How to Fix Pelvic Prolapse (and what that even means?)
When it comes to how to fix pelvic prolapse, the term “fix” is debatable. There isn’t a lot of solid evidence that any intervention other than surgery can anatomically lift and maintain a pelvic organ in its original position. However, there are things people can do to reduce or eliminate their symptoms of pelvic organ prolapse and return to or continue with their desired exercise program with or without modifications.
Learning about pelvic organ prolapse as a person experiencing it, or as a pelvic floor provider, can be very confusing! Evidence-based research on how to best manage prolapse is either lacking or conflicting. Based on what I’ve learned from experts in the field and the published evidence that currently exists, here’s what I’m going to cover:
What is a pelvic organ prolapse
Risk factors for developing pelvic organ prolapse
Types of pelvic organ prolapse
Pelvic organ prolapse measurement and grading
What an assessment by a pelvic floor physical therapist may look like
Treatment options
What is a pelvic organ prolapse?
Pelvic organ prolapse (or POP for short) is the descent of one or more of the pelvic organs into and sometimes down and out through the vagina. Common symptoms include:
The sensation and/or appearance of a vaginal bulge
A feeling of fullness, heaviness, pressure or aching in the pelvis. This feeling may worsen after exercise, coughing, or standing for long periods.
Pain or discomfort in the pelvis, low back, or during intercourse
Urine leakage or incomplete bladder emptying
Constipation or difficulty having a bowel movement (posterior wall prolapse)
Bleeding from the exposed skin of the vagina (high grade prolapse)
Pain, discomfort, or numbness during sex
Fatigue in the legs
Difficulty inserting a tampon due to the bulge
Recurrent urinary tract infections due to incomplete bladder emptying
Pelvic organ prolapse results from changes, most commonly caused by pregnancy and childbirth, to the ligaments, muscles, and fascia which support the pelvic organs. Genetics, age, repetitive straining/constipation with bowel movements, chronic cough, and repetitive heavy lifting in the workplace are also associated with prolapse.
What are the risk factors for developing pelvic organ prolapse?
Vaginal childbirth - the first delivery has a more significant impact than subsequent births and forceps delivery further increases the risk
Older age - but not necessarily related to menopause
Genetics - maternal family history may be somewhat linked
Levator hiatus avulsion (from vaginal childbirth) and someone with a larger levator hiatus area is at a greater risk
Possible factors that may increase risk (or may not - current evidence is inconclusive):
Getting an episiotomy during birth
Long 2nd stage of labor
Vacuum delivery
Large-headed baby at birth
High BMI is also conflicting, but so far, it may not be a risk factor for causing a prolapse but may influence prolapse progression over time. (Giri et al. 2017, Zenebe et al. 2021)
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What are the types of pelvic organ prolapse?
Types: (aka, what is dropping or bulging down into the vagina)
Anterior vaginal wall prolapse: cystocele, bladder prolapse, urethrocele
Apical prolapse: uterine or vaginal vault prolapse
Posterior vaginal wall prolapse: rectocele - the rectum pushes anterior into the vaginal wall (which is different than a rectal prolapse)
Enterocele: small intestine descending into the vaginal wall; rare
How is pelvic organ prolapse measured/graded?
Medical providers do a POP-Q assessment to measure the prolapse stage, which is graded Stage 1-4. This is not a perfect test though, and there are some things to consider with this assessment:
The stage is not predictive of a person’s symptoms or risk of progression. For example, some people have Stage 3 and have no symptoms or awareness of a bulge, and others at Stage 2 may have a lot of symptoms.
Other factors can influence the measurement: What time of day were they assessed? Did they exercise or perform a fatiguing activity prior to the assessment? Did they sleep well? Where are they in their menstrual cycle?
Is Stage 1 just “normal”? A large percentage of people who have no symptoms will test as Stage 1, even if they have never been pregnant or had kids. Maybe some fluctuation in organ position and movement is normal!
For people with prolapse, either with a formal diagnosis from a medical provider or not, it can be very scary!
Here are some things that we do know:
The prolapse stage often isn’t correlated with symptoms.
Mild anatomical descent (like Stage 1) may be normal.
Other seemingly unrelated factors influence the experience and symptoms of prolapse such as stress, anxiety, depression, sleep quality/quantity, etc. People who score higher on the Central Sensitization Inventory (CSI) tend to report more bothersome symptoms.
Changes in symptoms can be achieved even without anatomic changes - if you are wondering how to fix pelvic prolapse, consider a “fix” as being symptom-free and able to do the activities and exercises you love.
Prolapse does not automatically limit people in the activities or exercises they enjoy. Some people may need to modify, some may not.
If symptoms do increase with activity, this does not necessarily mean that the prolapse is “worse” as these changes may be transient and short-lived.
What Happens During a Pelvic Floor Physical Therapy Assessment?
First, we talk! We ask lots of questions about past medical and injury history, bladder and bowel function, menstruation and birth history, sexual health, physical work requirements, current physical activity and exercise, etc. We want to know about the person’s symptoms and what makes them better, or worse, and their concerns and goals. It helps to discuss with your pelvic floor PT (or OT) what you want to accomplish the most during your first visit.
How much you share is up to you! We want you to feel comfortable and our ultimate goal is to reduce fear about pelvic organ prolapse and inspire hope.
Physical Exam: What a pelvic floor physical therapist may assess:
Internal pelvic floor muscle assessment: muscle coordination, endurance, defect, pain, increased tone, mobility, etc.
External pelvic floor assessment: Visual observation of perineum and vaginal opening with “bearing down”/straining, measurement of levator hiatus area at rest and with maximal straining
Internal or External Pelvic Floor Assessment with Movement: what do the pelvic floor and perineum feel like in different positions during different activities and exercises?
All assessments and treatments are to be performed in accordance with patient comfort and consent.
Treatment: What You May Be Offered:
Manual therapy can be helpful for increased pelvic floor muscle tone and pain and improving awareness and coordination. Manual therapy can improve the connection between the pelvic floor muscles and the brain, which may help facilitate this.
Pelvic floor muscle training exercises (possibly - more on this in my Exercise with Prolapse blog)
Other sport-specific muscle training, especially if deconditioned or postpartum
Ongoing assessment of pelvic floor function during exercise and movement as you progress exercise difficulty
Self-help and symptom relief options - pessaries, supportive garment options, positions, etc.
Lifestyle changes and education
Referrals and collaboration with complimentary providers for a comprehensive and holistic approach to care: urogynecologist, OBGYN, mental health therapy, nutrition support, personal trainers, etc.
A Word About Pessaries
Pessaries or other supportive devices: A pessary is a device inserted into the vagina to support the pelvic organ(s) that are dropping. They are fit/managed by a trained medical professional and come in different shapes and sizes. They can be used daily or over multiple days with regular removals for cleaning.
A good fitting pessary eliminates a person’s symptoms of prolapse, is not uncomfortable to wear, and ideally the patient can insert and remove independently. Using a pessary can help a person achieve or maintain their desired exercise/activity goals. A pessary fittings can be performed by a skilled medical provider (PT as well) who has had special training to do so.
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Non-Conservative Treatment
Surgery can be helpful for improved quality of life and continued physical activity and exercise. Choosing surgery isn’t a “failure” - some patients aren’t able to achieve their goals with conservative management. A discussion about benefits and risks, including surgical failure and complications, should be discussed with a qualified surgeon (urogynecologist, urologist, or OBGYN).
In Summary
If you are a provider working with people who have prolapse, consider the person’s individual risk factors, goals, current abilities, and how they generate pressure and activate their muscles with movement and exercise. Get creative and have them try new ways of doing things and see if they can get different results (aka feel better). There is no “right” or “wrong” way and no “good” or “bad” exercise - it depends on what the person in front of you does and how you can help facilitate change if needed.
If you are a person with symptoms of a prolapse, with or without a formal diagnosis, seek out a skilled pelvic floor specialist (PT/OT) for an assessment. Ideally, have them check your pelvic floor externally or internally while doing exercise or activity - are you straining/bearing down? If you don’t get the experience you were hoping for, seek out a different provider. We all vary in our skill levels and training and just like with any profession, sometimes it takes a few tries to find the right fit!
Do you need help with your prolapse symptoms and want to work with me? If you live in the greater Minneapolis, Minnesota area, my clinic is in Edina, MN - let’s work together! Contact me to learn more.
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Disclaimer: The information in this blog post is for general purposes only and is not intended to be used as medical advice, diagnosis, or treatment. Refer to your medical provider for all questions and concerns regarding your individual care.
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