Pelvic organ prolapse and pelvic floor physiotherapy
Noticing a vaginal bulge or a feeling of something ‘coming down’ inside the vagina can be a quite a distressing experience. Your doctor may have diagnosed you with a prolapse, but what does that mean? There are various types and stages of prolapse and not all prolapses require surgery. Did you know that pelvic floor physiotherapy can help treat prolapse? Read on for more information about the different types and stages of prolapse and how physiotherapy can help…
What is a prolapse?
Pelvic organ prolapse is a lowering or descent of one or more of the pelvic organs (uterus, bladder or bowel) into the vagina. Prolapse can occur when the ligaments, muscles and connective tissue that provide support have become stretched or weakened and is usually associated with a vaginal lump or bulge (Haylen et al., 2016). This may occur due to:
Obesity
Chronic constipation/straining to move your bowels
Respiratory conditions with chronic cough/sneezing
Hormonal changes following menopause/ageing
Frequent heavy lifting
Pregnancy and childbirth or following some gynaecological surgeries
Genetic weakness of connective tissues (prolapse may run in families)
What are the symptoms of a prolapse?
Symptoms can vary depending on the severity and the organ which has prolapsed and may increase towards the end of the day. Symptoms may increase after a various activities such as straining during a bowel motion, chronic coughing, heavy lifting or being on your feet all day. Symptoms may include:
A lump or bulge at the vaginal entrance
A feeling of something ‘falling down’ inside the vagina
Difficulty emptying the bladder or urgency
Discomfort with intercourse
Difficulty passing a bowel motion
Lower back/abdominal ache or ‘tired’ sensation
These symptoms can greatly affect the quality of life including day to day activities, exercise and sexual function.
How common is a prolapse?
Prolapse is more common than what you may think. Up to 30% of women under 50 and up to 50% of women over 50 years may have a prolapse, (Aytan et al, 2014) however only 1/5 may have symptoms (Slieker-ten Hove et al. 2009).
Most prolapses are mild to moderate with stage I being most common. An anterior (front vaginal wall) prolapse is more common at 34% than a posterior (back vaginal wall) at 19% or uterus prolapse 14% (Swift et al, 2005).
Stages and types of prolapse
A prolapse can be mild with minimal to no symptoms (stage I-II), to severe (stage IV) where the prolapse is outside the vaginal entrance. A mild to moderate prolapse usually responds well to conservative physiotherapy management (Hagen and Stark, 2011). A severe prolapse is unlikely to be corrected with physiotherapy and may require further specialist management.
The main prolapse types: anterior wall, posterior wall and uterine prolapse are shown here as Stage II. There are however other types (enterocele and vaginal vault (after hysterectomy)) can occur, however are not as common.
No prolapse
Stage II anterior wall prolapse
Stage II posterior wall prolapse
Stage II uterine prolapse
https://www.augs.org/patient-services/pop-q-tool/
Can physiotherapy help treat a prolapse?
Yes, pelvic health physiotherapy can help with prolapse symptom management. Individual management is dependant upon specific prolapse symptoms, severity and the organs involved. This may include addressing any bladder or bowel dysfunction (particularly constipation which puts extra strain on the pelvic floor), activity modification and specific lifestyle advice in addition to recommending safe exercise to reduce symptoms while maintaining or improving your fitness.
Research shows that targeted pelvic floor muscle training can be effective in reducing the symptoms of prolapse in addition to improving the prolapse by up to 1 stage in some cases (Alves et al, 2015; Kashyap et al, 2013). Pelvic floor strengthening helps by improving the muscle bulk and muscle closure to lift and support the prolapse (Braekken et al., 2010).
An individual assessment of your pelvic floor to identify the structures involved and assess your muscle function and ability to perform correct pelvic floor exercise is essential to prescribing a successful treatment plan for your prolapse.
What is a pessary?
In conjunction with the above management, a silicone support pessary may also be very helpful in reducing symptoms and improving quality of life in some women (Bugge et al, 2020). A pessary is a support device that sits inside the vagina to support the organ/s required to relieve symptoms and in some cases improve bladder/bowel function. Having undergone advanced training in physiotherapy pessary fitting, Tracey can perform specific assessments, discuss any risks and provide you with information to decide if this is an option for you. If suitable, she is able to fit your pessary and arrange the necessary follow ups and educate you regarding self-care.
Ring pessary
Cube pessary
https://www.profem.com.au
If you are experiencing symptoms of prolapse and would like a professional physiotherapy assessment and treatment, book in for an appointment.
References:
Alves, F. K., Riccetto, C., Adami, D. B., Marques, J., Pereira, L. C., Palma, P., & Botelho, S. (2015). A pelvic floor muscle training program in postmenopausal women: A randomized controlled trial. Maturitas, 81(2), 300–305.
Aytan, H., Ertunç, D., Tok, E. C., Yaşa, O., & Nazik, H. (2014). Prevalence of pelvic organ prolapse and related factors in a general female population. Turkish journal of obstetrics and gynecology, 11(3), 176–180.
Bugge, C., Adams, E. J., Gopinath, D., Stewart, F., Dembinsky, M., Sobiesuo, P., & Kearney, R. (2020). Pessaries (mechanical devices) for managing pelvic organ prolapse in women. The Cochrane database of systematic reviews, 11(11), CD004010.
Braekken, I. H., Majida, M., Engh, M. E., & Bo, K. (2010, Feb). Morphological changes after pelvic floor muscle training measured by 3-dimensional ultrasonography: a randomized controlled trial. Obstet Gynecol, 115(2 Pt 1), 317-324.
Hagen, S., & Stark, D. (2011). Conservative prevention and management of pelvic organ prolapse in women. The Cochrane database of systematic reviews, (12), CD003882.
Haylen, B. T., Maher, C. F., Barber, M. D., Camargo, S., Dandolu, V., Digesu, A., Goldman, H. B., Huser, M., Milani, A. L., Moran, P. A., Schaer, G. N., & Withagen, M. I. J. (2016). An International Urogynecological Association (IUGA) / International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Organ Prolapse (POP). Neurourology and Urodynamics, 35(2), 137-168.
Kashyap R, Jain V, Singh A. Comparative effect of 2 packages of pelvic floor muscle training on the clinical course of stage I-III pelvic organ prolapse. Int J Gynaecol Obstet. 2013;121(1):69-73.
Slieker-ten Hove, M. C., Pool-Goudzwaard, A. L., Eijkemans, M. J., Steegers-Theunissen, R. P., Burger, C. W., & Vierhout, M. E. (2009). The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population. International urogynecology journal and pelvic floor dysfunction, 20(9), 1037–1045.
Swift S. E. (2000). The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. American journal of obstetrics and gynecology, 183(2), 277–285.