Understanding Pelvic Organ Prolapse and the Role of Pelvic Floor Physical Therapy
Do you experience vaginal or rectal heaviness or pressure, especially after giving birth? You might have a pelvic organ prolapse. Pelvic organ prolapse (POP) is when your pelvic organs (bladder, uterus, or rectum) descend into the vaginal canal. Prolapse is surprisingly common, not only among women who have had vaginal deliveries, but also in people who deal with chronic constipation or chronic coughs. Let’s dive into why prolapse occurs and how pelvic floor physical therapy is a vital component of prolapse treatment.
What is Pelvic Organ Prolapse?
The bladder, uterus, and rectum are supported from the pelvic floor muscles below and receive ligamentous support from above. When these tissues become weak or damaged, these organs descend into the vaginal canal.
There are several types of pelvic organ prolapse, each associated with a specific organ. These include:
Cystocele (Bladder Prolapse): The bladder bulges into the vaginal wall, caused by weakened anterior vaginal wall support.
Rectocele: The rectum pushes against or bulges into the back wall of the vagina due to weakened rectal support. This is different from a rectal prolapse, in which your rectum is visible out of the anus.
Uterine Prolapse: The uterus descends into or protrudes out of the vaginal canal when the supporting ligaments and pelvic floor muscles are compromised.
Vaginal Vault Prolapse: The top of the vagina weakens post-hysterectomy without the support of the uterus and collapses into the vaginal canal.
Enterocele: The small intestine (small bowel) descends and pushes at the top of the vagina.
Urethrocele: The inner lining of the urethra pushes out of the urethral opening into the vaginal canal.
Symptoms of Pelvic Organ Prolapse
While the symptoms vary depending on the severity and type of prolapse, common signs include:
A feeling of heaviness or pressure in the vagina/pelvic area.
A visible or palpable bulge in the vaginal area.
Difficulty urinating or having a bowel movement.
Needing to change positions during a bowel movement.
Incomplete bladder or bowel emptying.
Pain or discomfort during sexual intercourse.
Back or lower abdominal pain.
Degrees of Pelvic Organ Prolapse
There are 4 different levels, or degrees of pelvic organ prolapse, staged from 1-4.
Stage 1: The organ (e.g., bladder, uterus, or rectum) has moved slightly lower than its normal position into the vaginal canal. Typically, no symptoms are experienced, or they may be very mild, such as a slight feeling of pressure.
Stage 2: The organ has descended further, approaching the opening of the vagina. Symptoms may become noticeable, including a feeling of heaviness or pressure in the pelvic area. Some women may experience mild urinary or bowel symptoms, such as difficulty emptying the bladder or rectum. Some may also notice a visual bulge internally.
Stage 3: The organ has descended to the level of the vaginal opening or may slightly protrude from it. Symptoms are often more pronounced, such as noticeable bulging, pelvic pressure, urinary incontinence, or difficulty with bowel movements.
Stage 4: The organ has fully descended outside the vaginal opening. Symptoms are significant and may include a visible bulge, discomfort, pressure, difficulty with urination and bowel movements, and sexual dysfunction. This stage typically requires medical intervention, such as a pessary (more on pessaries shortly) or surgery, to relieve symptoms and restore support to the pelvic organs.
Many women have a grade stage 1-2 prolapse and might not even realize it because they have no symptoms. Women with stage 3-4 tend to have more symptoms and might require more aggressive treatment such as surgery.
How Common is Pelvic Organ Prolapse?
POP is relatively common. Up to 50% of women who have had vaginal deliveries experience some degree of prolapse. Vaginal childbirth, especially when associated with prolonged labor or the use of an assisted device such as forceps or a vacuum, is a significant risk factor for prolapse. The likelihood of developing POP also increases with age, obesity, chronic coughing, and a history of hysterectomy.
There is also a genetic component to prolapse. Genetic predisposition influences the strength and elasticity of connective tissues. Studies show that women with a family history of POP, especially in first-degree relatives (mothers or sisters), have a higher likelihood of developing the condition. Hormones such as estrogen can also play a role.
How is Pelvic Organ Prolapse Treated?
There are a couple of different treatment options for pelvic organ prolapse. Pelvic floor physical therapy should be the number one line of treatment for pelvic organ prolapse. Pessaries can also help. In more extreme cases, there are surgical options, but all conservative options should be considered first. Let's take a look at some of these options.
Pelvic Floor Physical Therapy for Pelvic Organ Prolapse
Pelvic floor physical therapy (PFPT) is a conservative, non-surgical treatment option that can significantly alleviate symptoms of POP and improve quality of life. While pelvic floor physical therapy likely will not change the stage of prolapse, it can greatly reduce symptoms and allow you to return to the activities you love.
What does pelvic floor physical therapy look like if you have prolapse?
First, your pelvic floor PT should assess your posture. Many times, certain postures, especially when holding a baby or a toddler, can exacerbate prolapse symptoms. Your pelvic floor PT will educate you on ways to reduce symptoms. These should include:
Unclenching your glutes
A slight forward trunk lean, especially when holding the baby
Your pelvic floor PT should also watch you perform any exercises or movements you perform on a regular basis to make sure your form is not making your prolapse symptoms worse.
Then, your therapist should assess your hip range of motion and strength. Adequate hip and core strength are vital for proper pelvic floor functioning, and weakness in these muscles can exacerbate prolapse symptoms.
Your pelvic floor physical therapist should assess your pelvic floor muscles for tightness or weakness. Many times, overactivity of the pelvic floor can contribute to prolapse symptoms. Kegels are not always the answer and oftentimes can make prolapse symptoms worse. It is vital to see a pelvic floor PT who can assess these muscles and give you guidance specific to your body.
Your pelvic floor physical therapist will come up with a treatment plan tailored to what is going on with your body and specific to what your goals are. While pelvic floor physical therapy might not be able to reverse the prolapse, it can greatly improve your quality of life while addressing the symptoms. Pelvic floor physical therapy can help manage symptoms, which will help you avoid surgery and improve your quality of life.
Pessaries for Pelvic Organ Prolapse
A pessary is a medical device made from silicone or plastic designed to be inserted into the vagina to provide support for pelvic organs.There are many different shapes of pessaries, including rings, cubes and donuts. A ring pessary is the most commonly used for mild prolapse and stress incontinence. The cube and donut shapes are for more advanced prolapses.
A pessary works to support the prolapsed organs by keeping them in place. This can help reduce the heaviness or bulging feelings. A pessary must be fitted by a trained professional such as a urogynecologist, and should be monitored often by this provider. A pessary does not have to be worn at all times. You also are able to have a bowel movement while wearing a pessary. When using a pessary, it’s also important to work with a pelvic floor physical therapist to address the underlying cause of the prolapse to keep it from getting worse.
Surgery for Pelvic Organ Prolapse
Surgery for pelvic organ prolapse aims to restore the normal position and function of the affected pelvic organs. The surgical approach depends on the type and severity of the prolapse, the patient’s overall health, and their goals. However, it is important to work with a pelvic floor physical therapist after surgery to work on pressure management, just as you would work with a physical therapist after a major hip or knee surgery. Learning how to avoid bearing down with activities such as bowel movements or lifting heavy objects or children is imperative to recovery from prolapse surgery to prevent recurrence.
Can Prolapse Be Prevented?
Although it may not be entirely possible to prevent prolapse, there are several effective strategies to reduce the risk of developing it. Managing downward pressure on the pelvic organs is key. This includes addressing constipation, avoiding straining during bowel movements, and practicing proper breathing techniques when lifting heavy objects, children, or exercising. Additionally, consulting a pelvic floor physical therapist during pregnancy for push preparation can be highly beneficial in minimizing the risk of pelvic floor injury during childbirth and preventing pelvic organ prolapse.
Conclusion
Pelvic organ prolapse can feel overwhelming, but it is a manageable condition. With the help of pelvic floor physical therapy, women can regain strength, control, and confidence in their bodies. If you or someone you know is experiencing symptoms of POP, consulting a pelvic health physical therapist can be a life-changing step toward relief and recovery.
Taking the time to care for your pelvic floor isn’t just about symptom management—it’s an investment in long-term health and well-being.
