Pelvic organ prolapse affects approximately 30% of women between 20 and 59. (Here’s a Turkish study and a Swedish study that both found very similar rates of occurrence). And yet, this is a topic most people don’t talk about. Which is understandable. It can be uncomfortable. But if you’re looking for more information, you should have somewhere to turn.
What is prolapse?
Pelvic organ prolapse, or POP, is the descent of pelvic organs through the vagina. The term pelvic organs refers to the bladder, the uterus, or the rectum, and prolapse of each organ has its own name.
A cystocele is a descent of the bladder. A rectocele is a descent of the rectum, and uterine prolapse is the descent of the uterus. A woman can experience prolapse of one organ or multiple.
Most women experiencing prolapse describe it as a heaviness, fullness, pressure, or discomfort in the vagina. Some women have a sensation like there is something in the vagina or coming out of the vagina when there shouldn’t be anything there. They may feel like they need to hold it in. Sometimes, they experience incontinence as well. And some women have prolapse and no symptoms at all.
What causes prolapse?
There are two main reasons for a prolapse to occur.
- Trauma during delivery. This can include excessive stretching or tearing.
- Muscle weakness combined with too much pressure.
When trauma occurs during delivery, it can damage the muscles or fascia that support the internal organs. They normally act like a sling, closing the bottom of the pelvis and maintaining the organs within it. But if the muscles are torn during delivery, they may need to be repaired or rehabilitated to regain function. Fascia, on the other hand, is like the shiny, white stuff when you cut up raw chicken. When it is damaged, it cannot regenerate itself. Sometimes, it requires surgery, while other times, increasing strength can make up for the structural deficit.
Now, let’s take a look at the combination of muscle weakness and too much pressure. The same downward pressure that can contribute to incontinence also plays a role in prolapse. This analogy belongs to a researcher named Victor Bonney. In 1934, he described the vagina like the inward-turned finger of a rubber glove (pictured left below).
If there is a balance of pressure with the system (or the glove), then the finger remains turned in. However, if there is too much pressure downward, it can push the finger back out of the glove (pictured right below). A similar thing happens in a women who creates excessive downward pressure. She can push her pelvic organs down and out of her vagina, just like the finger.
Other factors to consider with POP
Besides trauma and pressure regulation, genetic factors can also contribute to the development of prolapse. This twin study found more similarities in occurrence among identical twins than fraternal twins, indicating the influence of genetics. Genetic factors that might be significant include posture; degree of ligament laxity; or the shape, size, or positioning of specific body parts.
While ligament laxity can be an inherited trait, hormones also influence it. The hormones of pregnancy and breastfeeding create a relaxation in soft tissue. This is beneficial in preparation for childbirth, but it causes excessive give, or motion, in a woman’s joints and fascia. This increased softening can also increase the chances of prolapse because there is less support around the vagina.
Grades of prolapse
As with most issues related to the human body, not all prolapses are created equal. For the best outcomes, I always recommend starting with a good pelvic floor physical therapist.
A prolapse can be graded on a scale from 0-4. In the picture above, each number indicates the position of the cervix for the corresponding grade. The grades are:
- 0 = no prolapse
- 1 = the organ(s) is in the vaginal canal
- 2 = the organ(s) is at the opening of the vagina (This is the degree of prolapse depicted above.)
- 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 help to position the pelvic organs. If they are intact, a full recovery may be possible. However, depending on the degree of damage, symptoms and function can improve but some may not resolve entirely.
Although surgery is probably the first solution most people think of for prolapse, this study found that 58% of patients had a recurrence of their prolapse after surgery. This means the surgery failed more often than it succeeded.
In this case, 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 are not likely to be addressed by surgery. They are also exactly the kind of drivers that can cause recurrence, especially if they were the original culprits in the first place.
This isn’t to say that surgery isn’t an answer. But learning to regulate pressure prior to surgery may increase the chances of a successful outcome.
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 most, if not all, movement patterns.
Posture, breathing, abdominal function, and hip imbalances can also impact pelvic floor function. Any of these can influence a woman’s ability to contract her pelvic floor as well as her awareness of when she is or isn’t. Lastly, strengthening of other muscle groups can help women to create alternative strategies that don’t require as much downward pressure on the pelvic floor.
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. This results in less bad habits and fewer opportunities to create the pressure that contributes to prolapse.