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Pelvic Organ Prolapse - Female

Pelvic Organ Prolapse - Female

If you are reading this then you are probably being proactive to prevent or improve prolapse.

"Pelvic organ prolapse (POP) refers to loss of support for your organs leading to an altered position of one or more of your organs into your vagina." (Source page 57)

Your support comes from your pelvic floor muscles, ligaments and a web of tissues.

Your organs are your bladder, urethra, uterus, vagina, bowel and rectum.

Wear and tear on your supporting tissues can lead to prolapse.

You may experience one of more of the following:

  • the feeling of a lump (“something coming down”),
  • low backache,
  • heaviness,
  • dragging sensation,
  • or the need to push on or near the prolapse in order to empty your bladder or bowel.

The position and your awareness of your prolapse can change from morning to evening and day to day depending on your activity level.

You will often notice it more at the end of the day, after long periods of standing, lifting, carrying or exercise and less when you are lying.

Prolapse may be more prominent at times of abdominal straining e.g. coughing or straining to empty your bowels.

The picture below shows a stage 2 bladder prolapse. This is also known as an anterior vaginal wall pelvic organ prolapse.

The picture below shows a back vaginal wall prolapse.

Other types not shown here are womb (uterus) and top of your vagina prolapse after hysterectomy.

What causes or worsens prolapse?

Prolapse is caused or worsened by:

  • Pregnancy and childbirth. More vaginal births, more risk.
  • Straining to empty your bowels.
  • Hysterectomy increases the risk of prolapse.
  • Vaginal hysterectomy and hysterectomy performed for pelvic organ prolapse are the strongest risk factors for having more pelvic floor surgery.
  • Strenuous exercise, heavy lifting.
  • Smoking and chronic cough.
  • Being overweight
  • Chronic Anaemia
  • Vitamin D deficiency
  • Thoracic kyphosis
  • Hypermobility also known as being double jointed.
  • Ageing process

How common is prolapse?

Based on women reporting a feeling of a mass bulging into the vagina, pelvic organ prolapse has about a rate of 5 and 10 out of every 100 women.  (Source page 57)

There is an estimated lifetime risk of surgery for prolapse of 7% to 11%.  (Source page 59) 

Will it get worse?

A study of 161,000 post menopausal women suggests that prolapse is not always long standing and progressive.

Spontaneous improvement is common, especially for stage 1 prolapse.

Progression was less common in women of normal weight.

Progression was more common in women who had more pregnancies and births. (Handa et al 2004)

So what do I do?

Below is a government link that summarises treatment options for pelvic organ prolapse.

Australian Commission on Safety and Quality in Health Care - POP consumer information sheet

Your physiotherapist can help you understand, implement and maintain the lifestyle changes and pelvic floor exercises mentioned here.

These take time to work and need to be continued over your whole life.

Assessment

Assessment at Innerstrength is very holistic so be prepared to answer a variety of questions about your bladder, bowel, pelvic floor and sexual situation.

Diagnosis is usually done using examination to identify which part of your vagina has moved. 

Your physiotherapist will be able to give you an idea of the stage of your prolapse, when you are lying.

If you haven't already had an examination please read the Informed Consent For Examination - Female form before arriving at your next appointment and be ready with questions.

If you feel comfortable your physiotherapist can assess your proplapse  whilst you squat or stand to get a more accurate idea of what you are expereincing.

If you are experiencing bladder or bowel problems together with your prolapse you could download and complete a bladder diary for 2 or 3 days and a bowel diary for 7 days.
 
 

Dealing with the diagnosis

If you notice a prolapse or have been told that you have a prolpase by your Obstetrician / Gynaecologist, GP or Physiotherapist, you might be understandably concerned or upset.
You are not alone.
You may be experiencing feelings of confusion and fear about what it is and will it get worse.
Others describe anger, disappointment, frustration, sadness and a feeling of loss.
Your physiotherapist will listen, be supportive and kind and will try to help you with your individual needs at this time.
The podcast below might help you understand prolapse more and eventually accept it and help you maintain your efforts towards actively managing and preventing progression as best you can. Pelvic Health Podcast
If you feel overwhelmed at all you may like to talk to our psychologist Jo Sheedy.

What is Intra-abdominal pressure?

Intra-abdominal pressure is the pressure that happens inside your abdominal area between your diaphragm muscle at your ribs and pelvic floor in your pelvis.
When you cough, laugh, strain and do strenuous activities the pressure is high and when you lie down or sit it is low.
It is a great design to create a strong base for our bodies to move and requires excellent timing, symmetry, strength and endurance.
 
 
The human pelvic floor is designed to get us ready for movement.
It should work before you can see your body move. (Source) 
In picture A below you can see electrodes that were placed inside study participants vagina and anus to measure pressure.
Then they were given a signal to lift their arm.
Below in A you can see a recording of a male study participants anal muscle activity starting before shoulder movement.
In B you can see the same effect the early pevic floor and anal muscle activity in women.
For many of us our pelvic floor is too tense, too late, too slow or too weak to do what it was designed to do.
If it doesn't get us ready for movement and or we overload it with exercise, pregnancy, heavy lifting, obesity, that pressure downwards can take its toll.
Click on this link to youtube to watch a video that explains intra-abdominal pressure.
Pelvic floor rehabilitation to retrain this reflex makes sense.
 

Pelvic floor and Prolapse

The picture above shows the relationship between your pelvic floor and tissues.
The boat is uplifted and supported by the water and the moorings are loose.
Similarly your organs are uplifted by your pelvic floor & your tissues are loose.

If there was no water, the boat would sink and the moorings strain and break.
Similarly an ineffective pelvic floor can result in tissue stretch & breakage, incontinence & prolapse.
This is most likely to happen slowly and progressively and be felt more after straining to open bowels, heavy lifting, at the end of the day, after exercise or when you have cough or sneeze alot.

What is my pelvic floor?

Cick here to read about your pelvic floor.
 

 

How can I manage or prevent prolapse?

Below is a link to an excelllent consumer information sheet for treatment options for pelvic organ prolapse or POP.
 
 
Here are some suggestions to help you manage your prolapse.
These strategies will prevent further prolapse while you improve the active support of your organs.
If you choose to have surgery these suggestions will help you prepare and recover from surgery.
 

Do


Pelvic Floor Muscle training - Your physiotherapist will take you through your Intensive Personalised Pelvic Floor Rehabilitation Programme. 
(No two programmes are alike.)
Empty your bladder completely.
Rest - Intermittent lying down or lying with your bottom in the air if your are bothered by the dragging sensation.
Low impact exercise - consider lower impact choices such as cycling, swimming or walking.
Use vaginal lubricant during sexual intercourse to increase comfort and reduce friction & stretching.
Use prescribed vaginal oestrogen
Learn Dynamic pelvic floor Bracing(The Knack)- your physiotherapist will teach you how to lift your pelvic floor muscles dynamically as you move to lift your organs and protect your tissues.
 

Don't


Strain to empty your bowel or bladder.
Lift heavy objects especially from the floor (see below)
Stand for prolonged periods if this worsens your dragging feeling
If your bladder or bowel emptying has been affected by your prolapse your physiotherapist will help you manage this.
Sometimes improving your bladder and bowel emptying takes months to years to achieve.
Also you can read and discuss how to empty your bladder with your physiotherapist at your next appointment.
Also you can read and discuss normal bowel habits with your physiotherapist at your next appointment.
 

Lifting (toddlers or other objects)

The way you lift and the height that you lift from influences the pressure downward.
A study picutred below measured 4 types of lifts and how much vaginal pressure each lift made in women.(Gerten 2008)
A Lifting a bucket from the floor
B Lifting a bucket from the floor with assistance from a table.
C Lifting a bucket from a table.
D Being passed a bucket.
They then loaded up the bucket with 5/10/15kgs and measured the downward pressure.
The result was that being passed a bucket created the least pressure and lifting a bucket from the floor created the most.
In fact there is more pressure lifting an empty bucket from the floor than beiing passed 15kg bucket.
 
Mothers and Grandmothers could consider the height of the surface they change the baby and where you store the nappies.
You could ask your toddler to climb up onto a chair and assited the lift by asking them to jump.
 
If you are at the gym. place the weights you are lifting on a table rather than the floor.
Place your wet washing basket on a table and not the ground.
Can you change the way you lift in your daily life?
 
 
 

Can I continue to have sexual intercourse with a prolapse?

Yes if it is comfortable.  Be very generous with your use of personal lubricants.

Click here to read more abou Personal Lubricants.

How effective are pelvic floor exercises for prolapse?

Please click here to read about the level of evidence for the role of pelvic floor exercises in improving or managing prolapse.

How do I do pelvic floor exercises?

Your physiotherapist will take you through your Intensive Personalised Pelvic Floor Rehabilitation Programme
No two programmes are alike.

What exercise can I do?

We get asked what exercise can I do everyday.
We have Core Floor Restore exercise class which gives you an opportunity to experience pelvic floor friendly exercise and do pelvic floorexercise as well.
Click here for further information.
 
Click here to discover more information about Pelvic Floor Friendly Exercise Ideas and Resources.
 

What happens if I cannot do pelvic floor exercises?

Your physiotherapist will teach you how to do them and if you still can't you can use equipment.
One type is EMG biofeedback EMG (Neurotrac) and the other is Electrical stimulation
 

What happens if lifestyle changes and pelvic floor muscle exercises don't work?

There is a small proportion of women still bothered by prolapse despite doing pelvic floor exercises to increase and then maintain their pelvic floor in tip top shape.
This is likely due to the injury sustained during childbirth and or another health condition affecting pelvic floor control.

If this is you then you have the following choices.

  • Live with it.
  • Try a pessary
  • Try Surgery

Do I have to have surgery?

The choice is ultimately yours
  • Lifestyle changes
  • Pelvic floor exercises
  • Pessary
  • Surgery
About two out of every three women with over 5 years of bothersome prolapse choose conservative management(including a vaginal ring pessary.)rather than surgery (Kapoor et al 2009.)
For every three women who initially desired surgery one changed their mind and opted to continue pessary use (Clemons et al 2004a.)
Surgery was chosen if women were sexually active, and had more quality of life impairment due to sexual dysfunction (Kapoor et al 2009.)
However, increasing age increased the likelihood of a woman choosing a pessary rather than surgery (Heit et al 2003.)
 
 

What is a pessary?

Please click here to learn more about pessaries.
 

Tell me more about Surgery

Surgery is the mainstay of prolapse management for many years, especially for symptomatic or advanced stages of prolapse. 
Although there is increasingly high-quality evidence to guide surgical practice, the longevity of prolapse repairs remains unclear.
 
 
Some experts suggesting that re-operation for recurrent prolapse will be inevitable for some women (Brubaker et al 2009).
Reports suggest that previous prolapse surgery, more severe prolapse, the need for vaginal digitation and incomplete bowel emptying are factors associated with a choice of surgery over a pessary (Heit et al 2003; Kapoor et al 2009).
 
Reports suggest that prolapse repair surgery may fail in 30%  (Olsen et al 1997) to 58% (Whiteside et al 2004) of patients. 
That means it is successful in 70% or 42% of cases.
The front vaginal wall is regarded as the most vulnerable to failure (Whiteside et al 2004). 
Failure of surgery is thought to be associated with increased intra-abdominal pressure (Weir et al 2006; Gerten et al 2008; Mouritsen & Larsen 2003) but other factors such as a wide levator hiatus (pelvic floor opening) and pelvic floor muscle weakness (Ghetti et al 2005) have also been identified.
 
Mesh prolapse repairs.
To improve the longevity of prolapse repairs various types of synthetic mesh have been used.
Below is a review of prolapse surgery from 2016.
It compares prolapse surgery using mesh versus natural body tissue.
 

Financial Assistance

Click here for information about financial asistance

Your questionnaires to track your progress

Please fill in the following questionnaires now and before every appointment:

Pelvic Organ Prolapse Symptom Score
Pelvic Floor Muscle Exercise - Self Efficacy

Transvaginal Mesh complications support services

In Victoria, a Mesh Information and Help Line is available by calling 1800 55 6374 (1800 55MESH).
The information line is supported by the Continence Foundation. Calls are returned for all messages left, within 24 hours.

Safer Care Victoria has published information and provides links to important information such as credentialing and freedom of information resources on the public website:
www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/Transvaginal-mesh

Specialist multidisciplinary services are provided at:
Royal Women’s Hospital       Phone: 03 8345 3143 
Mercy Hospital for Women   Phone: 03 8458 4500 
Monash Health                    Phone: 03 9928 8588
Western Health                    Phone: 0481 908 118
 

Services at these hospitals include:

  • Mercy Hospital for Women. A multi-disciplinary team provides services for affected women. Services include urogynaecology, urology, colorectal surgery, pain management and community linkage with psychiatric services.
  • Monash Health. The Pelvic Floor Unit leads care, in conjunction with physiotherapy, pain management, and where indicated, colorectal, urology and plastic surgery. Other specialised services include psychology, a sexual and relationship difficulty clinic, and a continence nursing service.
  • Royal Women's Hospital. Urogynaecology is the lead discipline, with services such as plastic surgery, urology and colorectal surgery are also involved, depending on patient needs. Patients can also access pain physicians and physiotherapists.
  • Western Health. Services include urogynaecology, urology, colorectal surgery, pain management and community linkage with psychiatric services. The lead discipline is urogynaecology with a multidisciplinary clinic involving urology, pelvic floor physiotherapy and continence nursing.