Ep 03: Pelvic Organ Prolapse

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PODCAST EPISODE #03

CHARLOTTE CONLON AND HEIDI BARLOW ARE WOMEN’S HEALTH PHYSIOTHERAPISTS FROM FLOW PHYSIO CO, BASED IN THE SUTHERLAND SHIRE.

In today’s episode Charlotte and Heidi talk through the pelvic organ prolapse and management strategies.

Pelvic Organ Prolapse

What is a pelvic organ prolapse?

There are three organs in the female pelvis. The bladder, uterus and the rectum. A pelvic organ prolapse is the slipping down of one or more of the pelvic organs into the vagina. 


How common is it?

1 in 2 women who have had a baby will experience prolapse symptoms at some stage in their life. 

How does it occur?

In understanding how prolapse occurs, you first need to understand what normally holds the pelvic organs up in place. Two main support structures:

  1. Fascia

  2. Pelvic floor muscles 

The fascia is the primary support holding the organs up inside the pelvis.

Stretch and damage to the fascia can occur due to increased downwards pressure during the pushing stage of labour. It can also result from chronic constipation due to long term straining.

The strength of the fascia is dependent on your genetics. Women who have loose connective tissue are at higher risk of getting a pelvic organ prolapse, whereas women who have strong connective tissue have a lower risk.

Therefore, a woman with a strong pelvic floor can still have a prolapse if there is damage or stretch to the fascia. We like to refer to the pelvic floor muscles as the “back up” support system to the fascia support system. 

What types of prolapse are there?

The type of prolapse is defined according to which organ is slipping down.

In a uterine prolapse, the uterus drops down into the vagina. This is sometimes called a urethrocele. 

In a bladder prolapse, the bladder drops down and creates a bulge into the anterior wall of the vagina. This is sometimes called a cyctocele.

In a rectal prolapse, the rectum drops down and creates a bulge into the posterior wall of the vagina. This is sometimes called a rectocyle.

How is the severity of the prolapse determined?

The stage of the prolapse is determined by how far the organ(s) is descending into the vagina. 

Stage 1: The organ descends into the upper half of the vagina/vaginal wall

Stage 2: The organ descends into the lower half of the vagina/vaginal wall

Stage 3: The organ descends past the entrance of the vagina

Stage 4: The organ descends out completely

What symptoms might someone have if they have a pelvic organ prolapse?

  • Heaviness or dragging sensation in the vagina, lower abdomen or lower back 

  • Lump or a bulge in the vagina

  • Incomplete emptying of the bladder or bowel 

  • Discomfort with sexual intercourse 


Can a prolapse be fixed?

It is important to be aware that we cannot “cure” a prolapse, we can not magically fix the damage to the fascia however we can definitely make you symptom free and stop the prolapse from worsening overtime. 

What does treatment involve?

There are three goals for treatment of prolapse: 

  1. Increase upward support

  2. Reduce strain down through the organs and fascia

  3. Symptom management

1. Increase Upward support

PELVIC FLOOR MUSCLE TRAINING

By strength training the pelvic floor this can help take the strain of the fascial support system and for many women can take away the symptoms of prolapse. We need to work on the coordination, power and endurance of the pelvic floor muscles. 

INTERNAL SUPPORT

Pessaries are a medical grade silicone support system that can work for many women to help provide upward support to the pelvic organs and fascia. See pessary section for further information. 

EXTERNAL SUPPORT

Many women find wearing supporting clothing such as the EVB compression underwear or activewear helps manage symptoms of prolapse. 

Strengthening of the pelvic stabiliser muscles can also give some added support so general lower and upper body strength training is essential. 

2.  Reduce strain down through the organs and fascia 

REDUCE HEAVY LIFTING 

Reduce heavy lifting where possible. We want to try to avoid lifting anything that makes us hold our breath. This increases intra abdominal pressure and can put added strain on the fascia. This does not mean that you can never lift heavy again, we need to slowly build your lifting capacity up so that your pelvic floor and others muscles can tolerate the load. 

MANAGE CONSTIPATION 

Sitting on the toilet and straining puts a lot of stress on the fascia and doing this daily can be very detrimental. Make sure you are drinking plenty of fluid and eating a balanced diet. Talk with your GP about medication that could help if things are not improving 

MANAGE RESPIRATORY CONDITIONS 

Coughing can put a lot of strain on your fascia so managing symptoms of this is crucial.

MANAGE BODY WEIGHT

If you are overweight this can put lots of strain on your pelvic floor and fascia. 

3.  Symptom management 

REST IN A SUPINE POSITION DAILY 

Resting for 10-15 minutes in a supine position as shown below can give the fascia and pelvic floor muscles a break from gravity and it can be really helpful with symptoms.

TOILET HABITS

If you have trouble with urinating and feel like the urine will not come out or you struggle to empty your bladder: 


  • Lean forward if you have a bladder prolapse this can allow for easier emptying or standing up move hips around sit back down and try again 

  • Lean back if you have a uterine prolapse this position may be helpful to empty your bladder

If you are having trouble emptying your bowels your prolapse is most likely from the posterior wall (rectum):


  • Leaning back can help emptying the bowels

  • Pressure on the perineum (area of skin between the vagina and anus) can help gently lift the prolapse. This can also be done internally by putting a thumb inside to gently push the rectum back while emptying your bowels, if this helps talk to us about tools we can send you that aid with this. 


What is a pessary? 

Pessaries do not work for everyone, about 80% of women find relief from them, but we like every woman to know what they are and that they are an option to help support their prolapse and minimise symptoms. A pessary is a silicone device that is inserted by a physiotherapist or gynecologist, into the vagina to help support a pelvic organ prolapse . A pessary can be very useful to help you continue  to be physically active and participate in chosen activities which may typically worsen a prolapse. A pessary can be worn all the time or it can be worn just when demands are high i.e. when running or jumping. 

Every woman's body and their prolapse is different therefore the type and size of pessary will vary immensely from woman to woman. The type and size will depend on the type of prolapse, the symptoms it causes and your anatomy. The pessary has to be fitted correctly and it may take several tries to get the right one. 

Can I have surgery ? 

For some women if conservative approaches are unsuccessful, surgery is an option that women can consider. It is never the first line approach and we highly recommend trialing conservative management including pelvic floor exercises and a pessary for at least 6-12 months. It is also important to remember that surgery is not successful on everyone and if you continue to have downward pressure on the area such as constipation or increased body weight the surgery can often fail, so it is important that all the conservative options are exhausted first.  


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