Pelvic Organ Prolapse
My inspiration for this post is that on the evening of September 24th, my amazing colleague, Dr Nadia Wahid, will be giving a talk on pelvic organ prolapse. If you want to get a head start on the topic, please read on . . .
Definition
Pelvic organ prolapse occurs when an internal organ presses into the vagina. It may create a sensation of pressure in the lower abdomen, back, or perineum, or make it feel as if something is bulging out of the vagina. If prolapse is severe enough, a pelvic organ may actually bulge out of the vagina.
Risk Factors
There are several risk factors for pelvic organ prolapse including pregnancy, childbirth, obesity, frequent coughing or sneezing, lifting heavy weights with poor breathing techniques, or participating in high-impact exercise without proper shock absorption from your legs, and hypermobility such as in connective tissue disorders such as Ehlers Danlos Syndrome, and laxity of body tissues due to menopause and aging.
Types
Organs in the pelvis that are capable of prolapsing include the urethra, bladder, uterus, vaginal vault, intestines, or rectum. Here is a brief description of each type of prolapse:
- Urethracele: Prolapse of the urethra.
- Cystocele: Prolapse of the bladder.
- Cystourethracele: Prolapse of both urethra and bladder.
- Uterine Prolapse: Prolapse of the uterus.
- Vaginal Vault Prolapse: May occur after hysterectomy. Prolapse of the proximal vagina, the part of that was closest to the uterus before the uterus was surgically removed.
- Enterocele: Prolapse of the small intestine.
- Rectocele: Prolapse of the rectum into the posterior wall of the vagina.
- Rectal Prolapse: Prolapse of the rectum coming out of the anus.
Grading
Pelvic organ prolapse is graded by severity, with zero indicating that there is no evidence of prolapse and 4 being complete eversion. In stage 4, the organ slips entirely outside the vaginal opening.
Because of the effects of gravity, the severity of pelvic organ prolapse changes based on time of day and activity level. Often, prolapse is less pronounced in the morning, because most people lie down to sleep and have had many hours without gravity pulling the prolapsed organ toward the vaginal opening. Prolapse is typically more pronounced at the end of the day, after vigorous exercise, or after repeated coughing or other increases in abdominal pressure pushing down onto the pelvic organs. It’s very possible for one of your healthcare providers to diagnose you with a grade 1 prolapse and another to say you’re a grade 2. It will all depend on the time of day that you are tested, what your activity level has been like that day, the position in which you are tested, and whether you are asked to cough or bear down during testing. If you are tested in the morning and tested lying down on your back without coughing, you will likely not be graded with as severe a prolapse as you would have been if you had seen your provider in the evening, after an active day, were tested standing up in a wide squat, and asked to cough.
Physical Therapy Treatment
A pelvic floor physical therapist will grade your prolapse, test your muscle function, assess your posture and work with you to develop a plan to decrease symptoms associated with pelvic organ prolapse. Typical symptoms include feelings of heaviness or pressure, difficulty initiating urination or defecation, difficulty completely emptying the bowel or bladder, urinary or fecal incontinence, constipation, and urinary urgency or frequency among others.
Physical therapy is effective in decreasing symptoms associated with grade 1 and 2 prolapse. Therapy may include muscle strengthening or stretching, exercise, visceral manipulation, breath control, posture corrections, practicing lifting and carrying objects with good form, and training in exercise modifications. Therapy will include whatever treatments are most appropriate to your specific symptoms, concerns, priorities, and lifestyle.
If you don’t get enough symptom relief from physical therapy alone for a grade 1 or 2 prolapse, or if you have a grade 3 or 4 prolapse, your therapist may suggest use of a vaginal pessary.
Pessaries
A pessary is a device that provides support for the pelvic organs much like a bra provides support for the breasts.
If you and your therapist think a pessary may be a good option for you, you may want to start with an over-the-counter product. The Revive pessary is inserted much like a large tampon. This silicone bladder support may be cleaned and reused for up to a month. Another over-the-counter is the Poise Impressa. It’s also inserted like a tampon, but it is disposable. It comes in three sizes. Size 1 is the smallest and size 3 is the largest. You should start at the smallest size and gradually size up as needed to further improve your symptoms.
While the above options may help, many women find it is even better to have their therapist fit them for a pessary. These fitted pessaries provide much more customization than do the over-the-counter options. They may be used for many years before being replaced so long as they are worn, removed, cleaned, and stored property. Below is an example of some pessary shapes. There are even more shapes and sizes than those shown. Your pelvic health physical therapist will help you find the one that is best for you.
Pessaries are often a helpful supplement to pelvic floor physical therapy for non-surgical treatment of pelvic organ prolapse. When used as part of a comprehensive treatment plan that also addresses posture, breathing, muscle training, and activity modification, the pessary may be useful in decreasing bowel, bladder, sexual, or pelvic pain problems caused by prolapse.
Summary
There are effective non-surgical treatments for pelvic organ prolapse. Please attend the Physical Therapy Your Way virtual community event on 9/24/24 at 7pm.
Click Here to Register for this free informative event: https://form.jotform.com/83005883557160
Physical Therapy Your Way blog by
Dr. Brauna Carl, PT, DPT
Women’s Health Clinical Specialist (WCS)
Pelvic Rehabilitation Practitioner Certification (PRPC)
