Understanding Pelvic Organ Prolapse

What IS prolapse?

Green circle = bladder; blue circle = uterus; purple circle = rectum; arrow = vagina

Pelvic organ prolapse is the descent of pelvic organs through the vagina. Specifically, pelvic organs include the bladder, the uterus, and the rectum. So, a prolapse could involve one or multiple of these organs.

Now that we’re on the same page, let’s just admit that this is highly unlikely to be fodder for your next dinner party conversation or even for play group. But given that it affects approximately 30% of women—that’s almost one third of women—between 20 and 59, it’s probably something we should learn to talk about. (Here’s a Turkish study and a Swedish study that both found very similar rates of occurrence).

To be clear, the professional best suited for a discussion of this type is a pelvic floor physical therapist. But if you’re experiencing symptoms, it’s not a bad idea to discuss it with the mothers who are close to you. You never know who else might be affected. Thirty percent is A LOT of women, and spreading good information means people with the right answers need to be talking.

Why does it happen?

L: the inward turned finger of the glove is similar to a vagina; R: downward pressure can push the finger back out.

There are two main reasons for a prolapse to occur.

  1. Trauma during delivery—in other words, excessive stretching or tearing—OR;
  2. Muscle weakness combined with too much pressure.

Now, you might be asking yourself exactly what cause #2 means, so I have a great analogy to share with you. Although I can’t claim credit for it, I think this is a perfect way to visualize what’s going wrong. In 1934, a reasearcher named Victor Bonney pointed out that the vagina and the abdominal cavity are like an inward turned finger and a rubber glove.

The vagina is like an inward folding that points upward from the bottom of the pelvis. Similarly, a finger on the glove is folded upward and in toward the rest of the glove. If the top of the glove is tied closed and you squeeze the main part of the glove, it will push that inward-turned finger back out. Likewise, if a woman creates downward pressure in her abdominal cavity, she can push her pelvic organs down and out of her vagina.

Other factors to consider

In addition to trauma and the improper regulation of pressure, there can also be genetic factors that contribute to the development of a prolapse. This twin study found more similarities in occurrence among identical twins than among fraternal twins, indicating that genetics play a role in the development of prolapse. Genetic factors that might be significant include posture; degree of ligament laxity; or shape, size, or positioning of specific body parts—just to name a few.

To be clear, ligament laxity refers to how much give there is in a woman’s ligaments and can affect joints but also conditions like prolapse. Another factor that can affect ligament laxity is hormones. The hormones of pregnancy and breastfeeding cause increased laxity in ligaments and can consequently have effects on joints as well as increase the chances of prolapse.

What to do if you have a prolapse?

Women who have prolapse often describe a sensation like a tampon or something else inside of their vaginas when nothing is there. They may also feel like something is falling out or like they need to hold something in. Lastly, some women describe a heavy sensation in their vaginas, and a prolapse may be accompanied by the unintentional leaking of urine.

The picture shown above is a grade 2 uterine prolapse. The numbers indicate the position of the cervix (lowermost aspect of the uterus) for the corresponding number grade.

A huge part of any recovery from prolapse is always to find a good pelvic floor physical therapist.

A prolapse can be graded on a scale from 0-4, where:

0 = no prolapse

1 = the organ(s) is in the vaginal canal

2 = the organ(s) is at the opening of the vagina

3 and 4 = the organ(s) has descended outside of the vaginal opening

Grades 3 and 4 will generally need to be treated with a pessary in addition to pelvic floor physical therapy, but with grades 1 and 2, recovery depends upon the condition of the connective tissues. Connective tissues are the fascia, nerves, muscles, and ligaments that play a role in the positioning of the pelvic organs. If they are intact, a full recovery may be possible. However, if they have been damaged to a greater degree, symptoms and function can still improve, but more intervention may be necessary.

Recovery from prolapse

Surgical intervention

Although surgery is probably the solution most people think of for prolapse, this study found that 58% of patients after surgery have a recurrence of their prolapse. In other words, the surgery was more likely to fail than to succeed.

In a situation like this, it’s important to consider why the failure rates might be so high. If we return to the two main causes for prolapse, it seems likely that the tearing and stretching could be repaired surgically. On the other hand, if the woman has muscle weakness and generates downward pressure, these seem less likely to be addressed by surgical repair. They also seem more likely to cause the recurrence of prolapse since they are one of the original causes in the first place.

On the other hand, learning to correctly regulate pressure prior to surgery may increase the chances of successful surgery.

Conservative treatment

In addition to the possible use of a pessary, conservative treatment involves the use of exercise to promote healing from a prolapse. First, the woman must learn an awareness of her pelvic floor and whether it is doing too much or too little. If she is creating downward pressure onto her pelvic floor, she will need to relearn how to stabilize without bearing down. If this is the way she generates strength, she may need to relearn all movement patterns.

In addition to pelvic floor function, correcting posture, breathing, abdominal function, and hip imbalances can all play a role in healing a prolapse. Any of these can affect a woman’s ablity to contract her pelvic floor as well as her awareness of it. Additionally, they can all play a role in learning to create strength and stability without bearing down.

Like therapy in general and postpartum women in particular, the treatment needs to be tailored to the woman. There is no one-size-fits-all answer. In combination with personalized care, better outcomes are also seen with earlier intervention. It just results in less opportunities to create downward pressure or cause damage to the pelvic floor.

Please share this with the mothers in your life. You never know who needs to hear it.

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