics
3. Surgery (hysterectomy, etc.)
4. Menopause (estrogen deficiency)

It is especially common to experience feelings of prolapse shortly after childbirth. However, while common, it is definitely not normal and there are things you can do to help minimize this discomfort. Trauma during childbirth (regardless if you had a vaginal or cesarean section)  can lead to pelvic floor weakness, denervation, perineal scarring which can all contribute to prolapse. After having your 6 week check-up with your OB-GYN (please tell him or her what you are feeling!) and ask to visit a pelvic floor PT! We can give strategies to help minimize prolapse discomfort as quickly as possible and help with movement patterns such as lifting your baby, lifting the car seat, and picking toys off the floor and with less discomfort.

Prolapse is predominantly a gravity issue. So people with prolapse may feel more “pressure” when they’re on their feet for prolonged periods, or walking for prolonged periods. It is also common to feel worsening of prolapse symptoms after increased intra-abdominal pressure activities, such as during a squat or after straining during a bowel movement. When we strain or hold our breath, the pressure that is in our abdomen has nowhere to go but down the other hole or vagina! Repetitive weightlifting, straining during work-outs or on the toilet, can lead to prolapse due to this excessive pressure pushing down on our pelvic organs. This does not mean people with prolapse should never squat again or ever lift weight again! With the right muscle activation, timing and sequence with the appropriate breath work, it’s a great idea to do squats, run and perform your usual work-outs! Initially, there may be some helpful modifications as you start to utilize and/or strengthen different muscles (hint hint, pelvic floor, core, back and hip muscles) so that your symptoms don’t worsen overtime.  The breath is imperative when it comes to work-outs. Coordinating with the breath helps manage the intra-abdominal pressure so that the pressure towards your vagina is minimized and controlled. This is something we can focus on during physical therapy rehabilitation. 

While we are on the topic of intra-abdominal pressure, constipation is a big contributor to pelvic floor dysfunction. Visiting your primary physician or gastroenterologist is a great first step. Some strategies that you can immediately implement are:

1. Diaphragmatic breathing on the toilet
2. Using a squatty potty to make defecation an easier process with significantly LESS straining
3. Drinking plenty of water
4. Abdominal massages can help trigger peristalsis 

I have noticed more older women coming into the clinic for prolapse. This is due to tissue changes in the pelvic floor, primarily due to changes in our hormones (predominantly estrogen) after menopause. This alone can cause pelvic floor muscle dysfunction. Think menopause effects and add… grandchildren! This is asking for more demand on the pelvic floor with a lot of lifting and getting up/off the floor, etc. While it is a glorious time to be with grandchildren, don’t think what you are experiencing is normal just because of aging. Pelvic physical therapists can help, so that your time with your grandchildren can stay wonderful and fun! 

Having surgery can also contribute to prolapse. During surgery, there can be some damage to some ligaments, fascia, and other layers of pelvic connective tissue that are part of the support system in your pelvis. After surgery, often there are changes physiologically (i.e. taking out the uterus during a hysterectomy) that is new anatomy that your body needs to address. Sometimes there is enough support, and sometimes there is less support. Scarring after pelvic and abdominal surgeries can lead to connective tissue restrictions and/or paniculosis that can weaken the support system. Regardless of how old the surgery may be, scarring can persist and can lead to adhesions externally or internally leading to some of your symptoms. 

Wondering what a prolapse assessment looks like in a pelvic physical therapy room? 

First, we listen to your story, and ask tons and tons of questions about various parts of your life, including what it is like on the toilet, sexual history, when do you feel symptoms, what makes you feel better, and most importantly what are your personal goals.

Things we would look at during a pelvic floor PT exam:

• Posture 
• Lifting patterns/managing intra-abdominal pressure
• Breath
• Discussion of toileting habits
• Assess for any adhesions or connective tissue restrictions, assess incisions’ mobility if had any pelvic or abdominal surgeries

Pelvic floor muscle exam : 

1. Integrity of the tissue - is it truly weak or is it extremely tight? - either way may exacerbate prolapse symptoms but the treatment plan would be different!
2. Assessment of the pelvic floor contraction or “kegel”
1. Can you perform correctly? If so...
2. How long can you hold a pelvic floor contraction?
3. Can you do quick contractions? How many? How quickly?
3. Prolapse - sometimes I assess for prolapse while the patient is lying on her back; but like I mentioned earlier, prolapse is a gravity issue. More often than not, I assess for prolapse in standing position or during the activity that the patient reports feeling symptomatic. A lot of providers will assess for prolapse when you’re lying on your back. But… lying on your back is not the issue, right? Position is key.
1. Then, we may ask you to maximally bear down and check for laxity in the vaginal walls that may be explaining your symptoms. 

There are different kinds of grading for prolapse. Very often, it is based on distance of descent (most commonly used is the POP-Q). As physical therapists, we do not diagnose prolapse, however we can diagnose degrees of laxity in the vaginal walls when prompted to bear down, and our job is to find out why.

Each and every session consists of further education based on your current symptoms. Your pelvic floor physical therapist should describe an individualized treatment plan for you based on your evaluation/assessment findings. This may include pelvic floor, low back and hip muscle strengthening, or it may include more stretching and pelvic floor relaxation exercises. Depending on the severity of the prolapse or your symptoms, there are garments you can wear over your underwear to provide extra pelvic support. In addition, there are pessaries, a non-surgical option that can provide internal pelvic support. Pessaries are a removable device that can be inserted in the vagina. There are many different kinds, including an over the counter pessary called impressa. 

Another common observation I see in my practice is that the grading of the prolapse very often do not correlate with my patients’ symptoms. There’s the main POP-Q grading scale for prolapse and there are 4 grades of severity. Grade 1 is least severe while grade 4 is most severe and is measured through distance of descent. Often, my patients come to me and they tell me they have been diagnosed with a  grade 1 or even 0 prolapse, but report a high level of discomfort/pain and feel it almost all day, even when sitting! I also see people on the opposite side of the spectrum where they report a diagnosis of prolapse grade 2 or 3 but rarely feel symptoms of prolapse. Regardless of severity of prolapse, the symptoms are not normal and CAN be addressed and further minimized. There are many recent studies showing significant improvement in prolapse symptoms following pelvic floor physical therapy. After analyzing 4 randomized studies, the probability of improving prolapse by one grade (less descent) after pelvic floor muscle training was 17% (Jundet, et al.).  Don’t ever let anyone tell you your symptoms don’t make sense or that no more can be done to relieve you of your prolapse symptoms.  

You are not alone and we can help.

In conclusion…

1. Don’t be shy! Speak out about all of your symptoms. No matter what grade (0-4), don’t let anyone minimize how you feel.
2. Address constipation. The effects are real. 
3. The breath is also real. Your pelvic floor muscles thrive on the diaphragmatic breathing style.
4. Don’t think you are not allowed to squat or exercise again. With appropriate management of intra-abdominal pressure, the right movement training and initial modifications, you should be able to return to doing what you love. 
5. Make sure providers assess for prolapse in positions that aggravate your symptoms.
6. Don’t assume pelvic floor contractions or “kegels” are the best thing to do. 
1. Do you know how to perform a pelvic floor contraction correctly?
7. There are external and internal options, such as garment support and/or pessaries.
8. Come visit a pelvic floor physical therapist :) 

Written by: Carly Soltman, PT, DPT, Pelvic Floor Specialist 

References:

Jundt K, Peschers U, Kentenich H. The investigation and treatment of female pelvic floor dysfunction. Dtsch Arztebl Int 2015; 112: 564-74. DOI: 10.3238/arztebl.2015.0564