Prolapse: am I at Risk?

Prolapse - What is it Really? 

Prolapse or Pelvic Organ Prolapse (P.O.P) is a condition where one or multiple pelvic organs (your bladder, uterus or rectum) descend into your vaginal canal. While this can sound downright terrifying - stay with me. 

Prolapse is not only extremely common, affecting around 50% of women, but it’s very treatable; often with just some exercise and lifestyle changes. And don’t worry, your vagina isn’t actually falling out. The organs are still anchored to you by connective tissue; they just start drooping. Akin to a tree leaning onto a tent. The tent wall will cave in a little but the tree isn’t going to poke through the tent. 

What does Prolapse Feel Like?

• Heaviness or pressure in your vagina

• A visible bulge or bulging sensation in your vagina

• A feeling like a tampon is falling out of your vagina

• Difficulty starting your stream of urine or fully emptying your bladder 

• Constipation or difficulty emptying bowels 

• Urinary leakage

• Lower back pain (for some)

• Symptoms are worse when you are constipated, at the end of the day, when you are exercising or lifting heavy objects or when on your period. 

Symptoms vary from person to person and the severity of your symptoms do not necessarily correlate to the severity of your prolapse. Some have prolapse and no symptoms associated with it. Some have a very mild prolapse with significant symptoms. Also note that prolapse symptoms can vary throughout the day and are typically felt more in the evening as the weight of gravity accumulates throughout your day. 

Diagnosing Prolapse 

Symptoms are a good indicator for whether or not you have prolapse, but you will need an exam by a Gynecologist or Pelvic Floor Physical Therapist to truly diagnose your prolapse. FYI: many women are only examined for prolapse while lying on their back. Due to gravity, you may not accurately diagnose a prolapse in this position. The most comprehensive exams are conducted in multiple positions, including standing. 

You may hear the term ‘Cystocele’ used to describe a bladder prolapse, this is the most common form of prolapse. A rectal prolapse is referred to as a ‘Rectocele’ and a uterine prolapse is referred to as a ‘Descensus’ or ‘Procidentia’. Each type of prolapse can be categorized by a grade based on the severity aka how far down the organ has descended. These grades are ranked on a numeric scale ranging from 1 as the most mild to 4 as the most severe. 

What causes Prolapse?

Prolapse is correlated with pelvic floor muscle weakness. This is because the pelvic floor muscles help support your pelvic organs, like a hammock. So if there is weakness or dysfunction among these supportive muscles, your organs may start to droop. Below are some of the most common conditions that lead to weakness and/or excessive pressure on your pelvic floor, ultimately increasing your risk of developing prolapse. 

• Pregnancy and childbirth 

• Chronic constipation

• Obesity

• Menopause and aging 

• Hysterectomy (as you are removing a primary base of support for your pelvic floor muscles)

• Chronic coughing or sneezing (allergies, chronic lung conditions, etc)

• Connective tissue disorders like Marfan syndrome or Ehlers-Danlos syndrome

• Long term participation in high-impact sports like long distance running or crossfit (with improper form and breathing mechanics…. we will get to this next) 

So what about Breathing?

Our bodies are a pressure system. When you do things like poop, lift, cough, laugh or sneeze - you are adding pressure to your system. And if you don’t properly coordinate your breathing with these activities, all of that pressure will be exerted downwards on your abdominal and pelvic walls. Overtime, this downward pressure becomes excessive for your support system (muscles, ligaments, etc) and contributes to conditions like prolapse, diastasis recti, urinary incontinence, hernias, etc. Straining or holding your breath while pooping or lifting are common habits I see that contribute to prolapse - oftentimes, people don’t even know they are doing it.

This is why we focus on a concept called intra-abdominal pressure (IAP) management when treating prolapse. If you learn to coordinate your breath so you are exhaling on the “exertion” or the hard part of the activity, you are essentially releasing a pressure valve and allowing air to go out through your mouth - redistributing pressure that would otherwise go down on the pelvic floor muscles. An example would be: inhaling as you squat down and exhaling as you come back up. Or inhaling as you go to reach for baby and exhaling as you pick up baby. 

Treatment Options

Treatment depends on the severity of prolapse but more importantly your symptoms. Pelvic floor exercises and pessaries are both recommended as first-line treatment options for pelvic organ prolapse. 

• Pelvic Floor Physical Therapy not only includes strengthening of the pelvic floor muscles but strengthening of the surrounding musculature (hips, abdominals, lower back, etc). Therapy also incorporates IAP pressure management strategies, toileting techniques, prolapse relief positions and constipation management.

• Pessaries are a silicone device you insert in your vagina that helps hold pelvic organs in place. You can be fitted for one by your doctor (typically a gynecologist or urogynecologist) or can purchase an over-the-counter option. It’s important to try different shapes and sizes until you find the right fit. The pessary should be comfortable and easy to insert/remove. If you’ve been fit for a pessary by your doctor but find it uncomfortable, it’s important to advocate for a re-fitting as it can often be a goldi-locks situation. Some choose to wear the pessary all day and others choose to wear it with specific activities like exercise. If you have significant vaginal atrophy (thinning) or pelvic floor tension, you may not be a good candidate for a pessary.  

• Hormone treatments like a vaginal estrogen cream can help with menopausal changes including vaginal atrophy (thinning) and dryness. By applying estrogen to your vaginal tissues, you can “bulk” the pelvic floor muscles and offer more support to your pelvic organs, ultimately reducing prolapse symptoms. 

• Dietary changes like adding more fiber to your diet and increasing hydration can help manage constipation, which reduces the need to strain and reduces the pressure from backed up stool on your pelvic organs. Dietary changes can also contribute to weight loss which may also improve symptoms.

• Surgery is reserved for those that have tried the above conservative treatments without success. Typically, only those with a grade 3 or grade 4 prolapse will be a good candidate for surgery. However, this is a general guideline and not a rule. It’s most important to assess your symptoms, conservative treatment response and quality of life when making this decision. I recommended consulting with both a Urogynecologist and a Pelvic Floor Physical Therapist before determining if surgery is the best option for you.