Imagine this: one day you are in the shower and look down to see something that almost looks foreign to you coming out of your vagina. You also have noticed that you leak urine more and have feelings of a pressure feeling in the vaginal area that just doesn’t feel quite right. This scenario may seem crazy, but it is a common narrative I hear as a physical therapist specialized in pelvic health when women have developed a pelvic organ prolapse. Many women do not know what a pelvic organ prolapse is unless they are diagnosed with one, or have learned about the risks of having one through the pregnancy process. It is a condition that is often not talked about among family, friends and colleagues. This is unfortunate because there are many things that can be done to prevent the development of a pelvic organ prolapse, and conservatively manage one that has already developed.
A pelvic organ prolapse occurs when a pelvic organ in your body such as your bladder, uterus, or bowel drops lower than its anatomical position into the vagina or rectum. These are many different kinds of pelvic organ prolapse (POP) that are listed below:
- Cystocele (prolapse of bladder)
- Enterocele (prolapse of small bowel)
- Rectocele (prolapse of rectum)
- Uterine prolapse (prolapse of the uterus)
- Vaginal vault prolapse
Symptoms of pelvic organ prolapse include:
- Feelings of bulging in the vagina or rectum, sometimes you may even see a physical bulge coming out of the vagina or rectum.
- Incomplete bladder or bowel emptying with sometimes needing to splint for a bowel movement.
- Urinating then getting up from the toilet and feeling like you have to urinate again.
- Low back and sacral pain worse in upright positions and exercise that is relieved by lying down.
- Urinary Incontinence.
- Difficulty starting a urine stream or weak urine stream.
* It is also possible to have a small grade pelvic organ prolapse and have no symptoms at all.
The prevalence of pelvic organ prolapse varies across populations, with a higher prevalence in Caucasian females, especially those with increased overall laxity in their connective tissue. Having a vaginal delivery versus a C section, prolonged pushing during labor, menopause, chronic constipation, or participation in high level athletic activities with poor mechanics are some factors that can increase your risk of developing a pelvic organ prolapse. A recent systematic review linked obesity to a greater likelihood of having a pelvic organ prolapse versus women with a normal BMI. Some of these risk factors women cannot control, however many can be controlled through practicing good pelvic floor habits and maintaining a healthy lifestyle.
Below are some great tips for preventing pelvic organ prolapse:
- Practice proper breathing mechanics with lifting heavier objects. I tell patients “double E.” Exhale on the effort. For example when you lift a heavy box, exhale as you lift up. Holding your breath will cause all of your abdominal pressure to shoot downwards towards your pelvic floor muscles.
- Maintain a healthy weight. If you are in pain that is preventing you from exercise, get physical therapy first so they can help guide you towards a healthy active lifestyle right for your body.
- Avoid chronic constipation by maintaining a healthy diet and managing stress. Consider buying a squatty potty or putting a stool under your feet when passing a bowel movement. Do not hold your breath baring down. Exhale as you bare down, or you can practice bowel opening sounds such as “SSSS” like a snake, or a low tone “moooo” sound.
- If you are leaking with exercise get your pelvic floor muscles screened to see if you need intervention from a pelvic health physical therapist to improve the coordination of your pelvic floor muscles. Leaking is a sign that your core system in not stabilizing well and needs attention.
- Maintain good core strength. There is a difference between having good core strength and having a six pack that looks visually appealing. Core strength involves proper breath and coordination of core muscles with movement, not your ability to do 100 sit ups. In fact, the excessive crunching movement of sit-ups can cause a lot of pressure downward through your pelvic floor muscles that can increase your risk of leaking and prolapse.
- If you are post-partum wait at least 6-8 weeks before returning to high impact activities. If you are leaking with exercise still at 6-8 weeks it is a sign your body is not ready for high impact activity and you need to see a pelvic health physical therapist.
If you do have a pelvic organ prolapse, there are conservative options to help manage your symptoms and potentially resolve the prolapse in select cases. Pessaries are devices that can be inserted into the vagina or rectum to help support the pelvic organs, especially during times of exercise. Pelvic floor physical therapists can teach appropriate pelvic floor muscle exercises to improve the coordination and strength of the pelvic floor muscles to support the pelvic organs more efficiently. The use of pessaries with combined pelvic floor muscle training has been shown to decrease prolapse symptoms and improve the quality of life in women with pelvic organ prolapse. Pelvic floor physical therapists can also teach you lifestyle modifications to avoid excessive intra-abdominal pressure such as proper lifting mechanics with breath coordination, and postural habits throughout the day. Exercise modifications can be provided to prevent worsening strain on the prolapse and keep you active. Additional strengthening exercises are often provided for the lumbopelvic complex to address any orthopedic issues that may be causing excessive strain on the pelvic floor muscles.
Andrea Wood, PT, DPT, PRPC
Barber MD, Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int Urogynecol J. 2013. 24(11): 1783-1790.
Cheung RY, Lee JH, Lee LL. Vaginal pessary in women with symptomatic pelvic organ prolapse: a randomized controlled trial. Obstet Gynecol. 2016. 128(1): 73-80.
Giri Ayush, Hatmann K, Hellwege J, et al. Obesity and pelvic organ prolapse: a systematic review and meta-analysis of observational studies. AJOG. 217(1): 11-26.