21 November 2016
This blog is an intro to a wide ranging topic, but will cover a lot of the basics by asking the following questions:
Simply put, a prolapse is a shifting downwards or outwards of a structure. In pelvic health, this applies to all or part of an abdominal organ.This could be a bladder, womb, or rectum (back passage). The common acronym in healthcare circles is POP: Pelvic Organ Prolapse.
In women, our anatomy unfortunately predisposes us to reduced support of the pelvic organs compared to men. We have a vagina and a urethra (bladder outlet), both tubes from outside to in. Rather than a continuous pelvic floor group of muscles, women have to accommodate these tubes within the space of their pelvic floor. Men have helpfully outsourced their urethra away from the undercarriage and don’t need to work around a vagina.
The abdominal organs are usually supported by:
– the pelvic floor muscles
– ligaments and fibrous connections within the abdominal cavity. Organs will be ‘connected’ to organs, blood vessels, nerves, all suspended and supported in their own space, and gently moving with our body movements and breathing.
When these supports are either removed (e.g. in gynaecological surgery), damaged (e.g in childbirth) or weakened (e.g. the pelvic floor, by disuse, overuse, or trauma), a prolapse can result.
Typically, there are a variety of symptoms which, if you’re not generally aware of your pelvic workings, can seem unrelated, or insignificant. However, each symptom is worth investigating in its own right, because the body works as a whole and by addressing warning signs you may prevent the prolapse worsening or even becoming an issue.
Vaginally – a feeling of bulging or heaviness. Often described as a feeling of ‘pushing downwards’ or ‘dragging’
Bladder – stress incontinence or urgency incontinence. Some women who have had these a while might also find they have to change their position to start urinating, and their stream is weak. Others experience incomplete emptying, or frequent visits to the loo at night as a result.
Bowel – difficulty evacuating bowels, ironically leading to straining (discussed below). There may be flatal incontinence (unable to control gas) or faecal incontinence. Some women might find they have to use their fingers to either support the undercarriage or press against the back vaginal wall to enable a poo to come out. Urgency to empty the bowels is also a feature.
Sexually – intercourse might be obstructed, or painful. There may be a feeling of laxity in the vaginal tissues, and vaginal ‘wind’ is another common issue.
However, a prolapse will wax and wane – symptoms may come and go, depending on activity, monthly cycles, and in different ways in different women.
It is entirely possible to have a prolapse and enjoy pain-free sex, or have a prolapse with urinary continence issues but not faecal. Each person has a unique set of factors – it’s not one size fits all.
N.B. If you do not experience any of these symptoms, but do have a prolapse, it is termed an “Anatomic Prolapse”. Unfortunately, if you are not experiencing symptoms, the current healthcare system may not treat you. Undoubtedly, if you have a prolapse but no symptoms, this is a great scenario, considering! However, the view at Arcadia is that women in this situation would benefit hugely from education around their prolapse to ensure they are looking after their bodies and preventing worsening and onset of symptoms.
Each organ can prolapse, and unfortunately in rare cases, more than one organ can prolapse.
Cystocele: Anterior Prolapse
An anterior prolapse is when the bladder is not fully supported by the structures it normally would rely on. It usually tips backwards and gravity takes it downwards, pressing on the front vaginal wall. All prolapses have different stages (and these vary depending on which scale you use). The basic bladder prolapse stages are show below, but suffice to say right here, a grade one prolapse will not show outside your body or necessarily affect your day to day life. A grade 4 prolapse is more likely to be visible and cause significant discomfort.
Rectocele: Posterior Prolapse
This is when the support of the rectum is compromised. This could happen after childbirth if a woman tears, or after injury or surgery. You can see on the left how the colon tends not to bulge out of the body, but rather pushes at the back wall of the vagina and creates a deeper pocket for itself just inside the anus. This can lead to feelings of incomplete emptying, pressure or discomfort, and unfortunately straining to try to get a stool out is likely to worsen it.
Apical: Uterine Prolapse
It is normal for the cervix (at the entrance of the womb) to raise and lower a small amount at different times throughout a monthly cycle. After childbirth, it is also common for the cervix to sit happily a bit lower than it did previously, and some women’s cervixes have always sat higher or lower than others – it’s an individual thing. However, the womb itself can lose support and descend, pushing downwards through the vagina, thus shortening it and in rarer cases, protrude outside the body.
Some women prolapse after having surgery to remove their uterus – the vaginal vault descends, folding in on itself – this is called ‘apical’ or ‘vault prolapse’.
What Stage is my Prolapse?
Each of these different types of prolapse have different levels of severity. The below picture is an example, showing the different grades of cystocele (anterior prolapse) grades 1-3. There are different grading systems in use in different healthcare environments.
If you can see your prolapse at the opening of your vagina or protruding outside, what you will actually see is not your bladder. It will be your vaginal wall, which is being pushed out and down by the prolapsed organ. Sometimes this is smooth, which indicates that the vagina itself has integrity and is supporting the prolapsed organ – not a situation that could continue forever, but it gives an idea of what structures are doing what. If the prolapse looks loose and wrinkled, there is likely a loss of support for the vagina itself.
There can be numerous contributing factors, and divided into a couple of categories:
Promoting Factors: Lifestyle choices, habits, other pathologies that contribute to risk:
Managing this last set of factors are the key ways in which we can promote our own abdominal health and avoid experiencing prolapse.
Simply put, YES. However, this doesn’t mean you can’t lift! It just means you have to be mindful of good posture and being consistent with excellent breathing dynamics while lifting (and throughout life!).
The abdominal ‘cylinder’ holds your internal organs, but this moves constantly as you do and as you breathe in and out. Your diaphragm moves down and flattens as you breathe in, pushing your organs south. This is NORMAL and not something we want to restrict! However, as you breathe in, your pelvic floor naturally ‘gives’, while remaining supportive of the organs. If we hold our breath, our pelvic floor will get over-worked, and eventually fail. Simply by breathing out and allowing that space for the pelvic floor to contract, will reduce your risk of POP from lifting.
Unfortunately, YES. Surgical repair has a significant failure rate – at around 25%.
The reasons are unclear, but recent articles suggest, generally, that techniques are still being developed, materials used such as mesh are still fairly new and therefore untested in the longer term, and it seems the sheer delicacy and complexity of the female pelvis is still being discovered. Fundamentally, the body functions are controlled by the nerves and muscles. Despite essential structural support being provided by the surgery, the patient will still need to retrain the nerves and muscles to regain full control of their function.
Surgery can give women back their lives and independence, and is a great blessing for some.
However, it is not something to be take lightly: the recovery is long and painful and can have added complications (e.g. immobility in later life, even in the relatively short term after an operation, can affect balance and falls rates – another game-changer). Some women find when a prolapse is repaired it can reveal other issues that were ‘blocked’ by the prolapse – it is possible for an over-active bladder or poor bowel habits to continue or reveal themselves as issues despite successful surgery.
Though patients report that surgery plus pelvic physiotherapy feels better than surgery alone, the evidence itself is not conclusive: there simply isn’t much of it at the moment. Nevertheless, physiotherapists are invaluable in educating women and supporting rehabilitation as a conservative option – even if surgery is deemed ultimately necessary, knowing your options and your own anatomy will help you get the best out of surgery and recovery.
Finally, unless the true cause of the prolapse is discovered, it will be at risk of happening again. That is why a whole-body approach is increasingly being used to assess and diagnose prolapses in physiotherapy, and why a whole-body approach is the best solution for overall long term success.
There are a few very simple, yet effective, ways of addressing prolapse, or risk of prolapse, from the outset. The Promoting Factors (see above) are key to identifying the individual’s root cause. Yes, the prolapse may have occurred after a difficult labour, but many small prolapses actually do resolve in the months after giving birth. Why do some improve and not others?
The body always works to bring itself back to harmony – part of physio is discovering what is holding back your body in its own unique situation. As mentioned above, something as simple as posture can affect the supporting tissues, something as commonplace as your position on the toilet, or your levels of hydration, can make a huge difference.
Pessaries are another option. Lots of women have taken matters into their own hands already and use tampons to support their vaginal walls during exercise. Though the principle makes sense, tampons bring their own risks (e.g. toxic shock syndrome) and should never be worn while you aren’t on your period.
Pessaries come in a huge range of shapes and sizes, and many women swear by them for support, comfort and peace of mind. Others however find them difficult to insert, remove, clean and manage generally. Some have great reviews on Amazon, but from a professional point of view can cause rather than solve longer term issues, e.g. repeated bladder infections, suction on the vaginal walls etc.
But please do consult your GP or gynaecologist if you are considering getting one. It’s easy to ignore the advice leaflet but it is so important to get it right. The best option is to have one fitted by a qualified professional (usually a gynaecologist).
I am on the forum all of this week: do get in touch with any questions converning women's health from lower back pain and pelvic pain, through to organ prolapse and abdominal separation.
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