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November 12, 2020
By Carolyn Yates, PT, DPT
Pelvic organ prolapse can be an unsettling thing to experience. The sensations you feel can be very foreign and if you do a quick Google search of your symptoms, you will most likely find horror stories and end up thinking surgery is your only option. But wait, there are non-invasive things you can do and if it’s caught early, surgery can be prevented. Just reading this article and familiarizing yourself with the symptoms and what a pelvic organ prolapse actually IS, is an important first step. Let’s dive in!
A pelvic organ prolapse (POP) is when a pelvic organ is displaced out of its normal position and pushed into the wall of the vagina due to weakness in muscles or the supportive tissues surrounding the organ. A POP is an issue that women may face after having a baby due to the stretching of muscles and tissues as your baby is growing inside of you and during delivery. One study that was published in April of 2020 found that 13.7% of women under 65 who have had a vaginal delivery will experience POP symptoms. Another study showed that having had at least one vaginal birth in addition to advancing age are the two main predictors of experiencing a POP. Many women may not experience POP symptoms immediately after birth or even in the early years afterwards but may start experiencing them later on in life.
A POP is named for the organ that is abnormally displaced, for example a bladder prolapse. To best understand what a POP is, it is helpful to see a picture. If you reference the picture below, you’ll see the three hollow cavities are the bladder, uterus, and rectum (from left to right). It can be helpful to think about where they are in relation to the vagina. The bladder and urethra (the tube that we pee out of) are in front of the vagina and the rectum (the tube that we poop out of) is behind the vagina. The uterus is the organ that is connected TO the vagina.
When we talk about prolapse, we are talking about these organs and where they are in relation to the vagina. A uterine prolapse is when the uterus is no longer supported sufficiently and begins to slip down INTO the vagina. A rectal prolapse (also known as a rectocele) is when the rectum is no longer supported sufficiently and falls forward into the posterior, or rear, wall of the vagina. A bladder prolapse (also known as a cystocele) is when the bladder or urethra are no longer receiving sufficient support and fall backwards into the anterior, or front, wall of the vagina. When you have a rectocele or cystocele, the two respective organs are pushing into one of the walls of the vagina and causing an abnormal bulging.
You do not actually SEE the bladder or the rectum, you see the bulging of the wall of the vagina being caused by the organ on the other side. Since you can’t see it, it can be tricky to describe to a healthcare professional, but if you can feel or see a bulge and describe where it is, that will help narrow it down.
The severity of a prolapse is graded on a scale of 0 to 4. 0 being the organ is fully supported and no abnormal displacement has occurred and 4 being the organ has displaced so fully that it is causing the wall of the vagina to be exposed outside of the body. But don’t be alarmed, stage 4 is very rare and you WILL feel symptoms long before you get close to a stage 4 pelvic organ prolapse.
The typical symptoms of a POP are often described with these words, “heaviness”, “pressure”, “pushing feeling”, “falling out”. Some women say they feel like their “body is touching itself”. Another way the symptoms have been described is that it feels like the sensation you get when a tampon is falling out. For most women, if you have any amount of pelvic organ prolapse, one of these symptoms will resonate with you.
A POP can also come with urinary or fecal dysfunctions, like incontinence, and sometimes can cause pain. These symptoms vary depending on what organ is being displaced and the severity of the displacement.
Treatment of a POP depends greatly on the stage. In most cases, women do not suddenly wake up one day with a stage 3 or 4; these stages can take years to happen. Understanding the signs and symptoms to know if you are developing a POP is the first step. For a stage 1 or 2, pelvic floor physical therapy is often a great place to start. You will work on strengthening your pelvic floor muscles to help better support your pelvic organs. Often, a stage 3 or 4 POP will require surgery to reverse the displacement. No matter what stage your POP is, pelvic floor physical therapy will be warranted to restrengthen your muscles.
Keep doing your exercises! Muscle strengthening takes 6-8 weeks for any amount of change to happen. The pelvic floor muscles are even harder to notice a change in strength because they are so small and you can’t exactly do something like a weighted bicep curl with your pelvic floor muscles to see if you’ve gone up in weight! Stay diligent and patient.
If you are being diligent with your exercises but your symptoms are very bothersome there are external supports you can use called “pessaries”. Pessaries are devices that you insert vaginally and they act as a sort of “shelf” to help hold your displaced organ up in place. Pessaries have been considered an “old lady thing” because historically, they have been used by the older population for urinary incontinence issues. However, pessaries can be excellent assistive devices for women with prolapse and can help you live a more normal feeling life as you are on your rehabilitation and strengthening journey. Pelvic floor physical therapists cannot prescribe pessaries but they are typically the people who will suggest them. You’ll have to go see your gynecologist to get them fitted. Be patient with this as well. There are many different shapes and sizes of pessaries and every woman’s body is different. If you are trying out a pessary and it doesn’t feel right, go back to your doctor! If the pessary is fitted correctly, you should not feel it once it is in, just like you don’t feel a tampon when it is inserted correctly.
The bottom line:
At the end of the day, if you have even the slightest feeling of a prolapse symptom, talk to your gynecologist or pelvic floor physical therapist. The sooner you start working on it the better! If you are not having any symptoms of prolapse then great, however, consider still doing some focused pelvic floor exercises and core retraining after giving birth as a proactive measure to help prevent prolapse symptoms later on in life.
Sigvard, Akervall, et al. “Symptomatic Pelvic Organ Prolapse in Middle-Aged Women: A National Matched Cohort Study on the Influence of Childbirth.” American Journal of Obstetrics and Gynecology, vol. 222, no. 4, Apr. 2020, p. 356, https://doi.org/10.1016/j.ajog.2019.10.007.
Jin-Sung, Yuk, et al. “The Prevalence and Treatment Pattern of Clinically Diagnosed Pelvic Organ Prolapse: A Korean National Health Insurance Database-Based Cross-Sectional Study 2009–2015.” Scientific Reports, 22 Jan. 2018, https://dx.doi.org/10.1038%2Fs41598-018-19692-5.
Carolyn Yates, PT, DPT is a Colorado State licensed Physical Therapist with a pelvic floor rehabilitation specialty. She received a Doctorate of Physical Therapy (DPT) from Belmont University School of Physical Therapy and is the owner and head physical therapist of Verity Physical Therapy & Wellness in Boulder, CO.
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